Ugh, I've been Yelp'd!

 “In 1996 {Dr. Dayan} tried a new laser he rented complaining of cost for under eye blepharoplasty that took all cheek bones fat/muscle and left black deep hollows because he didn’t know how to work it for my cost of $7,000. So I have had two fat transfers and innumerable fillers to hide mess he made of my face I will have to the grave: so look older than my years. I cannot stress this: he is a disaster/ BEWARE/DO NOT GO THERE!!!!!!!!!!!!!!!!. They would not help me when I complained. He shrugged: narcissistic jerk with attitude: do you seriously want a huge a-hole only out for your money with knives and needles and an ego trip? Really absolute worst in Chicago and American Medical Asc. Should take him down but plastic surgs are not regulated so you can not sue them if they disfigure you forever. Selfish moron with unsteady hands.”

–   [Name deleted]  Chicago IL 

“Dr. Dayan, I hate to tell you this but a negative review just posted,” my social media manager blared out to me just yesterday… Ugh… what a sinking feeling, I thought… talk about feeling like a total failure... I try so hard to make every patient happy and it hurts when I have failed. I still haven’t developed that thick alligator skin callousing me enough to detach emotionally. I am deflated, but recognizing it is a necessary discomfort to survey all criticisms. And if I am to be honest with myself, there are times when both my team and I could do things better. For that reason I believe these reviews can serve a positive purpose for medicine, and me in particular. So I inch my eyes forward and jump into a deep end of a cold pool of words; but this time, I quickly realize something, these frigid words can’t be true! I’ve never rented a laser and even more confirming, I wasn’t even in practice in 1996! This must be a fake review! But this is not the first time we have noticed this from the bowels of these online review sites, and I am not the only one. In fact, according to a Harvard Business School study, up to 16 percent of Yelp restaurant reviews submitted may be fake and are screened out. (1) According to a working paper from the Harvard Business School, fake reviews are often based on economic forces, and restaurants subject to increased competition are more likely to get phony negative reviews. (1)

Over the last few years, as we have been monitoring our social media mentions, we have noticed many reviews that are frankly impossible to be authentic. I have been cited as performing a procedure on a day when I can prove I was out of town, or the nameless allegedly maimed complained about a disastrous outcome from a procedure that I don’t even do. So on Yelp alone we have flagged and protested seven seemingly phony one star reviews of which three have been taken down by Yelp. However, the other four, Yelp in its judge, jury and executor self-assigned roles believe meet their secretive vetting criteria. Therefore, they refused to take these reviews down - including the one above that mentions a procedure allegedly done before I was even in practice! 

Yelp’s response to our protest, “We're writing to let know that we … evaluated {the} review… that you recently flagged. We decided at this time to leave it up after carefully assessing it against our Content Guidelines”   -The Yelp Support Team

Carefully assessing it!? You have got to be kidding me! What’s so careful about their assessment? And doesn’t it seem a little suspicious when a person posts a negative review 19 years after the fact? This can’t be fair, so I contacted an attorney who specialized in reputation management to inquire about options. But to my dismay he told me, 

 “As a practical matter, Yelp has repeatedly refused to remove numerous reviews that contain demonstrably false factual statements.  Because Yelp has federal immunity from liability for reviews posted by third-parties, the site cannot be sued.  Moreover, during the past three years, letters to Yelp have been unsuccessful.” 

However, Yelp has not an ounce of hesitation hiding the 12 five star reviews that they have deemed unworthy. 

And when we get a negative review, it affects our practice and other patients may feel greater permission to pile on.  Just after the review mentioned above posted, we saw a patient five years after her surgery demanding her money back. Our website’s “contact us” inquiries go down 37 percent the week after a negative review.

For better or worse, Americans seek out health information on the internet. According to a 2012 Pew research study, 72 percent of internet users in 2014 looked online for health information within the past year, and 20 percent of internet users have consulted online reviews of health care providers and treatments. But are patients getting a fair representation of the service they can expect to receive? Only a small minority - 3-4 percent of internet users have posted experiences about health care providers or treatments.(2) So who are the vocal minority that post their experiences?  There are a multitude of forums in which to rate physician experiences but no review site is better at coordinating a cult-like atmosphere than Yelp. Their branded reviewers are affectionately known as “Yelpers.” One of the credentials necessary to becoming a Yelper is that you have to be a frequent reviewer, and while I suspect the vast majority of Yelpers have honest intentions of providing valuable feedback to the community, others have famously learned how to prolifically mudsling from behind a mask of anonymity. Yelp’s proprietary and secret methods of judging legitimacy is intended to weed out small business owners from gaming the system by having their confederates write falsely positive reviews -  which Yelp proudly mentions they successfully screen. Yelp recognizes their criteria may result in some of the positive reviews unfairly being taken down, but that is the nature of their review processes. However, their algorithm also allows a small select group of narcissistic “Yelpers” to be disproportionally and perilously empowered, and empowered, they are, a one-star difference on Yelp can mean a real difference in revenue. (1)

On more than one occasion, we have had one of the rare but vocal Yelpers come into my office more than happy to announce their imperial status and power. A veiled threat if you ask me.  These abusive representatives expect more respect than the average Joe or else they will unleash their power.  At my request, my social media expert looked deeper into Yelp and was excited to tell me that we can offer to throw a party for Yelpers in which case, we can invite this entitled clique into our offices and show them a good time. They are known as CMYE Community Manager Yelp Event, and according to Yelp’s website, they are planned by a local Community Manager. These are the events to mingle with other Yelpers, connect with local vendors and businesses, and maybe even “land some awesome Yelp swag!”  Wow! Get some swag! Now who doesn’t want that? And of course this is not meant to be a bribe for a good review…but wait a second… thinking it further through… doctors really can’t or shouldn’t ethically be giving away swag, and do I really want to bring the lions into the lamb den when I can’t play by the same rules as other party host? .Forget it. What if one of them stubs their toe, is disappointed by our lack of giveaways or is convinced my reception looked at her cross eyed? This group has collectively proven itself highly critical, commenting on dusts of information and not thinking twice about the weight of their damning words. Why add to their power? So we decided against that. But maybe there is a better option? A Yelp Sales Associate let it be known that Yelp is a great place for small business owners to advertise. For the low, low price of only 1000 times the standard online rate and 100 times the premium that national advertisers pay, I too can shout my praises! (3) 

Advertising “protection” allegations are not specific to medicine. Others have sued claiming that Yelp extorts their small businesses.  But they lost on that theory in San Francisco’s 9th circuit court of appeals. (4) But the proletariats are not ready to be squelched, and say what you want, but hell has no fury like a group of scorned small business owners. Billion Dollar Bully a documentary depicting the practices and aftermath of Yelp’s reviews and policies on small business, may have had an impact on Yelps stock which sunk 4.5 percent soon after the trailers released (Reuters March 19, 2015) A Yelp spokeswoman, however, was not without a response, “The claims have no merit,” and that the film’s director, Kaylie Milliken, had a history of trying to mislead consumers on Yelp. “The claims ... have been repeatedly dismissed by courts of law, investigated by government regulators, including the FTC, and disproven by academic study.”

It appears for now the legal system has determined that Yelp’s practices do not constitute extortion, but the more important question perhaps that should be asked is, Yelp really serving the public well?  In other words, if Yelp is out there to truly “Help connect people with great businesses” as their mission statement says, are they doing that or is their “service” working in the opposite direction?  And if they are really interested in helping the public at large does lumping physicians in with other “businesses” make sense?

As physicians, we are particularly disadvantaged here. We are health care stewards first and foremost, and any other motive including economic gain should not interfere. This is completely opposite of all other businesses. And because we have a fiduciary responsibility to always act in the best interest of our patients, sometimes we have to refuse to treat or not provide a requested drug or procedure when not medically or ethically warranted. In other words we have to disappoint some patients in order to do the right thing. This is counter to normal business practice which is mostly guided by the customer is always right mantra. Therefore, shouldn’t this clearly separate the medical doctor from the other “businesses?”  Or at least should or could Yelp recognize this distinction?  Unlike a dry cleaner or a local restaurant, the average patient may find it difficult to nearly impossible to fully understand the logic and reasoning behind our decision-making processes. It takes four years of medical school and six to seven years of residency before we gain the knowledge necessary to make difficult decisions. We can try our hardest to explain it to a disgruntled person, but some will not be able to comprehend, want to hear, or accurately relate the story to their peers.  Add to this that as aesthetic physicians; we also see a body dysmorphic population that can reach 30 percent. (5) Additionally, whereas other small business owners have the right to defend their reputations and have successfully publicly exposed malicious Yelp reviewers,(6) we are bound by medical ethics and HIPAA  laws, with boundaries that still remain unclear to the medical providers, public and even regulators. We are advised at our conferences and in our literature that the best response is no response. Beat out the negativity by drowning it out with positive reviews we are told.  The problem is most happy patients move on and don’t take the time to report on their contentment.  And, even if they do, they are unlikely to jump through the hoops to become a “Yelper.”

Other non-Yelp review sites seem more democratic and less clique-defined in whom they allow reviewed, and probably have provided a better service to medicine and humanity. Their reviews are likely more representative of the public, but still far short of fairly representing the silent majority of people who are overwhelmingly satisfied. 

On the heels of the court’s decision, it seems clear we will have to learn to live in such an environment. And perhaps there is a good in that we all can benefit from negative criticism that keeps our egos in check and our practices focused on meeting patient expectations. Unfortunately, while as individual physicians we may get bruised psychologically and sustain a blow to our bottom line, perhaps a much greater disservice is being done. A review site that welcomes a biofilm of seemingly false and on occasion maliciously intended criticism toward individual doctors and healthcare may be harmful for the public. Unassuming consumers are effectively hurt by misleading, unchecked, unbalanced and non-validated information from untrained flippant influencers. A great doctor with a particular niche talent can potentially help many people in need but be defamed and made irrelevant by one blogger with an axe to grind. And it’s no surprise that the social-media-propelled anti-vaccination campaign has directly led to deadly measles outbreaks. Also very concerning is that some academic centers are now considering their physicians online reviews when evaluating their performances! This alarming news should put all physicians on alert. How far can we be from reimbursement, licensing and malpractice premiums also being affected by unsubstantiated reviews?  And while we can protest the review sites’ practices and the medical voyeurism that is fostered, it is unlikely to change anytime soon. Clearly, it is we who will have to adapt to a new form of communication to meet the increasingly flat world, where authority and status is more likely to be challenged then revered. However, in response we don’t need to act like lemmings being shepherded off a ledge. As physicians we are trained expert educators and perhaps one of our emerging roles is to educate patients about the true science – or lack of science at work here, expose, shed light and contribute professionally to these sites. Physicians must voice a strong message to the public that outcomes may vary based on individualities, that aesthetic medicine is not a perfect science and that the overwhelming majority of patients’ expectations are met or surpassed. 

As individual doctors we are highly vulnerable to a nameless, faceless attacker. It plays right into the hands of the review sites’ strategy giving them the much needed agar to grow their cultures. It is in their best interest to celebrate the negativity. Positive stories don’t make for good ratings on television, the news, in the tabloids, nor on review sites.  Alone and divided we are weak, but in the aggregate educating and advocating for our patients, our specialties and our practices our voice has more impact, influence and meaning. The review sites are a form of free speech that serve a well-meaning and strong purpose in our modern increasingly democratic society, but we as physician educators and providers have a critical role to play also. We are bound by a Hippocratic mandate and a moral obligation to challenge the dangers of misleading unsubstantiated medical information and allegations. It is incumbent upon us as physicians to expose inappropriate actions and teach our communities how to objectively analyze and dismiss soiling internet information. However, to be effective we must do it on the terms of a new generation in a language and manner that is understood and accepted. This is a challenge I am afraid we cannot disregard, not only do our reputations depend on it, but so too may the future and direction of health care.

-Steve Dayan

1. Luca, Michael and Zervas, Georgios, Fake It Till You Make It: Reputation, Competition, and Yelp Review Fraud (November 26, 2014). Harvard Business School NOM Unit Working Paper No. 14-006. Available at SSRN:https://ssrn.com/abstract=2293164
2. https://www.pewinternet.org/2013/01/15/peer-to-peer-health-care/
3. https://venturebeat.com/2012/02/06/yelp-advertising-is-a-rip-off-for-small-advertisers/
4. https://www.latimes.com/business/la-fi-yelp-ratings-20140905-story.html
5. Picavet VA. Plast Reconstr Surg. 2011 Aug;128(2):509-17
6. Robinison Willis. Daily Mail.com 15:13;26 March 2015.