Bizarro World

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Walking down the block to the shopping center I have my 10 cents weekly allowance in my pocket, and I know what I’m going to buy with it: the latest issue of the Superman comic book. (Comic books, for those who have never heard of Marvel Comics, were the graphic novels of the day when I was growing up.)

I don’t remember whether Superman got me interested in science fiction or the reverse but, in any event, the highlight of my day was when each new issue came out. I knew from experience when it was likely to appear at Woolworth’s, so I was rarely disappointed unless there was some rare shipping snafu. One of the most interesting recurring story lines related to Superman’s travails with Bizarro World and Bizarro Superman.

Bizarro World was in fact a bizarre, and thus pretty interesting, place to a 10-year-old, though perhaps not to the 10-year-old in everyone. Everything in it was the opposite of the regular world. Where Superman lived was a world much like 1950’s America. In Bizarro World, telling someone they were the most stupid, incompetent person around was the highest of compliments. And Bizarro Superman did his best (ie, worst) to do bad things, though since it was Bizarro World he was generally incompetent. Being kind, thoughtful, honest, reflective, ethical, and altruistic were the worst personal characteristics possible. Calling someone a mean, selfish, unethical liar was the kind of highly valued accolade to which anyone in Bizarro World would aspire.

Before you get that self-satisfied knowing look on your face, I’ll bet you think all this description is a not too veiled reference to certain aspects of public life in America over the last year. But you’re wrong; well sort of. . .

I’ll admit that it’s sorely tempting to think our current political world is a kind of Bizarro World, and I confess to thinking that way a time or two. But this column is about something different.

You may be familiar with the Sunday New York Times Magazine’s column, The Ethicist. Each week it features a letter or two asking whether a particular behavior is ethical, and the columnist-a philosophy professor at NYU, and sometimes guest commentators-responds. The letters all seem to be about real, albeit at times farfetched, situations. Clearly, though, and for obvious reasons, they are selected to grab and hold the readers’ attention.

Imagine my surprise, therefore, to see the headline in the February 26th issue, “Can Therapists Fake Their Own Online Reviews?”

I knew what the reference was without having to read the letter. We all know about this phenomenon of the Internet, purportedly in the interest of consumer protection, in which people log in to a website and rate various aspects of the experience they had with a clinician. The one referred to in the New York Times piece apparently charges a not insignificant amount of money to be listed on the site, just like Trip Advisor charges hotels for the best type of listing. Of course, the physician ratings are anonymous, though there is likely some modest amount of identifying data supplied to the website by the rater, as you’ll see if you keep reading.

I think of these clinician rating websites in more or less the same way I think about travel sites like Trip Advisor or Zagat. I use both those sites frequently, but I always take the ratings with a large tablespoon of salt. Even though there is always a name and location attached to Trip Advisor reviews, I don’t know who the reviewers might be, or even whether they are actual people someone paid to write a great review or to trash the competition.

The only saving grace to the sites is my belief that when there are a very large number of reviews (and for Trip Advisor this means hundreds and occasionally thousands), they could be worth considering. Of course, those numbers are hardly what any professional pollster would call a valid random sample. So, imagine a doctor’s website that has far fewer than 100 reviews. What do the reviews really tell you?

Insurers and the government use patient satisfaction ratings as valid quality indicators. It is well recognized though that even when patients are assured their review is anonymous, many believe they will get better care from their physicians if they give them a higher rating. And we all know that anonymity also provides a fertile cloak for someone with a grievance against a physician to gain retribution-whether that person is a patient.

I think that unfortunate outcome may occur more often than we think, just as it does on hotel and restaurant rating sites. Several years ago I looked at my rating on one of these sites, and found I had been given the lowest possible grade by a single rater. I wondered which patient might have had such a terrible experience. But I also then realized that in the months preceding the rating, I had actually been on a rare sabbatical leave. So, I wondered if it was really from a patient at all.

I contacted the website, and surprisingly got a live person on the phone to whom I explained the situation. The person said they’d look into it. Even more surprising, I received a call back several weeks later by the same person. He told me they had concluded the rating did not meet their “standards” and that it was already removed.

Going back now to the New York Times letter, the writer, a therapist of unknown professional degree, did indeed ask if it was OK for him to send in various comments as if they were from his patients. He didn’t want to ask them to do ratings because he, wisely, thought it would distort the therapeutic alliance.

He said he had posted various positive comments that his patients had made to him and had written them as if he himself were the patient. He thought this might be unethical, but was asking anyway since a number of clinician friends told him they had “primed the pump,” to use the writer’s words. And, he said, he didn’t want to deprive potential patients of his good work because they didn’t know he existed. He also didn’t want to waste his fee to the website.

I was glad to see the ethicist’s initially fairly harsh and completely unambiguous response that such behavior is obviously unethical. But I was quite disheartened that the ethicist thought it would be honest to post comments if the therapist signed his own name and said they were patients’ comments. And, to make matters worse, the “ethicist” said it wasn’t really his fault that he was being dishonest . . . the website’s setup made it too tempting. (Why did you rob the bank, Mr. So and So? Well, they just had all that money lying around.)

How many of you think that revealing information from within the confidentiality of the therapeutic relationship is honest-no matter how we said it-unless the patient says it’s OK? Could anyone believe such comments were actually from patients?

So much for the ethical ethicist.

Fake news has invaded the blogosphere and the political discourse in a number of countries, including ours. The mental health professions are no longer immune. It would be devastating to our credibility if this were really a widespread phenomenon. I fear it may be, but pray it’s not.

When I was 10, Bizarro World seemed crazy and terrible. Now I’m older, and I know it to be so. So would most everyone.