As far as we are aware, this is one of the first studies to directly examine factors influencing people’s willingness to rate their physician on PRWs. The two overarching groups of factors identified by this study suggest where future efforts regarding this issue may need to focus.
Relationship factors
Factors concerning the physician-patient relationship appear to be some of the most important influencing people’s willingness to rate their physician on PRWs, but also the most difficult to address.
Trust is important in all social relationships, although it is potentially even more important in the physician-patient relationship given the inherent imbalances of power, knowledge, and vulnerability that exist [
24]. Our study has confirmed the suggestion that patients’ willingness to disclose information about such a relationship is likely to be extremely low unless their expectations are far exceeded or feel that their trust has been violated in some way [
14]. Participants repeatedly reported that a very positive or very negative experience in the health care relationship as a crucial precondition for them too be willing to rate a physician. However, while such a rating trend is seen in the online rating of products [
25], this is not consistent with the evaluation tendencies that have been found on PRWs. Previous studies in Germany and the United States have consistently found that ratings on PRWs are overwhelmingly positive [
6,
26‐
29]. Participants in our study reported fears regarding the impact a negative rating may have for both themselves and physicians, and such fears have been reported by participants in previous research as well [
17]. These fears may be leading patients to self-censor and be one explanation for the low number of negative reviews.
Participants, however, reported that pro-active requests from physicians for ratings would increase their willingness to rate. Such pro-active requests for feedback (positive or negative) within a trusting physician-patient relationship maybe help reduce patients’ fears around posting reviews on PRWs and help increase the number of ratings on PRWs. Unfortunately, however, there is evidence that some physicians are currently urging patients not to post negative reviews on PRWs and are taking legal action against negative reviews that are posted [
5]. It has therefore been previously suggested that “the medical profession itself should do more to ensure that patients are not being actively discouraged by physicians to post critical reviews, as they are a potentially important opportunity for physicians to learn and improve care” [
14].
Technical factors
Participants also reported that there are currently several technical barriers to rating physicians on PRWs, including the time required for registration on PRWs, PRWs being too complicated and badly designed, and a lack of rating guidance in terms of allowable content. These findings support previously research that has highlighted the need to improve the design of PRWs [
20]. A recently published study examined the choice-making processes of participants` using the rating website TripAdvisor to select a hotel and the PRW Jameda to select a physician [
20]. It was concluded that whereas the information provided on commercial rating websites seems to fit customers’ needs, the similarly designed PRWs did not. It was noted that PRWs are currently set up in the same manner as an “experience good/service”, which consumers can only assess the quality after it has been experienced, by combining general information (location, accessibility, qualifications) of the physician with impersonal anonymous reviews by former patients [
20]. However, the selection of a physician could primarily be classified as “credence good/service”, which consumers cannot assess the quality of the product even after consumption and must rely more on interpersonal recommendations than public non-customized information. It was therefore concluded that there is a need for web designers and researchers to consider how PRWs could best provide trustworthy interpersonal information that is adjusted to individuals needs [
20].
Furthermore, patients’ perceived inability to evaluate certain aspects of physicians` practice, also suggests that changes to the way data is presented on PRWs may be required. In order to identify the aspects PRWs should offer for evaluation, a recent study by Rothenfluh et al. examined what physicians and patients thought were the relevant factors for identifying a good doctor and whether patients are capable of evaluating these aspects [
21]. It was found that physicians and patients agreed that infrastructure, staff, organization, and interpersonal skills are both important aspects of a good physician and can be evaluated by patients. However, while technical skills of a physician and outcomes of care were judged to be the most important aspects of a good physician, both physicians and patients agreed that these aspects could not be evaluable by patients [
21]. While combining patient reviews with quality reported has been previously suggested [
13], attempts to do so in experiments did not result in better physician selection results [
30]. It has therefore been recommended that there is a need for further research to find:
“…PRW formats in which health care consumers can voice their opinion on aspects that are deemed assessable, while condensing and summarizing technical quality of care information in a format that is understandable by health care consumers…” [
21].
While some participants reported that the ability to rate a physician on a mobile app would have a positive effect on their willingness to rate, it appears that these participants were not aware that the majority of German PRWs have already had mobile apps for many years. This may indicate that while awareness of PRWs is no longer a key barrier to using PRWs [
18], there may not be sufficient awareness of PRWs mobile apps which is acting as an obstacle to some younger people to rate their physicians. PRWs having targeted advertising of these mobile apps to younger people may therefore help efforts to increase physician ratings.
More generally, participants reported that the perceived high number of PRWs in the market was confusing and a disincentive for rating physicians. This supports recent research which examined the development of the frequency of ratings and evaluation tendencies on German PRWs over a 4 year period [
14]. It was found that many German PRWs added very few new ratings during this time and that current ratings are spread out across PRWs in an uneven manner [
14]. There are, however, signs that the German PRWs market is starting to consolidate. Three major public health insurance companies in Germany (Allgemeine Ortskrankenkasse (AOK), Techniker Krankenkasse (TK) and BARMER GEK), are now all utilising a central database known as “Weisse Liste”; recruiting ratings from their insurees via their own platforms, but pooling these ratings on the shared Weisse Liste. Indeed, the examination of German PRWs found that AOK, Germany’s largest public health insurer, has been able to quickly establish the PRW AOK-Arztnavigator as one of the most used German PRWs since being introduced nationwide in May 2011 (TK and BARMER GEK were not included in the study) [
14]. It remains to be seen whether this central database will lead to the German PRWs market further consolidating, however, it does appear to be a positive development and one that may help address concerns reported by participants in this study about the trustworthiness of PRWs operators, as public health insurance companies are seen as the most trustworthy organizations in Germany when it comes to data security [
31].
It may also be illuminating to consider previous research on consumers’ willingness to post electronic word of mouth on online rating websites in general. In 2012, Cheung and Lee developed a research model to explain why consumers are willing to spread positive electronic word of mouth on online rating websites, which they then examined using a sample of users from a restaurant rating website in Hong Kong [
32]. It was found that three factors were crucial to encourage consumers to share their experience with others on rating websites [
32]. Firstly, a sense of belonging (affective commitment) was found to have the biggest impact on consumers’ electronic word of mouth intentions. Second, enjoyment of helping other community members with their decisions (and saving them from having negative experiences) was also found to be crucial in affecting consumers’ electronic word of mouth intentions. Finally, reputation was found to be marginally significant, with some consumers willing to contribute their experiences because they want to be viewed as an expert by others. Reciprocity, moral obligation and knowledge self-efficacy were not found to have a significant relationship with consumers’ electronic word of mouth intentions [
32]. These findings suggest further measures that could be taken to improve technical aspects of PRWs and increase the number of ratings. To enhance patients´ sense of belonging to a community, PRWs could create mechanisms that allow patients to (1) create their own (anonymous) profiles, (2) create “groups” for a certain illness or disease, (3) and the ability to communicate directly with other users. The ability to communicate directly with other user may also help address the need to provide trustworthy interpersonal information. In Germany, public health insurance companies may be best placed to achieve a sense of belonging for their PRWs users, with patients likely already having some form of loyalty to the health insurance company. To promote the enjoyment of helping others, PRWs could create a mechanism that allow users who have provided useful reviews to other PRWs users to be identified and informed that they have helped others [
32]. Such a mechanism could also include publically visible metrics to contribute to users gaining a positive reputation on the PRW.
Limitations
This was a qualitative study that did not aim at collecting statistically representative data. Responder bias may have influenced the results; however, as those who responded to our survey and were willing to be interviewed are likely to be generally more interested in the issue, the identified factors influencing these participants´ willingness to rate physicians should be taken seriously. Additionally, all participants came from northern Germany which could have led to a bias as differences may exist between other regions in Germany with respect to PRWs. However, the study used a random sample of an average population from four North German cities of different sizes. Furthermore, non-responder analysis of the survey [
18], found no significant difference in gender, and while responders were slightly older than non-responders on average, the effect size was small. We therefore do not think that this issue has significantly impact our results and think the results reveal a more generalizable view of the average population regarding PRWs compared to previous research on PRWs using panel data. Responses were self-reported and, therefore, we do not know the actual use of PRWs.