Impact of Patient Rating Propensities on the Online Rating of Orthopaedic Surgeons. A Retrospective Analysis of Google Reviews

Impact of Patient Rating Propensities on the Online Rating of Orthopaedic Surgeons. A Retrospective Analysis of Google Reviews | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Patient Rating Propensities on the Online Rating of Orthopaedic Surgeons. A Retrospective Analysis of Google Reviews Omar Zakieh, Beshoy Williams, James F. Bathon, Kennadie Long, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7023085/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Online reviews are increasingly influential in patient decision-making when selecting a surgeon. Although healthcare-specific factors are known to shape patient satisfaction, the potential role of non-healthcare-related predispositions in shaping online reviews remains underexplored. Questions/Purposes: (1) Do individuals who leave extreme ratings (1-star or 5-star) for surgeons on Google tend to show similar rating behaviors when reviewing other products and services? (2) What is the difference in average rating behavior between these two reviewer groups? Methods A retrospective observational study was conducted across five academic institutions, evaluating Google reviews of orthopaedic surgeons. The purposes were to assess if individuals who leave extreme ratings (1-star or 5-star) for surgeons on Google tend to show similar rating behaviors when reviewing other products and services, as well as determine what is the difference in average rating behavior between these two reviewer groups. Reviewers were categorized into two cohorts: those who rated surgeons 1 star and those who rated surgeons 5 stars. The primary outcome was the average Google rating provided to other services and products by these reviewers. Results A total of 1,629 reviewers of 160 orthopaedic surgeons were included, of whom 97.2% (1584) provided either a 1-star or 5-star rating. Individuals who left extreme ratings for surgeons exhibited consistent rating behaviors elsewhere, with 1-star surgeon reviewers giving a significantly lower proportion of 5-star reviews for other products and services compared to 5-star surgeon reviewers (59.7% vs. 81.9%, p < 0.001). The average rating given to other products and services was significantly lower among 1-star surgeon reviewers than 5-star surgeon reviewers (3.7 vs. 4.5, p < 0.001) Conclusion Our findings suggest that patients who rate surgeons poorly may also tend to rate other products and services more negatively, while those who rate surgeons highly may exhibit a similar positive bias. These results highlight the potential influence of individual rating predispositions on online reviews, independent of healthcare-specific factors. Further research is needed to better understand how these tendencies affect patient satisfaction and to develop strategies for more objective review interpretations. Google Reviews Reviewers Orthopaedic Surgery Figures Figure 1 Background The accessibility of surgeon reviews has expanded significantly through numerous online platforms, including healthcare provider websites and patient forums. Prominent platforms such as Google, Healthgrades, Vitals, and RateMDs publish detailed reviews, featuring star ratings, written comments, and overall satisfaction scores. These reviews often serve as a valuable resource for patients when selecting a surgeon, as they are perceived to reflect the surgeon's expertise, quality of care, and interpersonal skills. In the age of social media and digital engagement, online reviews have emerged as a critical element in the patient decision-making process. 1 Evidence suggests that patients are more likely to choose surgeons with higher online ratings, indicating that favorable reviews can play a role in influencing patient preferences. 2 Notably, another study found that when selecting a provider, patients tend to prioritize the quantity of reviews over the average rating, highlighting the importance of the volume of feedback in shaping patient choices. 3 Patient satisfaction is influenced by several factors. A 2023 systematic review of 157 studies investigating patient satisfaction with healthcare services reported the most commonly cited factors included doctor characteristics, wait times, medical care, communication and information provided during visit. 4 A prior systematic review from 2021 similarly concluded that interpersonal factors, such as empathy and clear communication, often hold more weight in patient ratings than technical surgical skills alone. 5 Patient demographics and personality traits have also been explored as potential factors contributing to patient satisfaction. 6 – 8 These include but are not limited to age, sex, education, socioeconomic status, race, and religion. However, current evidence remains inconclusive regarding the specific contribution of each factor to overall patient satisfaction. Existing literature confirms that online reviews play a significant role in patient decision-making when selecting surgeons. While healthcare-related factors are known to affect patient satisfaction, evidence suggests that external antecedent factors, beyond the surgeon's control, may also play a role. 4 – 8 Therefore, we sought to assess if individuals who leave extreme ratings (1-star or 5-star) for surgeons on Google tend to show similar rating behaviors when reviewing other products and services. Additionally, we explored differences in average rating behavior between these two reviewer groups. Methods Study Design We conducted a retrospective observational study of Google reviewers evaluating orthopaedic surgeons. The study included all orthopaedic surgeons from our home institution, Vanderbilt University Medical Center, and one academic institution from each region (Northeast, South, Midwest, and West), as defined by Doximity.com. An online random number generator was used to select the institution from each region. Institutional Review Board (IRB) approval was obtained prior to the initiation of the study (IRB# 240706). The need for informed consent to participate was waived by the IRB and the study was adherent to the Declaration of Helsinki. Participants Reviewers were identified through the Google review pages of the surgeons. Inclusion criteria were: reviewers with publicly available Google rating and at least one more publicly accessible rating for another product or service. Reviewers with private accounts, without other product or service ratings, or who rated a surgeon 2, 3, or 4 stars were excluded from the analysis. Exposure Variable The primary independent variable was the surgeon rating provided by the reviewer. Reviewers were categorized into two cohorts: 1) reviewers that rated surgeons 1 star, and 2) reviewers that rated surgeons 5 stars. Outcome Variables The primary outcome of interest was the average Google rating that reviewers gave to other services and products. Additionally, the total number of reviews per reviewer and the proportion of 5-star reviews were collected. Statistical Analysis Descriptive and bivariate statistics were reported. Mean and standard deviation were reported for continuous variables. Normally distributed data were analyzed with a 2-tailed T-test. Alpha value < 0.05 was considered significant. All analyses were performed using SPSS version 20 (IBM Inc., Chicago, IL). Results Orthopaedic Surgeon Demographics A total of 160 orthopaedic surgeons from five academic institutions were included in our study. The institutions included Vanderbilt University Medical Center, University of Missouri, University of Utah, Boston University Medical Center, and Emory. Reviewer Ratings The total number of reviewers across all institutions was 1629 (Fig. 1 ), of whom 1584 (97.2%) either provided a 1-star or 5-star Google rating. Reviewers who provided a 1-star surgeon rating had a greater number of Google reviews than reviewers who provided a 5-star surgeon rating (23.6 ± 37.5 vs. 16.8 ± 34.6, p = 0.040), however there was no significant difference at any specific institution (p > 0.05) (Table 1 ). Reviewers who provided a 1-star surgeon rating had a significantly lower proportion of 5-star Google reviews (59.7 ± 32.1 vs. 81.9 ± 24.4%, p < 0.001) and lower average Google star rating (3.7 ± 1.2 vs. 4.5 ± 0.8, p < 0.001) than reviewers who provided a 5-star surgeon rating. Table 1 Comparison of Google ratings between reviewers who rated surgeons 1 and 5-stars Institution Surgeon Star Reviewer Total Number of Reviews Proportion of 5-star Google Ratings (%) Average Google Rating Mean ± SD P Mean ± SD P Mean ± SD P Vanderbilt University 1 29.6 ± 41.9 0.135 63.5 ± 31.9 < 0.001 3.9 ± 1.1 < 0.001 5 16.1 ± 27.7 82.9 ± 22.9 4.5 ± 0.7 University of Missouri 1 20.7 ± 25.1 0.946 60.4 ± 35.2 0.001 3.7 ± 1.3 < 0.001 5 21.4 ± 49.5 80.5 ± 26.2 4.5 ± 0.9 University of Utah 1 30.1 ± 55.9 0.620 57.8 ± 29.4 < 0.001 3.6 ± 1.2 < 0.001 5 23.4 ± 47.0 83.9 ± 19.5 4.6 ± 0.5 Boston University 1 12.3 ± 17.2 0.985 62.4 ± 33.7 < 0.001 3.7 ± 1.3 < 0.001 5 12.4 ± 27.8 81.8 ± 25.6 4.5 ± 0.9 Emory University 1 28.9 ± 42.0 0.096 55.1 ± 31.3 < 0.001 3.5 ± 1.1 < 0.001 5 16.9 ± 32.1 81.7 ± 24.5 4.6 ± 0.7 Total 1 23.6 ± 37.5 0.040 59.7 ± 32.1 < 0.001 3.7 ± 1.2 < 0.001 5 16.8 ± 34.6 81.9 ± 24.4 4.5 ± 0.8 Discussion Our study sought to expand on the evidence indicating that factors outside a surgeon's control may impact patient satisfaction. To explore this, we examined whether patients who provide either high or low surgeon ratings are similarly inclined to rate other products and services in a consistent manner using Google reviews. In our study, reviewers who gave a 1-star rating to surgeons had a significantly lower proportion of 5-star Google reviews and a lower average Google star rating for other products and services compared to those who rated surgeons 5 stars, across five academic institutions. Our results suggest that patients’ rating tendencies may reflect a broader pattern of behavior, wherein individuals who rate surgeons poorly are also more likely to give lower ratings to other products and services. Conversely, those who rate surgeons highly may exhibit a similar positive bias across various review platforms. This finding highlights the potential influence of individual rating propensities, independent of healthcare-specific factors, on patient satisfaction. This has significant implications for both patients and healthcare institutions. Patients relying on online reviews to select a surgeon may be unknowingly influenced by extreme rating tendencies, leading to skewed perceptions of a provider’s actual performance. For surgeons and hospitals, understanding these rating patterns can inform strategies for interpreting and responding to online feedback, such as emphasizing the importance of review volume, implementing patient education on rating systems, or incorporating additional metrics, such as peer reviews and patient-reported outcomes, to provide a more balanced assessment of surgical care. Patient reviews have become a powerful tool in shaping the reputations of healthcare providers, including surgeons. Research indicates that patients increasingly rely on online reviews to make informed decisions regarding their care. In a study evaluating online reviews of dermatology practices, patients placed significant value on physicians who demonstrated kindness and respect, conducted thorough physical exams, expressed empathy for the challenges of skin conditions, and were mindful of treatment costs. 9 Similarly, a study examining patients' online ratings of neurotologists identified the most influential factors as accurate diagnoses, quality bedside manner, sufficient time spent with patients, effective follow-up, and perceived helpfulness. 10 While these healthcare-related factors contribute significantly to patient satisfaction and rating, it is important to acknowledge that non-healthcare factors, beyond the surgeon’s control, also play a similarly important role. A study by Johnson and colleagues, which analyzed 1400 survey responses from the offices of 11 orthopedic spine surgeons, identified several nonmodifiable demographic factors associated with higher patient satisfaction scores. 8 These factors included older patient age, lower education levels, non-commercial insurance types, and demographic concordance between the patient and surgeon in terms of sex and ethnicity. These considerations underscore the multifaceted nature of patient satisfaction and suggest that online reviews may not depend solely on a surgeon's clinical abilities, but rather a broader range of factors, some of which are beyond the surgeon's direct influence. Response bias is a well-documented challenge in subjective reporting, affecting research findings across multiple domains, including healthcare, psychology, and consumer behavior. This observation aligns with findings from Nicolau et al., who demonstrated the presence of the halo effect in the hospitality industry. 11 Their study revealed that customer ratings of hotel attributes were significantly influenced by an overall predisposition, where positive or negative experiences in one area could skew perceptions of other, unrelated attributes. Importantly, they identified that negative variations in ratings, often referred to as the "horn effect", exerted a stronger influence on overall ratings than positive ones. The principle of negativity bias, described by Rozin and Royzman, suggests that negative experiences and evaluations exert a stronger influence than positive ones across various domains, including impression formation, memory, and decision-making. 12 One key manifestation of negativity bias highlighted by the authors was negativity dominance, where the presence of both negative and positive factors in an evaluation leads to an overall more negative judgment. This principle provides a compelling psychological basis for our findings. The tendency of 1-star reviewers to rate other products and services more negatively may align with negativity dominance, suggesting that their inclination toward negative evaluations extends beyond healthcare experiences. Wetzel et al. highlighted extreme response style as a key factor in polarized rating behaviors, where individuals disproportionately select extreme rating options, such as 1-star or 5-star reviews, regardless of the actual quality of the experience. 13 This aligns with our findings given 97.2% of reviewers provided surgeon with either a 1-star or 5-star review. In an observational analysis of 189,212 review, Han and Anderson describe online reviews often suffer from underreporting bias, as only customers with strong positive or negative opinions are motivated to post. 14 Further, they report that retailer-prompted reviews, such as hotels requesting feedback, help capture opinions from customers who would not otherwise post. Given the parallels between consumer and healthcare reviews, these findings suggest that surgeons and healthcare institutions may benefit from actively soliciting reviews from a broader range of patients to mitigate the effects of response bias and ensure a more representative assessment of surgical care. Our study has several limitations that should be highlighted. First, the retrospective design of this study precludes establishing causality between patient rating tendencies and surgeon ratings. While our findings suggest a broader pattern in reviewer behavior, they do not confirm a causal relationship. This limitation is further compounded by the absence of demographic data, which has been shown to influence consumer review behaviors. Additionally, we focused exclusively on Google reviews, which may not be representative of patient reviews on other platforms such as Healthgrades or RateMDs, where different populations or review behaviors may exist. Another key limitation of this study is its exclusive focus on academic medical centers, which may limit the generalizability of our findings to private practice settings. Unlike academic institutions, where referrals often stem from established healthcare networks, private practitioners may rely more heavily on online reviews to attract new patients. As a result, patient expectations and rating behaviors may differ between these settings, with private surgeons potentially experiencing greater pressure to maintain high online ratings. Finally, while we categorized reviewers into 1-star and 5-star cohorts, we did not assess middle-range ratings, which may provide a more nuanced understanding of patient satisfaction and review tendencies. Future studies should aim to include a broader range of institutions, platforms, and rating categories to address these limitations. Conclusion Our study suggests that online surgeon ratings may reflect broader individual rating tendencies rather than exclusively healthcare-specific factors. Reviewers who gave 1-star ratings to surgeons tended to rate other products and services lower, while those who gave 5-star ratings were more likely to rate other products favorably. This pattern highlights the potential influence of personal rating biases on surgeon reviews, which may skew patient perceptions and impact provider reputations. For healthcare providers, understanding these patterns can inform strategies for interpreting online feedback, such as emphasizing review volume, incorporating patient education on rating systems, and integrating additional evaluation metrics like peer reviews and patient-reported outcomes. However, our study has several limitations that warrant further investigation. The retrospective design precludes causal conclusions, and the lack of demographic data limits our ability to account for other factors that may influence reviewing behavior. Future research should examine whether these trends persist across diverse healthcare settings and explore strategies to mitigate response biases in online healthcare reviews. Abbreviations Vanderbilt University Medical Center (VUMC), Vanderbilt University Medical Center, University of Missouri (MU), University of Utah (UU), Boston University Medical Center (BUMC), and Emory. Declarations Ethics approval and consent to participate : This study was approved by the Institutional Review Board at Vanderbilt University Medical Center (IRB# 240706). Consent was waived due to the use of publicly available data. Consent for publication : Not applicable. Availability of data and materials : All data analyzed in this study were extracted from publicly available Google review profiles. Additional details are available from the corresponding author upon request. Competing interests : The authors declare that they have no competing interests. Funding : No external funding was received for this study. Authors’ contributions : AMA conceived the study design and oversaw data collection. KL helped with IRB submission and approval. OZ and BW conducted data collection and analysis. OZ and BW drafted the manuscript. JFB supported logistical tasks associated with the study. All authors contributed to longitudinal study support and critical revisions and approved the final version. Acknowledgements : No additional persons to acknowledge. Conflicts of Interest: Dr. Abtahi receives institutional research support from Stryker Spine. Dr. Gardocki is a consultant and teaching surgeon for Joimax, a consultant for Arthrex, a teaching surgeon and consultant with royalties for Integrity Implants, and a consultant with royalties for Spineology. Dr. Stephens receives institutional research funding from Globus and has received institutional research funding from Stryker. Dr. Zuckerman reports being an unaffiliated neurotrauma consultant for the National Football League and a consultant for Medtronic. References Hanauer DA, Zheng K, Singer DC, Gebremariam A, Davis MM. Public awareness, perception, and use of online physician rating sites. JAMA. 2014;311(7):734–5. 10.1001/jama.2013.283194 . Li X, Chou SY, Deily ME, Qian M. Comparing the impact of online ratings and report cards on patient choice of cardiac surgeon: large observational study. J Med Internet Res. 2021;23(10):e28098. Lu W, Wu H. How online reviews and services affect physician outpatient visits: content analysis of evidence from two online health care communities. JMIR Med Inf. 2019;7(4):e16185. Ferreira DC, Vieira I, Pedro MI, Caldas P, Varela M. Patient satisfaction with healthcare services and the techniques used for its assessment: a systematic literature review and a bibliometric analysis. Healthc (Basel). 2023;11(5):527. O’Rorke E, Mauch J, Liu Y, Friedrich J. Essential elements of surgeon communication impacting patient satisfaction: a systematic review. Plast Reconstr Surg Glob Open. 2021;9(10 Suppl):e3916. Abtahi AM, Presson AP, Zhang C, Saltzman CL, Tyser AR. Association between orthopaedic outpatient satisfaction and non-modifiable patient factors. J Bone Joint Surg Am. 2015;97(13):1041–8. 10.2106/JBJS.N.00950 . Boudreaux ED, Ary RD, Mandry CV, McCabe B. Determinants of patient satisfaction in a large, municipal ED: the role of demographic variables, visit characteristics, and patient perceptions. Am J Emerg Med. 2000;18(4):394–400. 10.1053/ajem.2000.7316 . Johnson BC, Vasquez-Montes D, Steinmetz L, et al. Association between nonmodifiable demographic factors and patient satisfaction scores in spine surgery clinics. Orthopedics. 2019;42(3):143–8. 10.3928/01477447-20190424-05 . Smith RJ, Lipoff JB. Evaluation of dermatology practice online reviews: lessons from qualitative analysis. JAMA Dermatol. 2016;152(2):153–7. Goshtasbi K, Lehrich BM, Moshtaghi O, et al. Patients' online perception and ratings of neurotologists. Otol Neurotol. 2019;40(1):139–43. Nicolau JL, Mellinas JP, Martín-Fuentes E. The halo effect: a longitudinal approach. Ann Tour Res. 2020;83:102938. Rozin P, Royzman EB. Negativity bias, negativity dominance, and contagion. Pers Soc Psychol Rev. 2001;5(4):296–320. Wetzel E, Böhnke JR, Brown A. Response biases. In: Furr RM, editor. Psychometrics and psychological assessment: principles and applications. Cambridge: Elsevier; 2016. pp. 349–63. Han S, Anderson CK. Customer motivation and response bias in online reviews. Cornell Hosp Q. 2020;61(2):142–53. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7023085","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":497807608,"identity":"914142d4-ee8f-41ed-957d-325cbb13594d","order_by":0,"name":"Omar Zakieh","email":"","orcid":"","institution":"Vanderbilt University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Omar","middleName":"","lastName":"Zakieh","suffix":""},{"id":497807609,"identity":"ec2f10e7-f735-4a7a-87c4-7ee1d2f1e3d2","order_by":1,"name":"Beshoy Williams","email":"","orcid":"","institution":"Meharry Medical College","correspondingAuthor":false,"prefix":"","firstName":"Beshoy","middleName":"","lastName":"Williams","suffix":""},{"id":497807610,"identity":"9feee357-d006-4acd-a486-bc40653b36fc","order_by":2,"name":"James F. 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A Retrospective Analysis of Google Reviews","fulltext":[{"header":"Background","content":"\u003cp\u003eThe accessibility of surgeon reviews has expanded significantly through numerous online platforms, including healthcare provider websites and patient forums. Prominent platforms such as Google, Healthgrades, Vitals, and RateMDs publish detailed reviews, featuring star ratings, written comments, and overall satisfaction scores. These reviews often serve as a valuable resource for patients when selecting a surgeon, as they are perceived to reflect the surgeon's expertise, quality of care, and interpersonal skills. In the age of social media and digital engagement, online reviews have emerged as a critical element in the patient decision-making process.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Evidence suggests that patients are more likely to choose surgeons with higher online ratings, indicating that favorable reviews can play a role in influencing patient preferences.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Notably, another study found that when selecting a provider, patients tend to prioritize the quantity of reviews over the average rating, highlighting the importance of the volume of feedback in shaping patient choices.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003ePatient satisfaction is influenced by several factors. A 2023 systematic review of 157 studies investigating patient satisfaction with healthcare services reported the most commonly cited factors included doctor characteristics, wait times, medical care, communication and information provided during visit.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e A prior systematic review from 2021 similarly concluded that interpersonal factors, such as empathy and clear communication, often hold more weight in patient ratings than technical surgical skills alone.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Patient demographics and personality traits have also been explored as potential factors contributing to patient satisfaction.\u003csup\u003e\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e–\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e These include but are not limited to age, sex, education, socioeconomic status, race, and religion. However, current evidence remains inconclusive regarding the specific contribution of each factor to overall patient satisfaction. Existing literature confirms that online reviews play a significant role in patient decision-making when selecting surgeons. While healthcare-related factors are known to affect patient satisfaction, evidence suggests that external antecedent factors, beyond the surgeon's control, may also play a role.\u003csup\u003e\u003cspan additionalcitationids=\"CR5 CR6 CR7\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e–\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eTherefore, we sought to assess if individuals who leave extreme ratings (1-star or 5-star) for surgeons on Google tend to show similar rating behaviors when reviewing other products and services. Additionally, we explored differences in average rating behavior between these two reviewer groups.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003eStudy Design\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWe conducted a retrospective observational study of Google reviewers evaluating orthopaedic surgeons. The study included all orthopaedic surgeons from our home institution, Vanderbilt University Medical Center, and one academic institution from each region (Northeast, South, Midwest, and West), as defined by Doximity.com. An online random number generator was used to select the institution from each region. Institutional Review Board (IRB) approval was obtained prior to the initiation of the study (IRB# 240706). The need for informed consent to participate was waived by the IRB and the study was adherent to the Declaration of Helsinki.\u003c/p\u003e\u003cp\u003e\u003cem\u003eParticipants\u003c/em\u003e\u003c/p\u003e\u003cp\u003eReviewers were identified through the Google review pages of the surgeons. Inclusion criteria were: reviewers with publicly available Google rating and at least one more publicly accessible rating for another product or service. Reviewers with private accounts, without other product or service ratings, or who rated a surgeon 2, 3, or 4 stars were excluded from the analysis.\u003c/p\u003e\u003cp\u003e\u003cem\u003eExposure Variable\u003c/em\u003e\u003c/p\u003e\u003cp\u003e The primary independent variable was the surgeon rating provided by the reviewer. Reviewers were categorized into two cohorts: 1) reviewers that rated surgeons 1 star, and 2) reviewers that rated surgeons 5 stars.\u003c/p\u003e\u003cp\u003e\u003cem\u003eOutcome Variables\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe primary outcome of interest was the average Google rating that reviewers gave to other services and products. Additionally, the total number of reviews per reviewer and the proportion of 5-star reviews were collected.\u003c/p\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eDescriptive and bivariate statistics were reported. Mean and standard deviation were reported for continuous variables. Normally distributed data were analyzed with a 2-tailed T-test. Alpha value \u0026lt; 0.05 was considered significant. All analyses were performed using SPSS version 20 (IBM Inc., Chicago, IL).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eOrthopaedic Surgeon Demographics\u003c/em\u003e\u003c/p\u003e\u003cp\u003eA total of 160 orthopaedic surgeons from five academic institutions were included in our study. The institutions included Vanderbilt University Medical Center, University of Missouri, University of Utah, Boston University Medical Center, and Emory.\u003c/p\u003e\u003cp\u003e\u003cem\u003eReviewer Ratings\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe total number of reviewers across all institutions was 1629 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), of whom 1584 (97.2%) either provided a 1-star or 5-star Google rating. Reviewers who provided a 1-star surgeon rating had a greater number of Google reviews than reviewers who provided a 5-star surgeon rating (23.6\u0026thinsp;\u0026plusmn;\u0026thinsp;37.5 vs. 16.8\u0026thinsp;\u0026plusmn;\u0026thinsp;34.6, p\u0026thinsp;=\u0026thinsp;0.040), however there was no significant difference at any specific institution (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Reviewers who provided a 1-star surgeon rating had a significantly lower proportion of 5-star Google reviews (59.7\u0026thinsp;\u0026plusmn;\u0026thinsp;32.1 vs. 81.9\u0026thinsp;\u0026plusmn;\u0026thinsp;24.4%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and lower average Google star rating (3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2 vs. 4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) than reviewers who provided a 5-star surgeon rating.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eComparison of Google ratings between reviewers who rated surgeons 1 and 5-stars\u003c/span\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInstitution\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSurgeon Star Reviewer\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eTotal Number of Reviews\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eProportion of 5-star Google Ratings (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003eAverage Google Rating\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVanderbilt University\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29.6\u0026thinsp;\u0026plusmn;\u0026thinsp;41.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.135\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e63.5\u0026thinsp;\u0026plusmn;\u0026thinsp;31.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.1\u0026thinsp;\u0026plusmn;\u0026thinsp;27.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e82.9\u0026thinsp;\u0026plusmn;\u0026thinsp;22.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eUniversity of Missouri\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20.7\u0026thinsp;\u0026plusmn;\u0026thinsp;25.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.946\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e60.4\u0026thinsp;\u0026plusmn;\u0026thinsp;35.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21.4\u0026thinsp;\u0026plusmn;\u0026thinsp;49.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e80.5\u0026thinsp;\u0026plusmn;\u0026thinsp;26.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eUniversity of Utah\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30.1\u0026thinsp;\u0026plusmn;\u0026thinsp;55.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.620\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e57.8\u0026thinsp;\u0026plusmn;\u0026thinsp;29.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23.4\u0026thinsp;\u0026plusmn;\u0026thinsp;47.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e83.9\u0026thinsp;\u0026plusmn;\u0026thinsp;19.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eBoston University\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.3\u0026thinsp;\u0026plusmn;\u0026thinsp;17.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.985\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e62.4\u0026thinsp;\u0026plusmn;\u0026thinsp;33.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.4\u0026thinsp;\u0026plusmn;\u0026thinsp;27.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e81.8\u0026thinsp;\u0026plusmn;\u0026thinsp;25.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eEmory University\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.9\u0026thinsp;\u0026plusmn;\u0026thinsp;42.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.096\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e55.1\u0026thinsp;\u0026plusmn;\u0026thinsp;31.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.9\u0026thinsp;\u0026plusmn;\u0026thinsp;32.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e81.7\u0026thinsp;\u0026plusmn;\u0026thinsp;24.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23.6\u0026thinsp;\u0026plusmn;\u0026thinsp;37.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e0.040\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e59.7\u0026thinsp;\u0026plusmn;\u0026thinsp;32.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.8\u0026thinsp;\u0026plusmn;\u0026thinsp;34.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e81.9\u0026thinsp;\u0026plusmn;\u0026thinsp;24.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study sought to expand on the evidence indicating that factors outside a surgeon's control may impact patient satisfaction. To explore this, we examined whether patients who provide either high or low surgeon ratings are similarly inclined to rate other products and services in a consistent manner using Google reviews. In our study, reviewers who gave a 1-star rating to surgeons had a significantly lower proportion of 5-star Google reviews and a lower average Google star rating for other products and services compared to those who rated surgeons 5 stars, across five academic institutions. Our results suggest that patients\u0026rsquo; rating tendencies may reflect a broader pattern of behavior, wherein individuals who rate surgeons poorly are also more likely to give lower ratings to other products and services. Conversely, those who rate surgeons highly may exhibit a similar positive bias across various review platforms. This finding highlights the potential influence of individual rating propensities, independent of healthcare-specific factors, on patient satisfaction. This has significant implications for both patients and healthcare institutions. Patients relying on online reviews to select a surgeon may be unknowingly influenced by extreme rating tendencies, leading to skewed perceptions of a provider\u0026rsquo;s actual performance. For surgeons and hospitals, understanding these rating patterns can inform strategies for interpreting and responding to online feedback, such as emphasizing the importance of review volume, implementing patient education on rating systems, or incorporating additional metrics, such as peer reviews and patient-reported outcomes, to provide a more balanced assessment of surgical care.\u003c/p\u003e\u003cp\u003ePatient reviews have become a powerful tool in shaping the reputations of healthcare providers, including surgeons. Research indicates that patients increasingly rely on online reviews to make informed decisions regarding their care. In a study evaluating online reviews of dermatology practices, patients placed significant value on physicians who demonstrated kindness and respect, conducted thorough physical exams, expressed empathy for the challenges of skin conditions, and were mindful of treatment costs.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Similarly, a study examining patients' online ratings of neurotologists identified the most influential factors as accurate diagnoses, quality bedside manner, sufficient time spent with patients, effective follow-up, and perceived helpfulness.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e While these healthcare-related factors contribute significantly to patient satisfaction and rating, it is important to acknowledge that non-healthcare factors, beyond the surgeon\u0026rsquo;s control, also play a similarly important role. A study by Johnson and colleagues, which analyzed 1400 survey responses from the offices of 11 orthopedic spine surgeons, identified several nonmodifiable demographic factors associated with higher patient satisfaction scores.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e These factors included older patient age, lower education levels, non-commercial insurance types, and demographic concordance between the patient and surgeon in terms of sex and ethnicity. These considerations underscore the multifaceted nature of patient satisfaction and suggest that online reviews may not depend solely on a surgeon's clinical abilities, but rather a broader range of factors, some of which are beyond the surgeon's direct influence.\u003c/p\u003e\u003cp\u003eResponse bias is a well-documented challenge in subjective reporting, affecting research findings across multiple domains, including healthcare, psychology, and consumer behavior. This observation aligns with findings from Nicolau et al., who demonstrated the presence of the halo effect in the hospitality industry.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Their study revealed that customer ratings of hotel attributes were significantly influenced by an overall predisposition, where positive or negative experiences in one area could skew perceptions of other, unrelated attributes. Importantly, they identified that negative variations in ratings, often referred to as the \"horn effect\", exerted a stronger influence on overall ratings than positive ones. The principle of negativity bias, described by Rozin and Royzman, suggests that negative experiences and evaluations exert a stronger influence than positive ones across various domains, including impression formation, memory, and decision-making.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e One key manifestation of negativity bias highlighted by the authors was negativity dominance, where the presence of both negative and positive factors in an evaluation leads to an overall more negative judgment. This principle provides a compelling psychological basis for our findings. The tendency of 1-star reviewers to rate other products and services more negatively may align with negativity dominance, suggesting that their inclination toward negative evaluations extends beyond healthcare experiences. Wetzel et al. highlighted extreme response style as a key factor in polarized rating behaviors, where individuals disproportionately select extreme rating options, such as 1-star or 5-star reviews, regardless of the actual quality of the experience.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e This aligns with our findings given 97.2% of reviewers provided surgeon with either a 1-star or 5-star review. In an observational analysis of 189,212 review, Han and Anderson describe online reviews often suffer from underreporting bias, as only customers with strong positive or negative opinions are motivated to post.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Further, they report that retailer-prompted reviews, such as hotels requesting feedback, help capture opinions from customers who would not otherwise post. Given the parallels between consumer and healthcare reviews, these findings suggest that surgeons and healthcare institutions may benefit from actively soliciting reviews from a broader range of patients to mitigate the effects of response bias and ensure a more representative assessment of surgical care.\u003c/p\u003e\u003cp\u003eOur study has several limitations that should be highlighted. First, the retrospective design of this study precludes establishing causality between patient rating tendencies and surgeon ratings. While our findings suggest a broader pattern in reviewer behavior, they do not confirm a causal relationship. This limitation is further compounded by the absence of demographic data, which has been shown to influence consumer review behaviors. Additionally, we focused exclusively on Google reviews, which may not be representative of patient reviews on other platforms such as Healthgrades or RateMDs, where different populations or review behaviors may exist. Another key limitation of this study is its exclusive focus on academic medical centers, which may limit the generalizability of our findings to private practice settings. Unlike academic institutions, where referrals often stem from established healthcare networks, private practitioners may rely more heavily on online reviews to attract new patients. As a result, patient expectations and rating behaviors may differ between these settings, with private surgeons potentially experiencing greater pressure to maintain high online ratings. Finally, while we categorized reviewers into 1-star and 5-star cohorts, we did not assess middle-range ratings, which may provide a more nuanced understanding of patient satisfaction and review tendencies. Future studies should aim to include a broader range of institutions, platforms, and rating categories to address these limitations.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study suggests that online surgeon ratings may reflect broader individual rating tendencies rather than exclusively healthcare-specific factors. Reviewers who gave 1-star ratings to surgeons tended to rate other products and services lower, while those who gave 5-star ratings were more likely to rate other products favorably. This pattern highlights the potential influence of personal rating biases on surgeon reviews, which may skew patient perceptions and impact provider reputations. For healthcare providers, understanding these patterns can inform strategies for interpreting online feedback, such as emphasizing review volume, incorporating patient education on rating systems, and integrating additional evaluation metrics like peer reviews and patient-reported outcomes. However, our study has several limitations that warrant further investigation. The retrospective design precludes causal conclusions, and the lack of demographic data limits our ability to account for other factors that may influence reviewing behavior. Future research should examine whether these trends persist across diverse healthcare settings and explore strategies to mitigate response biases in online healthcare reviews.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eVanderbilt University Medical Center (VUMC), Vanderbilt University Medical Center, University of Missouri (MU), University of Utah (UU), Boston University Medical Center (BUMC), and Emory.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cu\u003eEthics approval and consent to participate\u003c/u\u003e: This study was approved by the Institutional Review Board at Vanderbilt University Medical Center (IRB# 240706). Consent was waived due to the use of publicly available data.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConsent for publication\u003c/u\u003e: Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAvailability of data and materials\u003c/u\u003e: All data analyzed in this study were extracted from publicly available Google review profiles. Additional details are available from the corresponding author upon request.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCompeting interests\u003c/u\u003e: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eFunding\u003c/u\u003e: No external funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAuthors\u0026rsquo; contributions\u003c/u\u003e: AMA conceived the study design and oversaw data collection. KL helped with IRB submission and approval. OZ and BW conducted data collection and analysis. OZ and BW drafted the manuscript. JFB supported logistical tasks associated with the study. All authors contributed to longitudinal study support and critical revisions and approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAcknowledgements\u003c/u\u003e: No additional persons to acknowledge.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConflicts of Interest:\u003c/u\u003e\u0026nbsp; Dr. Abtahi receives institutional research support from Stryker Spine. Dr. Gardocki is a consultant and teaching surgeon for Joimax, a consultant for Arthrex, a teaching surgeon and consultant with royalties for Integrity Implants, and a consultant with royalties for Spineology. Dr. Stephens receives institutional research funding from Globus and has received institutional research funding from Stryker. Dr. Zuckerman reports being an unaffiliated neurotrauma consultant for the National Football League and a consultant for Medtronic.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHanauer DA, Zheng K, Singer DC, Gebremariam A, Davis MM. Public awareness, perception, and use of online physician rating sites. JAMA. 2014;311(7):734\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jama.2013.283194\u003c/span\u003e\u003cspan address=\"10.1001/jama.2013.283194\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi X, Chou SY, Deily ME, Qian M. Comparing the impact of online ratings and report cards on patient choice of cardiac surgeon: large observational study. J Med Internet Res. 2021;23(10):e28098.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLu W, Wu H. How online reviews and services affect physician outpatient visits: content analysis of evidence from two online health care communities. JMIR Med Inf. 2019;7(4):e16185.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFerreira DC, Vieira I, Pedro MI, Caldas P, Varela M. Patient satisfaction with healthcare services and the techniques used for its assessment: a systematic literature review and a bibliometric analysis. Healthc (Basel). 2023;11(5):527.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eO\u0026rsquo;Rorke E, Mauch J, Liu Y, Friedrich J. Essential elements of surgeon communication impacting patient satisfaction: a systematic review. Plast Reconstr Surg Glob Open. 2021;9(10 Suppl):e3916.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbtahi AM, Presson AP, Zhang C, Saltzman CL, Tyser AR. Association between orthopaedic outpatient satisfaction and non-modifiable patient factors. J Bone Joint Surg Am. 2015;97(13):1041\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2106/JBJS.N.00950\u003c/span\u003e\u003cspan address=\"10.2106/JBJS.N.00950\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBoudreaux ED, Ary RD, Mandry CV, McCabe B. Determinants of patient satisfaction in a large, municipal ED: the role of demographic variables, visit characteristics, and patient perceptions. Am J Emerg Med. 2000;18(4):394\u0026ndash;400. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1053/ajem.2000.7316\u003c/span\u003e\u003cspan address=\"10.1053/ajem.2000.7316\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJohnson BC, Vasquez-Montes D, Steinmetz L, et al. Association between nonmodifiable demographic factors and patient satisfaction scores in spine surgery clinics. Orthopedics. 2019;42(3):143\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3928/01477447-20190424-05\u003c/span\u003e\u003cspan address=\"10.3928/01477447-20190424-05\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSmith RJ, Lipoff JB. Evaluation of dermatology practice online reviews: lessons from qualitative analysis. JAMA Dermatol. 2016;152(2):153\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGoshtasbi K, Lehrich BM, Moshtaghi O, et al. Patients' online perception and ratings of neurotologists. Otol Neurotol. 2019;40(1):139\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNicolau JL, Mellinas JP, Mart\u0026iacute;n-Fuentes E. The halo effect: a longitudinal approach. Ann Tour Res. 2020;83:102938.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRozin P, Royzman EB. Negativity bias, negativity dominance, and contagion. Pers Soc Psychol Rev. 2001;5(4):296\u0026ndash;320.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWetzel E, B\u0026ouml;hnke JR, Brown A. Response biases. In: Furr RM, editor. Psychometrics and psychological assessment: principles and applications. Cambridge: Elsevier; 2016. pp. 349\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHan S, Anderson CK. Customer motivation and response bias in online reviews. Cornell Hosp Q. 2020;61(2):142\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Google Reviews, Reviewers, Orthopaedic, Surgery","lastPublishedDoi":"10.21203/rs.3.rs-7023085/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7023085/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eOnline reviews are increasingly influential in patient decision-making when selecting a surgeon. Although healthcare-specific factors are known to shape patient satisfaction, the potential role of non-healthcare-related predispositions in shaping online reviews remains underexplored.\u003c/p\u003e\u003ch2\u003eQuestions/Purposes:\u003c/h2\u003e\u003cp\u003e(1) Do individuals who leave extreme ratings (1-star or 5-star) for surgeons on Google tend to show similar rating behaviors when reviewing other products and services? (2) What is the difference in average rating behavior between these two reviewer groups?\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA retrospective observational study was conducted across five academic institutions, evaluating Google reviews of orthopaedic surgeons. The purposes were to assess if individuals who leave extreme ratings (1-star or 5-star) for surgeons on Google tend to show similar rating behaviors when reviewing other products and services, as well as determine what is the difference in average rating behavior between these two reviewer groups. Reviewers were categorized into two cohorts: those who rated surgeons 1 star and those who rated surgeons 5 stars. The primary outcome was the average Google rating provided to other services and products by these reviewers.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 1,629 reviewers of 160 orthopaedic surgeons were included, of whom 97.2% (1584) provided either a 1-star or 5-star rating. Individuals who left extreme ratings for surgeons exhibited consistent rating behaviors elsewhere, with 1-star surgeon reviewers giving a significantly lower proportion of 5-star reviews for other products and services compared to 5-star surgeon reviewers (59.7% vs. 81.9%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The average rating given to other products and services was significantly lower among 1-star surgeon reviewers than 5-star surgeon reviewers (3.7 vs. 4.5, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eOur findings suggest that patients who rate surgeons poorly may also tend to rate other products and services more negatively, while those who rate surgeons highly may exhibit a similar positive bias. These results highlight the potential influence of individual rating predispositions on online reviews, independent of healthcare-specific factors. Further research is needed to better understand how these tendencies affect patient satisfaction and to develop strategies for more objective review interpretations.\u003c/p\u003e","manuscriptTitle":"Impact of Patient Rating Propensities on the Online Rating of Orthopaedic Surgeons. A Retrospective Analysis of Google Reviews","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-12 01:14:16","doi":"10.21203/rs.3.rs-7023085/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0b2bb29d-c9e5-490e-a0ad-2f9e481a6d3c","owner":[],"postedDate":"August 12th, 2025","published":true,"recentEditorialEvents":[{"type":"decision","content":"Withdrawn","date":"2026-05-20T08:04:01+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-20T08:11:53+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-12 01:14:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7023085","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7023085","identity":"rs-7023085","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}