If you type the terms “San Francisco” and “plastic surgery” into the Google search engine — as countless people have —the first business that comes up is the San Francisco Plastic Surgery & Laser Center. Beneath the name of the business sits a short review: “Dr. Rajagopal is an excellent plastic surgeon. She is caring and experienced.” There's no source name attached.
A broader search for Rajagopal reveals countless positive reviews all over the Internet. She's apparently a “knowledgeable,” “truely gifted surgeon” with an “artistic eye” and access to “cutting edge” technology. On Citysearch, 30 out of her 32 reviewers have given her five stars, and numerous patients say there aren't enough stars in the rating system for a doctor of this caliber. She comes in on Sundays. She gives flowers to her patients at the end of their surgeries.
“Once you meet Dr. Usha Rajagopal, you'd wish she was your mother!” Rosie W. of San Francisco wrote in a Yelp review of the doctor. According to a review on one surgery forum: “if any of you are thinking of going to Dr. Rajagopal, go right ahead. She is top notch, and really knows what she is doing.”
There's just one big problem with all of these fantastic reviews directing readers to Rajagopal for medical procedures. It's impossible to know which of them — if any — were written by actual patients. In fact, some of the reviews appear to be classic cases of what's commonly referred to as astroturfing — ringing endorsements that look like a groundswell of support when in fact they are being paid for. The practice is named after Astroturf — synthetic carpeting designed to look like real grass.
While fake reviews intended to lure business certainly aren't exclusive to the medical industry, they seem considerably more insidious when the stakes can be life and death. No matter what the industry, publicly misrepresenting yourself in an attempt to bring in business is illegal under the Business and Professions Code in California.
But ever since doctor review websites sprang up in 2004, moderators have been dealing with fraudulent postings. The so-called reviewers sometimes make suspicious claims or over-the-top recommendations that seem unlikely to have come from real patients. Some reviews can be traced back to IP addresses in doctors' offices.
John Swapceinski, cofounder of RateMDs, says he's seen hundreds of incidences of what appear to be medical astroturfing. Because of the anonymity of the Internet, it is nearly impossible to tell who sat at the computer to post the misleading review. Maybe it was the doctor. Maybe it was the doctor's mother, son, friend, or all of them. Or maybe it was someone paid by the doctor.
In the case of Rajagopal, suspicions have been raised about a marketing professional hired to augment the surgery center's business by increasing its online presence. The marketing woman did a fantastic job of getting Rajagopal to the top of the Google rankings, but in doing so, she left behind a trail of evidence suggesting falsified patient reviews. According to a video Rajagopal made praising the marketing work, the woman's efforts may have steered numerous hopeful patients to Rajagopal's website and then into her office.
Some of Rajagopal's patients disagree about her purported capabilities, as does the Medical Board of California. Documents obtained from the board and San Francisco Superior Court show that some patients — who have not posted their stories in the comments sections — have been hurt by Rajagopal. In one instance, a 35-year-old woman who was undergoing a fairly routine plastic surgery didn't get the chance to tell anyone about the quality of the doctor's care. Due to what the medical board has called Rajagopal's “gross negligence,” the woman sustained a serious brain injury. She slipped into a coma, and never woke up.
It used to be that people found the goods and services they required through the Yellow Pages and recommendations from friends. Nowadays, they increasingly turn to the Internet for suggestions, even when it comes to something as serious as medical care. To find a local doctor, many people do Google searches, then look over the reviews that come up on top. Websites like RateMDs, Book of Doctors, Vitals, and HealthGrades have become popular. Yelp has also become a destination for those looking to gauge the popular opinion of local doctors.
“When shopping for a product or service, 73 percent of consumers use search engines to find local businesses from which to buy,” states the website of SF Web Consulting, the business Rajagopal hired. Pictured on that site, the red-headed owner and self-proclaimed SEO (search engine optimization) expert Tracy Rosecrans wears a bright smile.
“The Google algorithm? No mystery to us,” her website brags. “At SF Web Consulting, we know what it takes to be #1 … we'll get you to the top for the keyword search of your choice. Watch your brand new site take its place at the top of search results, and let the leads pour in.”
Understanding Rajagopal's online ascent first requires a visit to Rosecrans' YouTube page. That account, which Rosecrans admitted to creating under the screen name “trosecra,” establishes that Rajagopal is her client. A video posted on the trosecra account features Rajagopal describing how Rosecrans helped her business. “I'm Dr. Usha Rajagopal from SF Plastic Surgery and Laser Center,” she says in the video. “It's my pleasure to recommend Tracy from SF Web consulting. She has helped us tremendously.”
In the video, Rajagopal goes on to explain that over the last two years, her web presence has “skyrocketed,”which has brought in more business. “Most patients come from searching on the Internet or through word of mouth,” she says.
To get some idea of what Rosecrans was doing to elevate Rajagopal's web presence, search Google for “trosecra” and “Rajagopal.” Of the 15 or so hits that come up, many contain wildly positive reviews of the doctor posted by someone with the screen name “trosecra” on various websites. In some cases, trosecra claims to be a woman who had breast implants. In others, trosecra posts as a man who had surgery to reduce the size of his breasts.
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On Aug. 14, 2008, trosecra posted the following on SanFranciscoCitysearch.com: “Perfect Breasts!!!…Usha [Dr. Rajagopal] is an incredibly nurturing, warm person that loves what she does (and it shows!)…I always wanted to have breast augmentation surgery ever since I was 14, and it was the best decision!”
On Oct. 24, 2008, a posting appeared on Gynecomastia.org in which “trosecra” encouraged those with so-called man boobs to see Rajagopal. “I had gynecomastia procedure performed by Dr. Usha Rajagopal, and just wanted to let everyone know what a great surgeon she is,” trosecra wrote. “I was also recommended by a friend that was really happy with what a kind, experienced doctor she was. He gushed so much, I had to check her out.” The post also included before and after photographs of a man's chest: “I … felt so happy with the results, I thought I'd share them with everyone else.” Later, trosecra engaged with another user who was asking questions about the procedure. “Best decision I ever made!!” trosecra wrote. “Usha's a great doctor. I highly recommend her.”
Reached by phone for an interview, Rosecrans explained how she was able to raise Rajagopal's profile. “A lot of it is based on natural reputation and contacting websites and people who have worked with her,” she said. Rosecrans claimed she guides a process in which Rajagopal's office manager contacts patients after their surgeries and asks them to help promote the doctor.
When asked whether she ever contacted the patients or posted reviews herself, Rosecrans said no. “I don't post any reviews directly,” she said.
When asked why her screen name was attached to positive reviews of Rajagopal, Rosecrans changed her answer. “I did write one review for the doctor,” she said quietly. “That was because I actually went through a procedure with her.”
Rosecrans denied that she had ever posted as a man. “If you could forward that to me, it would be interesting to look at,” she said. The reporter did so, and asked follow-up questions about whether there was any explanation for Rosecrans' distinct screen name popping up with positive reviews for Rajagopal. She did not respond. Numerous calls and e-mails to Rajagopal and her lawyer also went unreturned.
One medical corporation has been formally caught astroturfing: plastic surgery franchise Lifestyle Lift. The medical corporation has about 40 locations across the United States, and was prosecuted last year by the New York state attorney general's office for instructing employees to pretend to be patients and spam the Internet with positive reviews.
The attorney general's office discovered the fraudulent reviews and fabricated websites purportedly started by patients of Lifestyle Lift, but was unable to prove the franchise was behind the effort until it subpoenaed corporate e-mails. They revealed how employees had been instructed by their superiors to pose as patients and send out fake reviews with the purpose of improving the reputation of the center. One e-mail told an employee to “put your wig and skirt on and tell them about the great experience you had.”
The employees started websites such as the now-defunct MyFaceliftStory.com, pretending to be satisfied customers who had nothing but wonderful things to say about their surgeries. “Ann” created a plausible-sounding journal about how she initially read horror stories about Lifestyle Lift online. “People were trashing Lifestyle Lift, their employees, their doctors, etc. I got scared and seriously thought about canceling my procedure,” she wrote.
Instead, Ann apparently did her own research in the waiting room, and found that the other patients were “pretty happy.” “Those negative stories did not add up at all,” she wrote. “Lifestyle Lift had done thousands of procedures, their doctors are board certified, and they have doctors from Harvard, Stanford, and all the top universities in the county.” She concluded that the negative stories were “made up” and had come from jealous doctors.
Of course, it turned out that Ann was the one who was made up.
“This company's attempt to generate business by duping consumers was cynical, manipulative, and illegal,” New York state Attorney General Andrew Cuomo announced in July 2009.
Lifestyle Lift received a $300,000 fine, and the franchise also agreed to take down the misleading web posts. “The case is believed to be the first in the nation aimed at combating astroturfing, a growing problem on the Internet,” Cuomo's office stated in a press release. The release also touched on the franchise president's excuses for engaging in the practice. Apparently he believed that negative Internet postings had hurt his company's reputation, and its success hinged on controlling what was communicated online.
In this case and others, though, it seems that the phony, glowing reviews are also used to cover an ugly reality.
According to the New York state Office of Professional Medical Conduct, one of Lifestyle Lift's doctors, Douglas Halliday, was charged last year with 10 counts of professional misconduct. One charge involved him injecting patients with what he told them was Botox but was in fact an unapproved drug. Halliday was put on probation and fined $20,000.
Here in the Bay Area, RateMDs' Swapceinski has seen hundreds of cases of obviously fraudulent reviews on his site, which can often be caught by an automated process meant to catch fakers. It “looks at things like IP addresses, cookies, the kind of browser the person uses, and how often the doctor was rated,” he says. “It goes through, and anything suspicious is deleted.” Readers of the site can also click on a red flag next to a posting and then explain why they believe the review should be deleted: “Sometimes they're able to prove to us that it's false, in which case we will delete.”
A search for Rajagopal at RateMDs brings up three anonymous reviews, all of which have given her perfect scores (five out of five) in each of four categories: staff, punctual, helpful, and knowledge.
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“Finally I have found a good plastic surgeon!…She did a great job fixing other doctors [sic] mistakes,” one reviewer wrote. “She actually operated on the right parts, what a refreshing change…She cares about doing a good job for the patient, not about her ego, unlike many of the male plastic surgeons. She is very sweet, knowledgeable…highly recommended!”
The next two reviews both complimented Rajagopal's artistry. “The Best in the Buisness [sic]!” one claimed. “Treats patients with care, comfort, and knowledge. Performs outstanding, if not miraclulous [sic], work and has a superior artistic side which helps to perfect a patients [sic] aesthetic desires.”
When brought to Swapceinski's attention, the last one struck him as phony. “Sounds like ballot stuffing,” he says. “I am going to remove it.”
There's no way to know whether those reviews were written by real patients, yet they are available to a very large number of readers. Swapceinski says his site gets about 1.1 million visitors per month, and has been growing between 50 and 100 percent each year since it was started in 2004.
Although Swapceinski and his colleagues have considered a variety of methods to keep reviewers honest, he says many were flawed. Requiring users to log in means only that they can do so by creating a throwaway Yahoo or Gmail address, which can be done in two minutes. Still, if a doctor ends up with a total of 25 or more ratings — which is considered “suspicious activity” on the site — users who want to rate that doctor are forced to log in.
Also suspicious: when the rating is written in technical language or discusses things patients wouldn't normally know, like the doctor's education, attendance at the latest conferences, number of procedures he or she has done, etc. Some reviews read just like ad copy.
“It's so blatant sometimes,” Swapceinski says. “I can look at the domain name of the IP address, and it will actually have a static IP with the doctor's office name right in it.” Although he sometimes wonders whether the patient rated the doctor while still at the office, he knows something is up when three reviews under different names appear from the doc's office in a matter of five minutes. “That doesn't look believable,” he says.
Despite how obvious the fakery may seem to be, it's nearly impossible to prove who's behind it. That's one reason the agencies in place to prevent fraudulent medical advertising — the Federal Trade Commission, state medical boards, and state attorney generals' offices — have seen very few of these kinds of cases.
California's medical board hasn't handled anything like the Lifestyle Lift case, according to spokeswoman Debbie Nelson. “We don't receive many complaints regarding false advertising,” she says. “But of the ones we do receive, many are physicians complaining about other physicians.”
Similarly, the state attorney general's office has not pursued cases tied to medical astroturfing, according to spokesman Evan Westrup. “If people are aware of these practices occurring in California, we encourage them to file a complaint with our office,” he says.
Mitchell Katz, a spokesman for the FTC, said his agency hasn't handled any of these cases either. He noted that it might be difficult to prove that advertising was unfair or deceptive if the identity of the person who posted it was unknown. Still, he says, “If you feel you have information about a person misrepresenting on the web … report that to the FTC. That could be a deceptive act in commerce.”
Katz's advice to consumers is to be wary of what they read, “especially when it comes to the web.”
There are places on the Internet where reliable information about doctors can be found. Those are the websites of state medical boards. A visit to the Medical Board of California's website and a search for Usha Rajagopal turns up some disturbing information. According to medical board documents, Rajagopal is on probation for making mistakes that put Nooria Aminy in a “vegetative comatose state.”
Starting around 2000, the 35-year-old Aminy had visited Rajagopal's office more than 10 times, according to the documents. Most of her procedures involved collagen and Botox injections. But on June 7, 2005, Aminy was scheduled for a surgery that would involve transferring fat from her stomach into her forehead. Apparently, after a brow lift that Rajagopal had performed, Aminy's forehead had been creasing between her eyebrows.
According to medical board documents, the first mistake Rajagopal made was to “advise the patient to eat on the morning of surgery, complicating her risks of nausea/vomiting, and respiratory arrest.” This is important during a surgery where the patient is given narcotics to alleviate pain.
Numerous drugs were used in Aminy's procedure, including lidocaine. The drug is described in the medical board documents as “a known cardiotoxin.” The documents also indicate that Rajagopal mixed four times too much lidocaine into a solution that was one-third of the usual volume, and she mixed that solution in a basin rather than the standard bag.
After Rajagopal injected the concentrated solution into the patient's stomach, Aminy got sick. “I feel like throwing up,” she told the doctor. Rajagopal put ice packs on Aminy's face and neck as the patient dry heaved. No nurse or anesthesiologist was present, and nobody was monitoring Aminy's vital signs. “This failure prevented early detection of an adverse effect of the narcotics,” the medical board documents reported.
When Aminy stopped talking and slipped into unconsciousness, Rajagopal requested a nurse. Then she told someone to call 911. When Aminy's vitals were finally recorded again, it became clear that her blood pressure had dropped and she wasn't getting enough oxygen.
When the paramedics arrived, Aminy's heart was slowing down. They used the defibrillator, but by the time she arrived at the hospital, she was comatose. The medical board documents say she sustained a severe anoxic brain injury, and would spend the rest of her life unconscious with a feeding tube.
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“This was done in a doctor's office, totally unequipped to handle an emergency,” Aminy's attorney, Bruce Fagel, said in a recent interview. “There was no anesthesiologist, no resuscitative equipment in her office. She [Rajagopal] had to call 911. It was a mess all the way around.”
On Oct. 7, 2007, the medical board accused Rajagopal of “unprofessional conduct through gross negligence with regard to her treatment of the patient.” On April 4, 2009, in the midst of Rajagopal's online marketing success, the accusation against her was resolved. Rather than take her case to a hearing, she agreed that the medical board could establish a factual basis for the charges, and gave up her right to contest them. In exchange, state regulators placed her on probation for three years.
During those years, Rajagopal is required to do 40 hours of educational programs aimed at correcting her “areas of deficient practice or knowledge.” She must take other courses and training programs, and must notify every hospital, physician's group, and malpractice insurer she was involved with of the board's findings. Rajagopal is also prohibited from supervising physician assistants. If she violates her probation, the board would have cause to revoke her license. Neither Rajagopal nor her lawyer responded to numerous requests for an interview.
In addition, three civil lawsuits against Rajagopal can be found in San Francisco Superior Court records, all involving the same type of claim. Patients say they received burns during laser hair removal in Rajagopal's office. Rajagopal denied wrongdoing in each of those cases.
Sharon V. got laser hair removal from one of Rajagopal's nurses back in 2001. Her neck was badly burned; two surgeries later, she still had a scar. “It was a huge horrible drama,” she says. “I've been scarred for life on my neck, right in the middle of the front.”
Chikako Ito sustained severe burns on her face, according to a legal complaint from 2004. The case was settled out of court. A third woman's case against Rajagopal was dismissed in 2007.
Sharon V. says she collected a $15,000 settlement, and used the money to open an art school for the disadvantaged in Mozambique. “I figured, you know what? I have extra cash now. I should do something good for someone else.”
Sharon V. found Rajagopal, she remembers, through a search on the Internet. She was shocked to learn the story of Aminy and of the rampant positive reviews. “I definitely think she needs to get her license revoked,” she says.
It is not common for a patient to die as a result of plastic surgery, according to a survey of more than a million procedures conducted by the American Society of Plastic Surgeons. The 2007 study found that out of every 100,000 office-based surgeries (as opposed to surgery in the hospital), about two resulted in a death. That's .002 percent. Most of the deaths were caused by the same complication: blood clots that resulted in pulmonary embolisms.
“The study shows that plastic surgery in accredited facilities is safe and that deaths are rare,” says surgeon Geoffrey Keyes, the study's coauthor.
That may be true, but the Aminy family's lawyer, Fagel, cautions patients about the other risks of undergoing surgeries in doctor's offices. For instance, there's uncertainty in how much compensation is available when something does go wrong.
“We did an asset check, and [Rajagopal] didn't have very much,” Fagel says. “She had a $1 million insurance policy, but for a victim that suffered a hypoxic brain injury, that was not very much.” Injuries like the one Aminy suffered — which require constant medical attention for the remainder of a lifetime — bring settlements of between $6 and $9 million, he said.
Although Fagel could have forced Rajagopal out of business and into bankruptcy, it wouldn't have done much for his client, he said. It made more sense to take the $1 million. “In most cases, where there is adequate insurance, we can make a substantial difference to the family,” he says. “This was one where we couldn't.” He calls Rajagopal's probation from the medical board “a slap on the wrist.”
With the money, Aminy's family placed her in a facility in Sacramento where the staff-to-patient ratio was extremely low, Fagel says. Yet things only got worse. “We had to watch her deteriorate,” says one family member who asked to remain anonymous. “What happened was really hard on the family.”
Aminy went through numerous operations, according to the family member. She had kidney failure and lung failure. There were many times when doctors were unsure whether she would make it through the night. More than two years after entering a coma, Aminy got pneumonia. On Aug. 11, 2007, she died, never having regained consciousness.
The family member was disturbed to learn about the praise of Rajagopal on the Internet, and angered about the concept of astroturfing, particularly when linked with medicine. “It's not like a hairstylist,” she says. “People's lives are in their hands. … Somebody else could die, too.”
Looking back over the rave reviews of Rajagopal, there's one exchange on Gynecomastia.org that may demonstrate the power of anonymous postings. Several users are relating their wonderful experiences with Rajagopal, and even urging others to travel from afar to see her. It was apparently enough to convince another user, “GPYY,” that Rajagopal was the doctor for him.
“Thanks to the website and the support of this community, I finally decided to do something about my gyne,” GPYY proudly announced. “I had my pre-op with Dr. Rajagopal yesterday and have a scheduled date of June 24th for the surgery…WISH ME LUCK!!!”
