Decoding Health Care

Part 31: Choosing a doctor

I always thought that since I was a doctor, when the time came and I needed a doctor myself, I would know just who to go to. After all, I had practiced in my community for many years and knew most of the physicians. It turns out that I was only partially correct.

I have an excellent primary care doctor. I met him when he was one of the very first hospitalists in the hospital where I admitted my patients. He was young and eager. He was also compulsive, thoughtful, and empathetic. I liked how he took care of my patients. When he decided to open his practice, I decided I wanted him as my doctor. That was 15 years ago. Over the years he has taken on more administrative responsibilities, and so my primary care has been delivered by his physician assistant. I made a good choice.

But when I decided to have my knee looked at, I went to an orthopedist that I had known for more than 20 years, mostly because I served on hospital committees with him. I had seen him once before, about 10 years ago, and had arthroscopy which went off without a hitch. But this time things weren’t quite as satisfying. For one thing, I waited over an hour in the waiting room and then another 30 minutes in the exam room. And when he came in, to say the evaluation was cursory would be generous. I know a little about medical billing based on level of service (complexity of care delivered), and I am unaware of any level of service that was fulfilled by that encounter.

His conclusion was that my problem was arthritis, that I needed to decide when I was ready for intra-articular injections and that I would ultimately need surgery. As it turns out he was right. But it sure didn’t feel that way at the time. It felt a little like he didn’t think there was much to talk about; when a fat guy limps into your office with knee pain, it’s a no-brainer. I was dissatisfied. I had chosen him because he had an excellent reputation in the hospital where I had worked. But I rarely shared patients with him, so I had never really experienced his bed-side manner.

What bothered me was that I had seen a lot of patients with osteoarthritis in my career. In fact, trying to tease out whether a cancer patient’s bone pain is due to metastasis or benign disease is really common and often challenging. My symptoms seemed to come on very suddenly and I felt the pain was pretty severe. I also had a knee effusion. So I decided to see a rheumatologist, again someone I had known for years from practice who I respected. I only sent him the patients I found particularly challenging and I was never disappointed. And when I became his patient, he was extremely thorough and communicated his thoughts very clearly. Ultimately, he concluded osteoarthritis was the diagnosis and that I should see an orthopedist.

This time, I asked him for a recommendation. More precisely, I asked him who he would go to if he were the patient. He did not hesitate. I did a little asking around, mostly of other people who had seen this orthopedist for the same problem, and the reviews were very positive. And that’s how I found my surgeon, who I have been very pleased with. He is direct but did a thorough job of describing my options and ultimately preparing me for surgery. He told me at the beginning, “You will know when it’s time for surgery.” He was totally correct.

Why do I spend such a long time telling this story? Because I think it is pretty typical. There is no doubt I had little or no idea how best to choose a doctor. I got it right sometimes and wrong others. And this is precisely the predicament most people find themselves in.

There is a remarkably sparse literature on how people pick their doctors. In fact, most of the “recommendations” come either from insurance companies or provider (physician groups, their consultants, or hospitals) organizations. The few studies that discuss their survey methods suggest that personal recommendations from either friends/families or other doctors weigh heavily (How Do Patients Choose Physicians? Evidence from a National Survey of Enrollees in Employment-Related Health Plans - PMC). In choosing hospitals, people feel reputation is important (National Evaluation of Patient Preferences in Selecting Hospitals and Healthcare Providers - PMC). At least one study suggests that people check their insurance coverage. One factor that rarely gets mentioned is how doctors or hospitals perform on quality measures.

Part of the reason that quality doesn’t enter into the equation is that there are so few quality measures publicly accessible. But there is some really interesting data on cardiothoracic surgical outcomes and the impact of reporting of data compiled by the Department of Health in New York. This data has been available since 1990 (https://www.health.ny.gov/statistics/diseases/cardiovascular/). The idea was simple. There was a lot of variation in CABG outcomes, so the goal was to report the outcomes so patients have a choice. What happened?

Not as much as you might hope for. On the one hand, public reporting led to improved cardiac outcomes over time (perhaps because the surgeons stopped doing really risky operations that had a bad outcome). But on the other hand patients did not necessarily go to the highest quality centers. Why? Because patients listened to what their cardiologists told them and the cardiologists did not always share this info with them (https://www.ahajournals.org/doi/10.1161/circoutcomes.113.000506). So transparency isn’t enough because other factors have such a strong influence.

There is some data however, that people are starting to look more closely at doctor information available on line. In fact, almost 2/3 of people look online before choosing a doctor (https://pmc.ncbi.nlm.nih.gov/articles/PMC6169945/#:~:text=Background,prior%20to%20a%20health%20consultation.) But 2/3 of these people don’t find looking online useful. What exactly are they looking for?

One thing they might be interested in are on-line reviews of physicians. This is not necessarily a good thing (https://pmc.ncbi.nlm.nih.gov/articles/PMC6526774/). Ask any physician what they think of their on-line grades. You are likely to get an earful. If you type into your search engine the question of whether on-line reviews are accurate, you will get one of two answers. If you look at the question from the perspective of the health care establishment, the answer is no, that there is poor correlation between grades and quality measures. But if you look at the answer from the perspective of patient testimonials, the answer is a resounding yes, that they are accurate. Why the disparity?

When you look at the physician or hospital grades that are positive, they often mention factors like wait times, convenience, and other non-quantitative aspects of the health care experience. They do not mention pathways or guideline compliance, or some other objective quality measure. And this drives doctors nuts. When I was in practice, the on-line grading sites were just getting established. I had very few grades. Some of them were very positive (“He’s a big teddy bear”) but I remember one particularly vituperative negative review. And I knew exactly the patient who submitted it, and I knew exactly why.

That patient who submitted the negative review was in a really bad place with an advanced malignancy for which there were no good options. They brought in reams of computer printouts for trials they weren’t eligible for as well as a number of unconventional treatment suggestions. I shot them all down. And I suspect I didn’t seem very open-minded. I communicated very poorly and wasn’t empathetic enough. I wasn’t medically wrong. My recommendations were evidence based. I recommended hospice. But that wasn’t what that patient needed from me at that time. I just wasn’t listening closely enough.

If you look at the reasons that patients choose to change doctors, there are a couple that stand out. One is that there is a bad or unexpected outcome. The other is that the physician failed to communicate: they didn’t listen, they didn’t explain, they didn’t give me the time I needed. I would argue that these two reasons are clearly related to one another. Interestingly, in an article from1957 (Thirteen Reasons Why Patients Change Doctors - PMC) that outlines why people change doctors, some still ring true today (not relieving symptoms or not communicating effectively) while others haven’t stood the test of time (and are almost funny by today’s standards, like prescribing bad tasting medicine, not showing adequate respect to the senior members of a patient’s family and not recognizing the patient outside of the office). But we should remember that poor outcomes and poor communication are also the reasons doctors find themselves in malpractice suits.

How best to choose a doctor isn’t immediately clear to me. It almost seems like a crap shoot for most people. In my experience, personal observation (or a recommendation from someone who personally observed the physician) has served me the best. Reputation was a terrible substitute. Which is curious because reputation is the primary mechanism for choosing where to go for a second opinion. Doctors hate when you ask them: “Who would you go to ?”. I heartily endorse asking this question. But also ask them why.

I definitely believe that more transparency regarding performance on quality measures would be helpful in promoting informed consumer behavior. Several important measures regarding hospital performance (and especially safety) are now available (https://www.cms.gov/medicare/quality/initiatives/hospital-quality-initiative/hospital-compare). We need more of that. Consumer on-line evaluations are like a lot of stuff on the internet; healthy skepticism is required.

In fact, I think healthy skepticism should be the recipe for how we approach much of what we read about medicine in the popular press. You cannot believe everything you read. That will be the topic of my next post.