In Search of a Good Doctor
By PAULINE W. CHEN, M.D.
http://www.nytimes.com
In response to my recent column on patients trusting doctors too much, several readers wrote in about the difficulty of finding or sifting through information on doctors and diseases. Many asked for suggestions, so a couple of weeks ago I contacted several nationally respected leaders in family medicine, pediatrics, internal medicine, oncology, surgery and anesthesia and asked them to share their advice on researching doctors and diseases.
Many of the doctors I spoke to or exchanged e-mail with made commonsense suggestions that were not unexpected. They urged patients to find out which doctors their closest friends really like, to ask a prospective doctor questions like how much experience he or she has with a specific condition or operation, and to make sure that as a patient you feel part of a shared decision-making process and comfortable saying how you feel, or that you don’t understand or that you respectfully disagree.
But many of the physicians also shared links to valuable Web sites, several of which I was unfamiliar with. All the sites are free to the public and accessible to anyone with an Internet connection. When I looked at these sites while writing this column, I became really excited as a patient about the amount of information available. For example, one site from the Department of Health and Human Services called Hospital Compare (www.hospitalcompare.hhs.gov) allows you to select three hospitals within a 25-mile radius of your home. It also lets you compare a wide variety of quality indicators, like the percentage of heart failure patients who were given discharge instructions, the percentage of surgery patients given prophylactic antibiotics at the right time, or the percentage of hospitalized patients who felt that doctors or nurses “always� communicated well (the differences among hospitals surprised me).
And according to several of the doctors I spoke with, the amount of information available to patients will only increase in the future.
Throughout our conversations and e-mail exchanges, every one of the doctors stressed the importance of patients doing research and becoming an active part of the medical team. “This is a shared responsibility between the physician and the patient for the patient’s health,� said Dr. Ted Epperly, president of the American Academy of Family Physicians.
Dr. Lisa V. Rubinstein, president of the Society of General Internal Medicine, said that sharing in decision-making “will help raise the quality of care given by any clinician, because it will sharpen the focus on the key decision points and help the clinician put a plan in place that the patient understands and agrees with.�
Here is a summary of these experts’ advice and the Web sites they use themselves and recommend to patients, friends and family.
Choosing a Doctor
All the doctors I contacted stressed the invaluable contribution of a good primary care doctor in helping patients identify specialists or other physicians. “I cannot emphasize enough how important it is for every patient to have a trustworthy primary care physician who can help them navigate our challenging, but potentially excellent, health care system,� said Dr. David T. Tayloe Jr., president of the American Academy of Pediatrics.
Primary care doctors can identify qualified subspecialists through local and national networks or professional organizations. “Even for a patient in a distant city,� Dr. Rubinstein said, “I can usually find a local respected colleague who knows someone in the general area.�
When a primary care doctor does not have a recommendation or when the patient does not have a primary care physician to turn to, Dr. Rubinstein advised identifying high quality medical groups or hospitals that “carefully monitor the quality of the clinicians affiliated with them� and that provide “decision support, continuous quality improvement and continuing education to keep their clinicians functioning well.�
Data on hospital and medical group quality is more readily available to the public than information on individual physicians, and Dr. Rubinstein offered several Web sites (see below) that patients can use.
One way to help assess the quality of individual physicians is to establish that a doctor is board certified, Dr. Epperly said. To become board certified, doctors must complete a full residency at an accredited training program, pass written and, depending on the specialty, oral examinations, and provide proof that she or he has experience with a defined set of clinical problems and technical procedures. However, cautioned Dr. Roger A. Moore, president of the American Society of Anesthesiologists, “board certification is one indication, but it’s certainly no guarantee.�
Another way to get a sense of physician quality is to contact the national professional society for that doctor’s specialty.
“There is lots of good information at professional societies compared to years past,� said Dr. Thomas R. Russell, executive director of the American College of Surgeons. “On our Web site, for example, you can go look at a surgeon’s profile and see what they do.�
A breast cancer patient can, for example, find out if a recommended surgeon has a practice devoted exclusively to breast disease versus a more general practice. Or a patient with a colon mass can choose a surgeon who is not only board certified in colorectal surgery but also has a special interest in laparoscopy, or minimally invasive surgery.
Generally, membership in the national professional society of a specialty — often referred to as being a “fellow� in the organization, as in Fellow of the American College of Surgeons, or F.A.C.S. — requires board certification and a certain degree of clinical experience. Many physicians will denote their specific society affiliation after the M.D. in their name; for example, if the doctor is a fellow of the American College of Physicians, the national professional society of doctors specializing in internal medicine, his name might appear as “Joseph Smith, M.D., F.A.C.P.�
The advice of close friends and colleagues can further help to distinguish among doctors. “I suggest that people first identify the hospital where they wish to be admitted,� said Dr. Jeffrey P. Harris, president of the American College of Physicians. “Ask the hospital for a list of board-certified internists with admitting privileges. Then ask trusted friends, neighbors and colleagues whom they see and feel comfortable with.�
The last — and most critical — part of deciding on any physician is the first appointment. Most of the doctors I contacted unequivocally stated that patients should know what to expect and arm themselves with the right questions. And, as Dr. Rubinstein said, bedside manner is only one of many concerns. “While excellent quality health care integrates caring with doing the right thing medically,� she said, “a caring attitude can mask poor quality medicine.�
Dr. Richard L. Schilsky, president of the American Society for Clinical Oncology, recommends that cancer patients meeting an oncologist for the first time ask about board certification in the specialty needed, length of time in practice, experience with the patient’s specific problem, membership in professional organizations and participation in clinical trials.
If the patient is meeting a surgical oncologist for the first time, Dr. Schilsky recommends also asking the surgeon about the number of times annually she or he performs the specific operation needed, as well as the hospitals in which those operations are performed. While it is difficult to specify a standard number patients can keep in mind, research has shown that hospital mortality rates are lower when those operations are performed frequently.
Some individuals may feel uncomfortable questioning their prospective doctors, but becoming more active and knowledgeable can only improve your care. There is even a nonprofit group, the Foundation for Informed Medical Decision Making, devoted to educating patients to become more involved in their health care decisions (see below).
Researching Your Condition
All the doctors I spoke with urged patients to exercise caution when going through information from commercial or industry Web sites.
“The Web can be a good place but also a dangerous place,� Dr. Epperly said. “It’s important to find sites that aren’t biased and that provide evidence-based information.�
Many of the doctors suggested going to sites supported by patient advocacy groups or nonprofit groups that are focused on certain diseases. Such sites often offer not only information but also active online communities.
Almost all of the national professional societies now have part of their official Web sites devoted to patients. These sites and links are excellent sources of information on the illnesses treated by that specialty and, in the case of surgical or anesthesia professional organizations, the procedures performed.
“Our specialty site, familydoctor.org,� Dr. Epperly said, “aims to help meet patient needs on common afflictions in this country. The content is written by experts and presented in a way that people without medical training can understand.�
Finally, several of the physicians also recommended several federally sponsored Web sites as excellent resources.
Web Sites
The following is a compilation of recommendations from the physicians mentioned in this column. It is by no means exhaustive but should provide a starting point for those interested in researching their doctors or conditions.
Decision Making:
1. Foundation for Informed Medical Decision Making: This site (www.informedmedicaldecisions.org), endorsed by the Society of General Internal Medicine, offers information and tips on how patients can become more actively involved in the medical decision-making process and get the care that is right for them.
Researching on the Web:
1. Medical Library Association: The Medical Library Association has compiled a guide (www.mlanet.org/resources/userguide.html) to help individuals sort through the myriad offerings on the Web. Included is an M.L.A. “Top 10� most useful consumer health Web sites.
Researching Physicians and Hospitals:
1. State boards of medicine: State medical boards can provide information regarding a doctor’s licensure, training and history of disciplinary action.
• The New York State Board for Medicine (www.op.nysed.gov/) and, in New York City, the New York County Medical Society (www.nycms.org).
• To locate other state boards, the American Medical Association provides a listing. (www.ama-assn.org/ama/pub/category/2645.html)
2. The American Board of Medical Specialties (www.abms.org/): The A.B.M.S. has a doctor-finder function that will pull up a physician’s board certification.
3. The Agency for Healthcare Research and Quality (www.talkingquality.gov/compendium/index.html) : The A.H.R.Q. has compiled health care “report cards� that provide comparative information on the quality of health plans, hospitals, medical groups, individual physicians, nursing homes and other providers of care.
4. The United States Department of Health and Human Services, Hospital Compare (www.hospitalcompare.hhs.gov): This site provides information from participating hospitals on how well those hospitals care for patients with certain medical conditions or surgical procedures. Also included are the results from patient surveys on quality of care during hospital stays.
5. State of California Report Card (www.opa.ca.gov/report_card): This site, from the California Office of the Patient Advocate, provides report cards of various health insurance plans, medical groups and doctors in California. Some other states have similar sites.
Researching a Disease, Condition or Procedure:
1. National professional medical societies: Below is a sampling of some of the larger national societies. Many societies have sites specifically designed for patients.
• American Academy of Pediatrics (www.aap.org)
• American Society of Anesthesiologists (www.asahq.org)
• American College of Physicians (www.acponline.org)
• Society of General Internal Medicine (www.sgim.org)
• American Society of Clinical Oncology (www.asco.org)
• American Academy of Family Physicians (www.aafp.org)
• American College of Surgeons (www.facs.org)
• American College of Obstetricians and Gynecologists (www.acog.org)
2. Medline Plus: Supported by both the National Library of Medicine and the National Institutes of Health, Medline Plus (www.medlineplus.gov) offers patients an array of information on health topics, drugs and current news. In addition, there are interactive tutorials, surgery videos, health information for older adults and links to clinical trials and health information for older adults.
3. Centers for Disease Control and Prevention: The C.D.C. (www.cdc.gov) is an excellent patient resource for communicable diseases and preventive and public health.
4. The American College of Physicians Foundation: In conjunction with the American College of Physicians, the ACP Foundation (foundation.acponline.org) offers succinct and clear health information for patients.
5. For cancer patients: There are three Web sites that can serve as excellent starting points:
• The National Cancer Institute (www.cancer.gov)
•The American Cancer Society (www.cancer.org)
• The American Society of Clinical Oncology (www.cancer.net)
6. My HealtheVet: Veterans, their advocates and employees of the Veterans Health Administration have access to extensive quality information and patient education resources through this site (www.myhealth.va.gov), from the Department of Veterans Affairs.
To share your thoughts, join the discussion on the Well blog, “Doctors’ Favorite Medical Web Sites.�
