Perspective: Finding a doctor – I know. You know. But the patient doesn’t have a clue.

By Charles A Pilcher MD FACEP
January, 2014

One of the toughest challenges for any health care provider is being asked “Who should I see for…?” by a friend or family member.

I have an answer. My fellow physicians have an answer. My nurse colleagues have an answer. Attorneys involved in medical malpractice, both plaintiff and defense, have an answer. But our patients usually don’t have a clue.

How does one find the “best doctor” for whatever ails one? If one doesn’t have a friend or family member who knows the medical community, one is relegated to using the internet, asking friends, or relying on one of many physician referral services.

The drawbacks to these approaches are obvious:

  • The internet – or formerly the phone book – are unreliable because they are infused with self-promotion.
  • Asking friends gives one an evaluation based on a statistical “n” of 1. Whether the patient was happy or not says little about the overall competence of the physician.
  • Using a referral service is flawed because most such services are either subscribed to by a physician for a fee, refer only members within an association’s ranks, or use a strict “rotation” system based on nothing more than, e.g., being on a hospital’s medical staff.
  • Even asking a respected med mal attorney who they would see gives a skewed answer. In my career as a medical expert, I know of defense attorneys who would never send a family member to a physician they have defended. Conversely, I have heard plaintiff attorneys praise their client’s physician as “highly respected –  I’d see him myself – but something bad happened this time.” Another “n” of 1.

Yes, the above approaches can work, but they are not the result of the physician’s overall record, experience and quality outcomes. Those have only recently begun to be 1) tracked and 2) published. And then – even within HMO’s or closed panel groups where care is supposedly “standardized” – quality and outcomes vary. Group Health has studied this for their own physicians. Despite a heavy emphasis on evidence-based medicine and peer/management pressure to practice to certain standards, their metrics vary both within a single clinic group and even moreso between specialty groups practicing in differing parts of the state.

So what is the poor patient to do? Only the fortunate few have the option of asking a trusted medical professional “Who would you see for… ?”

My personal approach for surgical procedures is to ask an anesthesiologist. They sit in the same room during the surgical procedure, evaluate the patients before and after the procedure, and see the same surgeon do multiple procedures. More importantly, they see multiple surgeons do the same procedure. If anyone knows surgical quality first hand, it’s an anesthesiologist. Then, once you find your surgeon, ask him or her which anesthesiologist he or she recommends.

A similar approach can be used for finding a doctor in a new town. One can call a few surgeons’ offices, explain that you are looking for a new primary care physician and ask the surgeon’s nurse or MA “Who does Dr. ________ refer patients to when they need a primary care doctor?” The name that shows up most often is a good bet. Note that the process can be reversed for finding a specialist.

As Kathleen Bartholomew RN wrote in an op-ed piece in the Seattle Times last year:

“It wasn’t fair that as a nurse I had inside information that the general public could not access. I knew which surgeon had the highest infection rates, and which one had the most complications. I knew the healing power of caring relationships and witnessed significant differences in bedside manner firsthand. I received incident reports when a doctor delayed returning a page in the middle of the night, or when a nurse failed to catch a deteriorating condition. I knew. We all did. But no one outside the hospital did.” She continues, saying “Want to know where bad stuff happens? Which hospital? You can’t. Such knowledge is top secret. Furthermore, you can’t discern the negligent acts from the accidents.”

Because physicians and other health care professionals are human, mistakes will occur. Our goal as professionals is to reduce the number of mistakes to as close to zero as possible. One way to do that would be to more broadly share information about medical mistakes, just like the FAA, NTSB, ALPA and aircraft manufacturers do in the airline industry. In order to reduce the chance of a similar mistake re-occurring, an immediate preliminary report followed several months later by a thorough investigative report is published to all who might benefit. That is transparency, and is a model to be emulated.

But, as Bartholomew says, “Health-care professionals are silenced by a rigid culture that refuses to admit that medical professionals make mistakes… Consider that when sued, hospitals and health-care providers almost universally demand a sealed record in any out-of-court settlement of a lawsuit. At all costs, the public must not know. This is a business that routinely pays hush money for accidental death and injury, and gets away with it.”

Can we in good conscience let this practice continue? Must we keep burying our mistakes? Would a “no fault” approach to tort reform help?


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