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Rhetoric Ahead of Reality: Doctor Ratings Not Useful Yet

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Most physicians are competent and able to take care of most of the problems patients present with.'  The standards for getting into medical school are high and for getting out are higher.  I think this call for patients to become experts in picking their doctors is overstated.''  - David Rovner, MD, Professor Emeritus, Michigan State University

Most? What does most mean?'  Can most doctors treat me for the flu? How about pancreatic cancer? Must I conduct the same type of research to choose a doctor to set my broken arm that I do to find one to treat my mom's congestive heart failure? Is the same level and type of research necessary to find a good surgeon as for a primary care clinician?

There are no easy answers to these questions. The steady stream of media messages and articles urging us to thoroughly check out any new physician we might consult stand in stark contrast to my colleague David's opinion. The release of the latest Top Doctors from the US News and World Report's Best series is surely a sign that, in a declining print media market, lists of superlatives still boost magazine sales. But reports like these do little to help us understand what is at stake in doing so or to figure out under what circumstances it is important. Rather, they assume that we are sufficiently anxious or cautious to dive into conducting research prior to making any and all doctor choices.

I remain dubious that many of us will ever rise up from our sickbeds, postpone getting our broken arms set or take the time when seeking a primary care clinician to conduct the type of research such articles recommend before we consult a new doctor. After all, we tend not to believe that the quality of our health care varies much and we trust physicians above other professionals. And, as Jim Jaffe, former Hill staffer and health policy blogger has told me, When it comes to medicine, most patients settle for good enough most of the time. If you can get adequate care within 20 miles of home, why fly 1500 miles to the Mayo or Cleveland Clinic?

Nevertheless, there is a small but growing number of us who, under some circumstances (like receiving a potentially life-threatening diagnosis), will attempt to follow the advice of journalists and try to gather information from a wide variety of sources to inform our choice of physician.

Here is what Angela Haupt, in How to Find the Right Doctor, an article included in the US News Top Doctors online edition, suggests we will find:

  1. Despite well-meaning efforts by US News and other physician rating services, determining ' '  the quality of care a physician delivers is still a crap-shoot. The best methodologies rely on indicators that may increase the probability that a physician delivers high quality care: they identify doctors who are smart enough to go to a good medical school, receive board certification and are friendly enough to be nominated by peers[i] or they adhere to evidence-based indicators, none of which say anything about how a given physician keeps up with the literature, their experience with innovations in their field or the way they relate to curious, active patients and their loved ones.

  2. Patient ratings of physicians will only be meaningful when those other than the angriest and most enthusiastic go to the trouble of rating their doctors. Until then, bias prevails. And the profusion of sites where the mad, the eager and a few otherwise committed people can express their opinion on specific physicians makes it difficult both to rate a specific physician or to find reliable, generalizable information on the patient perspective of our possible choices.

And of course, for the vast majority of the 661,400 physicians in the US, there is no rating information available at all.

So despite the updated collections of physician ratings and the advertising hype that surrounds them, most of us simply rely on the admittedly flawed but at least familiar methods of asking for referrals from our physicians and the recommendations of trusted friends and colleagues.

It's important to remember that any objective information we might now or ever use to inform our choice of physicians will only ever help us make the first cut, i.e., to identify or eliminate candidates. The match of personal style between a doctor and patient is completely subjective, equally important and no less challenging for many people to use to include in their decision making. As David Rovner also noted, A very important aspect of choosing a physician is finding one that you are comfortable talking to. And even more importantly, that you feel free to question the reasons behind their recommendations, and they can respond in language that is understandable to you.

Given the current lack of useful objective information, we should be wary of imprecations for us to thoroughly check out any doctor before we consult him. For many of us, the idea that we can pre-judge the competence of a physician is presumptuous. Many of us have yet to be convinced that our own actions have the potential to prevent errors or improve our prospects. Many of us lack sufficient understanding of how medical specialties are defined, how care is organized and how to judge the adequacy of it, making such inquiries impossible.

These are big barriers we must overcome if thoughtful, careful efforts to consider our choice of doctors are to become a normal part of our search for the health care we want and need.'  Urging us to seek information that barely exists, and when it does, is not meaningful, sends us on a fool's errand.'

We are not fools.  Don't waste our time.

 

[i]Read Paul Levy's snappy account of the 'information' on which reputational surveys are likely to be based.

 

 

More Blog Posts by Jessie Gruman

author bio

Jessie C. Gruman, PhD, was founder and president of the Center for Advancing Health from 1992 until her death in July 2014. Her experiences as a patient — having been diagnosed with five life-threatening illnesses — informed her perspective as an author, advocate and lead contributor to the Prepared Patient Blog. Her book, AfterShock, helps patients and caregivers navigate their way through the health care system following a serious or life-threatening diagnosis. The free app, AfterShock: Facing a Serious Diagnosis, offers a pocket guide based on the book. | More about Jessie Gruman


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Comments on this post
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Jim Jaffe says
August 11, 2011 at 5:13 PM

the basic problem is that they ask the wrong question. the important issue is who the worst doctors are, not the best. that's because the best will always be oversubscribed and hard to gain access to in any event and there's no great harm in going to someone a bit further down the list. but there's great potential harm in visiting the worst, who'll probably be incompetent and even dangerous. but no one's going to compile a list like that because it would be less appealling to the public and legally problematic. we consumers would benefit from an undifferentiated list of physicians who exceeded basic competence or adequacy. not going to hold my breath until that one appears.

dirk says
August 12, 2011 at 11:06 AM

"Many of us lack sufficient understanding of how medical specialties are defined, how care is organized and how to judge the adequacy of it, making such inquiries impossible."
this is a very serious dilemma with no easy solution, in a ideal world we would have something like ethnographic studies done on these systems, but that won't happen.
I worry that because of the ways in which such listings are all too close to very familiar product quality surveys they do more damage than good by oversimplifying the process/relationships and giving people a false sense of security/control that will leave them quite unprepared for the complexities/tensions to come.

Why Physician Ratings Aren’t Quite Adequate Yet - Better Health says
August 17, 2011 at 5:02 PM

[...] a good medical school, receive board certification and are friendly enough to be nominated by peers[i] â?? or they adhere to evidence-  based indicators, none of which say anything about how a given [...]

Why Physician Ratings Arenâ??t Quite Adequate Yet « health care commentaries from around the world says
August 17, 2011 at 8:04 PM

[...] *This blog post was originally published at Prepared Patient Forum: What It Takes Blog* [...]

Why Physician Ratings Arenâ??t Quite Adequate Yet « Health News Vault says
August 18, 2011 at 3:21 AM

[...] *This blog post was originally published at Prepared Patient Forum: What It Takes Blog* [...]

SusannahFox says
August 19, 2011 at 11:37 AM

Jessie, thank you for adding context & color to a topic that I think deserves attention.

I'll add some data. In a national telephone survey (yes, both landline & cell sample) conducted in September 2010, the Pew Internet Project found:

- 16% of internet users have consulted online rankings or reviews of doctors or other providers.

- 4% of internet users have posted a review online of a doctor.

The more interesting insights emerge when we look at certain groups:

- 21% of online caregivers consult online doctor reviews, compared with 13% of internet users not currently caring for a loved one.

- 18% of internet users living with one or more chronic conditions have looked online for doctor rankings or reviews, compared with 14% of internet users who report no conditions. 6% of internet users living with chronic disease have posted such a review, compared with 3% of those who report no conditions.

These differences are statistically significant, but more importantly, they are significant because of the context of who is most likely to be a frequent health care consumer: someone living with a chronic condition.

- Internet users living with disability do not report a higher or lower likelihood to consult doctor reviews. However, they are more likely than other internet users to post reviews of doctors and other health professionals online: 8% do so, compared with 4% of those who report no disability.

All of this data was published in a report, "The Social Life of Health Information, 2011" which is available for free, along with the full data set:

http://www.pewinternet.org/Reports/2011/Social-Life-of-Health-Info.aspx