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The Limits of Physician Referral in Finding a New Doctor

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I've always assumed that the best way to find a new doctor or specialist – preferably within my health plan – was to rely on the advice of a doctor whom I know and trust, who knows my health history and understands what kind of expertise my condition requires. Recently, I have come to question that assumption.

Last year, my primary care doctor referred me to two specialty physicians to provide care for different aspects of my newly diagnosed metastatic lung cancer. Despite impeccable training credentials, prestigious positions and high marks from their peers, I fired both of them: one when he refused to discuss my treatment preferences and the other because he repeatedly forgot my diagnosis and recommended treatments made impossible by my condition.

That's a lot of firing for one person in such a short time, especially since I don't take doctor-firing lightly. I started those relationships with every intention that these physicians would be with me for the duration. Ending them involved a lot of self-doubt, research and trial-and-error communication before I made the decision to seek care elsewhere.

Clearly something went wrong. What?

The larger context in which we search for the right doctors to care for ourselves and our families is not encouraging. Reports of variations in the quality of health care, the under- and over-use of tests, and the frequency of medical errors are in the news frequently, framed by the notion that "we are all consumers now." It's no wonder that some of us have become more vigilant about which doctors we consult.

But our need for help with choosing good physicians has not yet resulted in more or better information with which to shape our choices. In an essay late last year, Carol Cronin, the executive director of the Informed Patient Institute, reviewed the current status of public reporting on the breadth and depth of information about physician quality and observed that it is spotty, often irrelevant to the decisions we are making and usually reported on a medical group basis. With so little objective information available, where do we turn to find the right doctor?

Referral by one's own doctor is probably the best bet, right?

Vikas Saini, cardiologist and president of the Lown Foundation in Boston, shared his perspective on physician referral: "It's amazing how difficult it can be for a doctor to decide whom to send one of his patients to. If you've trained at the place where you practice and have colleagues you've known for years, it is easier. But even in that case, I never really know how technically good a surgeon is in the OR, for example. Sometimes I have to ask around – residents, fellows, OR nurses and anesthesiologists who scrub in will often know – but you have to have a close personal relationship for them to talk. Feedback from patients helps, but there is no systematic way for them to tell me except at a next visit, and often that's so busy I won't know unless the patient volunteers something, which they do in the extremes of good or bad. 'Thank you for sending me to ____; she was wonderful!' or 'I never want to see that person again!'"

Physicians, then, are in much the same boat we are. They may be able to read more into the educational and training credentials of their colleagues than we do, they may be aware of egregious shortcomings and undoubtedly they know more about their workplace habits and their golf scores. But in the absence of physician-specific quality measurement and reporting (even as blunt an instrument as it currently is), our doctors are making guesses – some more educated than others – about the knowledge and skills of their colleagues.

Am I making a mountain out of a molehill here? David Rovner, a retired endocrinologist and professor at Michigan State University, thinks I am: "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."

Hard to say if he's right. We consult different kinds of physicians for different needs. Our desire for high-level expertise and a compatible partnership varies with those needs. Sometimes we seek a time-limited fix, sometimes we're looking to be followed over time with non-urgent occasional contact, and sometimes we need highly specialized, intensive monitoring and treatment. Certainly our sense that we should become experts on picking our doctors varies with the condition in question. And there is no doubt that when we seek the best pediatrician for our newborn or the best cardiologist after our father's massive heart attack, we should be able to rely on more than the inference afforded by credentials and the educated guesses of our referring physicians.

I told my referring physician about both of his unsuccessful referrals. His response echoed Dr. Saini's: "Both of these doctors came through great training programs, have amazing credentials and are in leadership positions at this very prestigious institution. I don't know them very well; they seem like really nice, smart guys. I really have no explanation for the errors in judgment they made, but I'm grateful to have this information. There's no way to know these things about your colleagues unless your patients tell you."

The quality of care that physicians deliver has always varied widely. The thing that has changed is that now we – the recipients of that variable quality care – know that it varies. Unfortunately, that change hasn't been accompanied by the measurement and reporting of quality, so neither we, our referring physicians, nor physician employers have real objective data to guide individual and collective choices. Historically, I have trusted in referrals by trusted physicians to compensate for this lack. And while physician referral certainly plays an important role in finding the right doctor, it is far less reliable than I thought or hoped.

For us, choosing our physicians – should we be lucky as to have the latitude to do so – is yet another example of where the market model of health care falls short. Patients and families find themselves needing to act as educated consumers of health care with scarce tools or guidance to do so effectively.

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


Tags for this article:
Health Care Quality   Cancer   Inside Healthcare   Medical/Hospital Practice   Patient Engagement   Health Information Technology   Jessie Gruman   Find Good Health Care  


Comments on this post
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Nancy Anderson says
January 29, 2014 at 9:49 PM

Fascinating and disturbing in equal measure.

Perhaps you could share with your readers how you found the right doctor(s) in the instance.

Josh Seidman says
January 30, 2014 at 3:08 PM

Your post also illuminates better what we need to measure more of going forward. David Rovner and your referring physician are probably (for the most part) right in terms of the technical skills, which helps us to identify where quality measures can be used to unmask the much greater variation that exists among providers -- e.g., in your case, ensuring treatment recommendations are personalized to individual needs, and willingness to discuss treatment options (see new Cochrane study on decision aids regarding importance of the latter).

Ileana Balcu says
January 31, 2014 at 5:20 PM

I am firmly convinced that we need to convince doctors to start showing up on social media, not with content bought from others or filled in by medical students, but with their own unique opinions and takes on things, just like Howard Luks, Bryan Vartabedian, Wendy Swanson.

This is how we know who a doctor is. If we can push enough of them to be present...

Even if I don't agree 100% with all that a doctor says at least I know where they stand if they share on social media.

Better measures are good, evaluations are good, but we also need descriptive information from patients, other doctors and the doctors themselves.

Marilyn Mann says
January 31, 2014 at 8:36 PM

I've had similar experiences. My internist has referred me to specialists that I ended up having to fire. It's distressing when it happens and can waste a lot of time and energy.

Komrad says
September 5, 2014 at 11:56 PM

I haven't been to a doctor for over a decade, but I've recently decided to start getting annual checkups. I have no information about doctors in my area outside of search results on the Web. There is no qualifying information included with the results that I can use to differentiate one PCP from another.

Wish me luck!