Personal Business: HEALTH AFTER 40
TAKING THE PAINS TO CHOOSE THE RIGHT M.D.
In a time of rapid change, increasing complexity, and myriad options in the
health-care industry, this is how I found my primary-care doctor: Sorting through the spartan list of physicians in my employer's managed-care network, I circled one who practiced near my office and could admit patients to a hospital I had heard of. In all, I dedicated about as much effort to the endeavor as I would to buying a toaster oven.
An educated consumer? Hardly. "The way most people go about choosing a physician is totally wrong," says Gary Schine, who operates a medical database search service. Coddled by a tradition of paternalistic doctor-patient relationships and by health insurance that until recently blindly paid all the bills, Americans haven't figured out that consumerism has its place in medicine.
Slowly, this is changing. Patients are learning more about health care--in part, because employers are obliging them to pay more of the costs. The inexorable rise of managed care is forcing many Americans to choose new doctors and providers to compete for our business. Yet finding the right medical care may be tougher than ever. Substantive comparative data that can help consumers choose practitioners remain the exception--leaving most people to rely on frustratingly subjective criteria. Meanwhile, health-maintenance organizations and preferred provider networks have narrowed the field from which many people can choose.
Consider: For generations, Americans started their search with recommendations from family, friends, and work associates. "Our philosophy is, get as many names as you can from as many different sources," says Michael Donio, director of projects for the People's Medical Society, a consumer advocacy group in Emmaus, Pa. The problem is, Uncle Harold's cardiologist probably isn't in the network of physicians fully covered by your employer's health plan.
So in the managed-care world, the hunt must be targeted. Look for recommendations among co-workers covered by the same medical plan. And if your current physician can't or won't join your insurer's network, he or she may be able to point you toward colleagues who have signed on.
In some cities, useful new publications can aid the initial search. Health Pages, started last year, is a chain of magazines currently published three times a year for the Boston, St. Louis, Pittsburgh, Atlanta, and Cincinnati/Dayton areas. The publication (212 505-0103) will be tailored for at least five more cities this year. Each issue contains partial listings of providers for certain specialties, with education, years of experience, hospital affiliation, and insurer network participation. The guide also reports prices for key procedures, based on doctors' responses.
Health Pages doesn't attempt to rate or recommend physicians. But How to Find the Best Doctors for You and Your Family (Castle Connolly Medical Ltd., $21.95) does. Available so far only for the New York City area, this book reflects a survey of 15,000 physicians, nurses, and hospital executives who were asked to name the best doctors in every specialty and subspecialty. Although it lacks input from consumers, the book is an impressive undertaking.
HOMEWORK. Absent such arbiters, you can undertake your own investigation. Check out a doctor's credentials, starting with medical school and residency. American medicinal schools generally have higher standards and more stringent admission requirements than foreign institutions. But residency programs, which prepare med-school graduates for specialties, are harder to call: While so-called teaching hospitals attached to universities often have the best residencies, quality can vary widely among specialties. Likewise, doctors' current hospital affiliations attest to their standing: Well-known medical
centers are likely to have higher standards for their staffs.
Make sure doctors are board-certified in their specialty by calling the American Board of Medical Specialties (800 776-2378) or checking the Directory of Board Certified Medical Specialists, available in larger libraries. Check, too, with your state health department for disciplinary actions taken against the physician. 10,289 Questionable Doctors, published by the Public Citizens' Health Research Group (202 833-3000), lists doctors who have been disciplined by state.
For a primary-care physician, the so-called gatekeeper you will rely on for the majority of basic care, the most important considerations for many patients will be convenience and bedside manner. But the hunt for
a specialist can take more work. Board certification becomes even more important, as does the date of the last recertification. Medical research moves quickly, and a specialist who hasn't been recertified in 10 years or is not affiliated with a teaching hospital may be unfamiliar with
new treatments. Patients with serious illnesses may want to seek out doctors who have authored academic studies on leading-edge treatments.
Managed care, of course, makes this sort of investigation problematic: The top experts in highly specialized fields probably won't appear on your HMO's list of approved providers. More often, you will rely on the recommendation of your primary-care doctor, who may not have had contact with the specialist in question. Insist on more than one referral, and be prepared to seek care outside your network if none of the referrals proves satisfying.
After narrowing your search to a few candidates, call each doctor's office and request an informational interview. As competition for new patients intensifies, more physicians are agreeing to such get-acquainted sessions at little or no charge. Some HMOs, such as Boston's Harvard Community Health Plan, arrange open houses where new members can question staff physicians.
What to ask? Get the basics: education, hospital affiliations, office hours, and fee schedules. More important, try to determine how comfortable you are with this person. Does he or she listen? Does the interview seem rushed? Do your personalities fit? In the end, personal rapport "has a tremendous bearing on the quality of your care," says John Connolly, publisher of the Castle Connolly guide and former chief executive officer of New York Medical College. If you like your doctor, you're more likely to schedule visits when you should and accept the prescribed care.
To many patients, the gut-feel assessment alone won't be satisfying. Consumers should be able to judge which doctors are best at their jobs--to analyze the quality of their surgery, the recovery rate of patients, the relative charges for their services. Hospitals, HMOs, and state organizations only recently have begun to develop measures of performance, largely in response to pressure from employers and insurance companies. In most cases, though, ratings for doctors aren't available to consumers, a reflection of widespread resistance within the profession.
"QUESTION OF CHOICE." One HMO, US Healthcare, has bucked the system. It offers a toll-free service providing members the results of patient surveys for each of the network's 6,500 physicians. The reports provide patient assessments of accessibility, empathy, and overall care, as well as a summary of the HMO's internal rating based on medical chart reviews.
When the service started a year ago, US Healthcare's phone lines were jammed. Small wonder: This is exactly the information people are seeking. "It's an important question of choice," says Neil Schlackman, the HMO's medical director. In large part, America's health-care system still discourages this sort of choice. For now, finding the right care takes a bit of homework--and too much guesswork.
Quizzing Dr. Right
More doctors are agreeing to introductory interviews with prospective patients. Here's what you should ask:
CREDENTIALS When was the doctor last recertified in his or her specialty? The more recent, the better. Which hospitals can he or she admit patients to? Affiliations with big medical centers are a plus. An academic appointment to a well-known medical school, or fellowship in a top medical society, such as the American College of Surgeons, can indicate professional achievement.
LOGISTICS Will the doctor see you on nights or weekends? Are house calls possible? More important, will the physician answer questions over the phone, rather than require an office visit? Is he or she part of a group practice and, if so, will others occasionally be caring for you? What sort of payment does the practice accept?
COMFORT Briefly describe your main medical concerns. Is the doctor attentive and supportive, encouraging discussion? Does he or she share your views on abortion, life-support, or other moral questions? If important, does the physician speak your native language and understand your cultural background? Finally, how long did you sit in the doctor's waiting room?Keith Hammonds