How to Judge Physician Quality
A recent report prepared for The National Bureau for Economic Research found that “The single most important factor (that explains regional variations in physician practices) is physician beliefs about treatment: 36 percent of end-of-life spending, and 17 percent of U.S. healthcare spending, are associated with physician beliefs unsupported by clinical evidence” (emphasis added).
And another recent report from the Dartmouth Atlas Project found that while use of hospice care for end-stage cancer patients has increased, most of that increase occurs in the last few days of life when it’s often too late for meaningful hospice care. It further found wide disparities among hospitals in use of hospice care and the alternative of expensive ICU care.
Today’s coverage of this report in The Boston Globe shows over a three-fold variation in the percentage of end-stage cancer patients dying in Massachusetts’ hospitals – from 13% at the non-profit North Shore Medical Center in Salem to 41% at the for-profit MetroWest Medical Center in Framingham.
These all suggest that the wide variation seen in physician practice behaviors is driven not by clinical evidence of what works best for the most patients, but by other factors. These include financial benefit to physicians and/or their affiliated hospitals (ICU care is the most expensive of hospital care). It also includes the aggressiveness of the local medical culture, which is itself generally driven by financial considerations (more aggressive treatments are more profitable for doctors and hospitals).
But how’s a patient supposed to factor these considerations into their own medical care? How’s a patient to judge whether or not their receiving the appropriate quality medical care or unnecessary care designed to fatten the wallets of their providers more than legitimately treat any real or suspected medical condition?
Who Are You to Judge Your Doctor?
Evaluating your physician is a tough one for many patients. Who are we, after all, to be judging our physicians – who generally have more education and skills than their typical patient?
Well, we’re the people entrusting our lives to them, and the lives of our family members. Yet most of us simply assume our doctors are competent and practicing quality medicine without any real basis for this often erroneous assumption. (The many factors contributing to physician under-performance are discussed in detail in Our Healthcare Sucks).
The obvious place to start is by eliminating any negatives, like prior lawsuits, licensure problems, or revoked hospital privileges. HealthGrades.com and similar websites can help you rule out physicians with questionable histories. State licensing boards (see healthguideuse.org/state_medical_boards.htm for links to state boards) are another source for such information.
Of course, you want more than the absence of negatives. Board certification in the doctor’s specialty helps assure physicians have met certain standards related to their specialty. The American Board of Medical Specialties provides an online means of verifying whether a physician is board-certified at abms.org or by phone at 1-866-ASK-ABMS (275-2267). You’ll need the full name of the physician to confirm board certification.
The “Bridges to Excellence” program is another measure of the commitment of a physician to improving patient care and of their effectiveness in doing so (see healthgrades.com for physician rankings).
Consider What Evidence-Based
Yet another way to assess the competence of your physician is to compare their treatment approach for your condition(s) with established clinical guidelines for these conditions. The non-profit Institute for Clinical System Improvement (icsi.org) is a recognized authority in this area and posts a number of clinical guidelines on its website. This can help you assess not just what your physician is doing with regard to your care, but whether he or she is not doing what clinical “best practices” suggest should be done.
Let’s look at just two of the most common medical conditions currently on the rise in the U.S. and other developed countries – type 2 diabetes and hypertension (high blood pressure) to give you an idea of how to apply this to your own circumstances.
If either of these conditions apply to you or a loved one, check off how many your doctor is currently using in your treatment regimen and how many are ignored or paid only lip service. Use this as your own personal medical “To Do” list to discuss with your doctor(s). It’ll improve communication with your doctor(s) and may positively impact your treatment regimen and avoid disease or disease complications.
Management of Type 2 Diabetes Mellitus*
Recommended Self-Management Program:
Education for self-management
Set Individualized Treatment Goals
A1C <7% and blood sugars at goal**(See note below)
Start or intensify statin dose
Blood pressure control: BP<130/80 mmHg (ACE inhibitors and ARBs are preferred first-line therapy)
ASA (aspirin)/antiplatelet medication unless contraindicated
Tobacco cessation if indicated
Ongoing Management and Follow-Up (Monitoring)
Monitor A1C every 3-6 months – review blood sugars each visit
Monitor blood pressure every visit
Monitor lipid profile yearly (cholesterol, triglycerides, etc.)
- Monitor liver enzymes every 3 months if on statins
- Annual assessment of complications:
- Targeted annual history and physical exam
- Specialist dilated eye exam
- Renal (kidney) assessment
- Comprehensive foot exam with risk assessment
- Cardiovascular and cerebrovascular complication assessment
If Treatment Goals Not Met:
Modify treatment based on appropriate guidelines
Consider referral to diabetes team or specialists
Assess patient adherence
Evaluate for depression
* Adapted and summarized (incomplete) from Health Care Guideline: Management of Type 2 Diabetes Mellitus. Nov. 2006, Amended May 2009. Institute for Clinical Systems Improvement. icsi.org.
** Recent evidence suggests the optimal HbA1c blood level for type 2 diabetics may be 7.5% and that those with levels under 6.4% actually had a 52% higher mortality rate and more heart attacks and strokes.
Hypertension Diagnosis and Treatment*
Confirmation of hypertension based on the initial visit, plus 2 follow-up visits with at least 2 blood pressure measures per visit
Standardized blood pressure measurement techniques (including out-of-office or home blood pressure measurements) should be employed
A thiazide diuretic is considered initial therapy in most patients with uncomplicated hypertension
Systolic blood pressure should be the major factor for the detection, evaluation and treatment of hypertension, especially in adults 50 years and older
Fewer than 50% of patients will be controlled with a single drug.
* Adapted from Guideline: Hypertension Diagnosis and Treatment.11/08. Institute for Clinical Systems Improvement. icsi.org.
Scoring Your Doctor
If you’re diabetic or have high blood pressure, how many of these steps does your physician use in your treatment? If 5 measures are recommended and your physician employs all 5, you’ve got a winner. 4 out of 5 is still acceptable, but you should ask why the 5th (missing) step is not being used in your treatment. Three or fewer steps in your treatment and you should start looking for another doctor.
You can visit icsi.org to review their guidelines for conditions that apply to you or your family.
Some doctors will resent your attempts to learn more about your condition and may even consider you questioning why they may not be following guidelines for your care as second-guessing their practice of the “art” of medicine. Good doctors, however, will welcome your interest and involvement and may have sound reasons for not applying a specific guideline to your particular needs.
If your doctor gets angry or upset with such initiatives on your part, take it as a raging “red flag” of probable incompetence.
Competent doctors aren’t defensive and should welcome your interest and help guide you to understanding why they’ve chosen to treat your condition as they have. They may even modify your treatment plan upon considering the relevant guidelines and the status of your condition(s).
Such open mindedness is generally a good sign of clinical competence and confidence.
 Survival as a function of HbA1c in people with type 2 diabetes: a retrospective cohort study. The Lancet, 375(9713):481-9. 2/6/10.