Sunday, January 11, 2009
Medical quality is like pornography, it's hard to define but we know it when we see it. Every participant in the health care arena - physicians, pharmacists, insurance companies, hospitals, pharmaceutical companies, our government and the public - all support the mission to enhance medical quality. What paralyzes the effort is that no one agrees how to get there or even how to accurately measure medical quality. You can test this yourself. Ask your friends and relatives about the quality of their physicians. You will likely receive glowing testimonials about their 'excellent' physicians. Yet, if you ask the important follow-up question, How do you know your doctor is so good?, then your smooth talking neighbor may start stuttering. Don't be too hard on him. If quality experts can't figure out how to assess medical quality, then I doubt that your neighbor or your Aunt Mathilda can do better.
Here's a sampling of tips from 'experts' on how to select a high quality physician. After each of their recommended questions to ask, I will comment in italics to provide a tincture of skepticism.
Is your doctor is board certified?
While board certification is of some value, in no way does it guarantee that the physician is a high quality practitioner. In addition, most physicians today are board certified anyway as most hospitals and insurance companies require it. If I am a decent physician, it has nothing to do with my board certification status. Nevertheless, many patients like to see certificates on their doctors' walls. Take a closer look at them. From a distance, you might not realize that they are for bowling tournaments, barbecue contests and dance marathons.
What is your doctor's complication rate for the procedure he is proposing?
First of all, he may have no idea what his complication rate is. I certainly don't know what mine is. Additionally, operations can have dozens of complications. Which specific complication would you be referring to? Keep in mind that a higher complication may simply mean the doctor treats sicker patients. A superb surgeon, for example, may have more complications because he accepts critically ill patients who other doctors won't operate on. Complication rates, therefore, can be very misleading. I'd be more suspicious of a physician with a 0% complication rate. This doctor must have very little experience.
How many times has the doctor performed the operation or procedure?
This statistic makes some sense. Numerous medical studies demonstrate that physicians who perform procedures and operations regularly have lower complication rates. It is not clear what volume of procedures is necessary. For example, is a gastroenterologist who performs 2000 colonoscopies yearly better than one who does 500? Not necessarily. In addition, a high volume of cases does not mean that the procedures were appropriate or medically necessary. Who wants to have a gallbladder expertly removed if it should be left alone?
What is the doctor's success rate for the treatment proposed?
Good luck defining success in medicine! Doctors and patients often define success differently. A doctor may feel successful because the high blood pressure is well controlled, but the patient is disappointed because he is still fatigued. In addition, physicians' offices are not research institutions that study their patients' clinical data. Most doctors may have a sense that they practice sound medicine and have favorable outcomes, but most have no scientific basis for this assertion. A doctor's comment, "I've had lots of success with this treatment", may reassure you, but I'd be cautious about assigning too much weight to this optimistic statement.
What is your doctor's medical malpractice history?
Now my blood pressure is rising. Excellent physicians are sued everyday who have done nothing wrong. Many of them settle their lawsuits for business reasons, not because they were negligent. We live in a society where many expect and demand compensation and reward for any injury, even if no one is at fault. I may not be able to unravel the medical quality riddle, but I know for sure that a doctor's medical malpractice history is the wrong tool.
Which medical societies does the doctor belong to?
Society membership means the doctor has sent in a check and has received a certificate to hang on his wall to impress his mother and his patients. While the societies may disagree, I don't think that membership implies medical quality. I belong to 4 professional societies and I doubt that my medical quality is four times better than a doctor who has joined only one.
Is there a fish tank in the waiting room?
Yes, I know this sounds silly, but it may predict quality as accurately as any of the questions above.
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Posted by Michael Kirsch, M.D. at 2:12 PM
Labels: Physician Quality