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Choosing a Doctor (by Consumers' CHECKBOOK)

Your primary care doctor should be a family practitioner, internist, or pediatrician (for children), or perhaps an obstetrician/gynecologist (for women). If you are in an HMO, you won’t be allowed to get your primary care from any other specialty. But even if you have traditional insurance, you are better off not to rely on a more narrow specialist—say, a surgeon—for primary care because a specialist may see the cures for your health problems in the tasks he or she is skilled to perform—surgery, perhaps, where drug therapy would suffice.

Until you have a primary care doctor you fully trust, you will have to take lead responsibility for selecting any specialist you need. This guide will be especially valuable to you in that situation. It will also have special value any time you need to select a specialist for a second opinion or any time you become dissatisfied with a specialist to whom your primary care doctor has referred you.

Even if you have a primary care doctor you feel you can rely on for referrals, you will still want to have an active role in choosing specialists. You will get better choices if you discuss a few candidates with your doctor, including candidates you identify in this guide. That is especially important if your primary care doctor has reason to select only from a limited set of candidates because of health plan or medical group referral procedures. In addition, only you can judge whether any specialist you use relates well to you personally and is convenient.

When looking for a good primary care doctor, one approach is to ask friends and associates for recommendations. Other options are to get recommendations from a doctor you have known in some other part of the country or from a local specialist you have used.

CHECKBOOK's Guide to Top Doctors includes listings of a small number of primary care doctors in each community. You can select one of the listed doctors. Alternatively, if you know that you need a specific type of specialist, you can select a specialist of that type using this guide (assuming your health plan allows you to go to a specialist of your choice) and you can ask that specialist to recommend primary care doctors.

In most communities, there are widely advertised phone numbers to call for doctor referrals. These referral lines are not always a good source of candidates. Many simply refer to any doctor who pays a fee to be listed. Others are set up by hospitals as a service for their affiliated physicians and as a way to channel more patients to these physicians. A hospital benefits when affiliated physicians get more patients because these patients are likely to use that hospital when the need arises.

If you decide to get referrals from a hospital, it makes sense to turn to a teaching hospital (if there is one in your community) and to ask for doctors who have teaching responsibilities. Hospitals attached to medical schools are good prospects, but you can also seek out other hospitals that have major programs to provide post-medical school (residency) training programs for substantial numbers of new doctors. Although the full-time faculty at medical schools may include only a handful of primary care physicians, a surprisingly large number of doctors teach—often putting in two or three hours per week in clinical work with medical students and residents while maintaining their own practices. The teaching experience exposes the doctor to new medical developments and to continued challenges to his or her own standards of practice.

Two national directories can help you in your search for doctors: American Medical Directory, published by the American Medical Association (AMA), and the Directory of Medical Specialists published by the American Board of Medical Specialties (ABMS). Both give a few key facts about the training and background of listed physicians. They are available at many libraries and provide listings on the Web through the links provided here.

If you are a member of a health maintenance organization (HMO) or preferred provider organization (PPO) or if you are considering becoming a member and want to know in advance about the doctors you might choose in a plan, you can cross-reference the list of prospects you compile from other sources with the health plan’s provider directory. In fact, you also may be able to use the directory or the plan’s administrative staff as a source of information on prospects. The directories often give background information on doctors, and some plan administrative staffs can give you a list of doctors who meet certain criteria you specify—for example, doctors who use a specific hospital or who are in a certain age range. Be advised, however, that many of these directories are not updated promptly by the health plans and may include or exclude certain physicians erroneously.

When you have identified a few potential candidates to be your primary care doctor, you will want to ask some questions about each. A few can be answered from the directories; others will require a call to the doctor’s office; and still others can be answered only by checking with other patients or by meeting—or using—the doctor. The following are a few of the more important questions. Many of these questions will also apply when you are checking out specialists.

  • Does the doctor work as a personal, or family, doctor on a primary care basis? For children, adults, or both?
  • Is the doctor taking new patients—specifically patients from your health plan?
  • At what hospitals does the doctor admit patients? You do well to have a doctor who can admit patients to both at a major teaching hospital, if there is one in your area, and at a well-run community hospital, which might be more pleasant for uncomplicated, low-risk procedures. There is a good chance these are the hospitals you will be admitted to if you need hospitalization—even if it is a different specialist who admits you. Your doctor is likely to refer you to specialists who practice at the same hospitals he or she uses.
  • Does the doctor use an electronic health record system? Will the doctor use the system to record the health history information collected from you and to recall this health history at the time of each encounter with you? Will the doctor use the system to enter lab service orders, x-ray orders, and/or prescription orders; will these orders be communicated directly to labs and pharmacies for you; and will the results of tests be communicated back to the physician and entered into your personal record electronically? Does the health record system automatically ask the doctor questions; check for possible drug interaction problems; and suggest tests, diagnoses, or treatments? Does the system automatically issue alerts about abnormal tests, the need to follow up on referrals, and other actions the doctor should take? Will it issue reminders to patients?

There is reason to believe that the greatest opportunities for improvements in medical care are in the implementation and use of electronic health record systems. But at this time only about 15 to 20 percent of physicians report using such systems, the systems vary greatly in features and capabilities, many are becoming outdated, and many doctors who have them use only a fraction of the features the systems offer.

  • Is the doctor "board certified" in his or her specialty? Although a well-recommended doctor who is neither "board certified" nor "board eligible" may serve you admirably, there seems to be little reason not to seek out certification, which means that the doctor has taken at least two to six years of post-medical school training and has passed a difficult exam.
  • Where did the doctor take his or her residency? If the hospital where the doctor took advanced post-medical school training—called a "residency"—has a recognizable university tie, this almost assures that the doctor received good instruction—for instance, Duke University Hospital or Stanford University Medical Center. But just because you can’t recognize a university connection in the name of the hospital does not mean there is none. Harvard University uses Massachusetts General, for example.
  • What medical school did the doctor attend? Virtually all medical schools in the United States are acknowledged to be of relatively high quality. A few other countries, such as Canada, Britain, Switzerland, and Belgium, have schools of comparable quality. So give special consideration to doctors who went to school in the U.S. or one of these countries. But remember that most experts think the location of a physician’s residency is more revealing than the medical school attended.
  • Has the doctor been singled out for special recognition by your health plan? More and more plans have programs to identify top-performing doctors—for example, primary care doctors who ensure that a high percentage of their diabetic patients get appropriate tests for hemoglobin levels and eye exams, and get other appropriate procedures.
  • When did the doctor graduate from medical school? This tells you roughly how old the doctor is. You may prefer a doctor who has many years of practical experience, who has seen firsthand a vast range of medical problems. On the other hand, you might want a younger doctor who is not likely to retire soon, forcing you to find another doctor. A recent graduate might also have more up-to-date training, although many doctors who completed their formal training many years ago keep current by way of teaching, hospital activities, and continuing education programs.
  • Does the doctor have teaching responsibilities at a hospital? If you found the doctor’s name through a hospital referral service, you may already have this answer. The answer is important because a teaching position reflects respect from colleagues and also assures that the doctor is regularly exposed to new developments and to questions from medical students and residents.
  • Does the doctor practice in a group or alone? Doctors who share an office may share ideas and maintain informal standards of quality. They may also be able to operate more efficiently by sharing costly equipment and specialized staff. Finally, if the group includes doctors with different specialties, referrals are convenient and your medical record can be comprehensive, incorporating all the specialists’ comments (but the group’s doctors might not be as flexible as you would like in referring you outside the group to the very best specialist for a particular health problem).
  • What are the doctor’s hours? Many doctors schedule weekend or evening hours to accommodate patients’ work schedules.
  • How does the doctor cover emergencies on nights and weekends? If a doctor does not have an arrangement with at least one other doctor to share "on call" duties, be wary. Where will you turn when the doctor is out of town, ill, or at a meeting?
  • Does the doctor give advice over the phone to regular patients? Does the doctor answer questions by e-mail? Is there a charge for such advice? Telephone and e-mail advice can be a great convenience—a partial substitute for the house call most doctors are reluctant to make. With malpractice liability looking them in the eyes, doctors will be careful about giving such advice in questionable cases, but most doctors give some advice over the phone, and many are now using e-mail. Very few charge to give such advice as long as patients come in for office visits occasionally and don’t call or e-mail every few days.
  • What is the usual wait for an appointment for a nonemergency medical problem? For a full physical exam?
  • Will the doctor deal with your insurance carrier? You save time if your doctor will bill your insurance company directly. If you are on Medicare, it is important to know whether the doctor will accept the Medicare payment as payment in full.
  • What is the charge to you for a routine follow-up office visit? For a routine follow-up hospital visit? For a typical general physical exam? These answers will give you a sense of what the doctor’s charges might be for other services also, and of how the doctor’s charges relate to the payment rules of your health plan.
  • Does the doctor make an effort to prescribe generic drugs whenever appropriate? Generic drugs are usually cheaper and just as good as their brand-name equivalents.
  • How convenient is the doctor’s office? Is there public transportation? Parking?
  • What lab, x-ray, and machine diagnostic tests can be done without your going to another office?

Before making a final decision about a physician, it’s a good idea to check whether the physician has been the subject of disciplinary actions. Unfortunately, the information currently available to consumers is limited, but residents of many states can get some information on disciplinary actions from state-run websites. We provide links to state medical board websites here, where you can find information on disciplinary actions.

When you have gathered all the information you can from calls to physicians’ offices, talks with friends, this guide, and other sources, you may want to visit the physician who looks best to you. This is not uncommon for patients choosing a new primary care doctor, but would be unusual for a specialist. A visit just to meet a doctor should be inexpensive or free. But some consumers will find a meeting of this kind awkward, and some of the doctors we have interviewed share this feeling. As a considerably more expensive alternative, you can schedule a physical exam.