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Primary Care Physicians (From CHECKBOOK, Fall 2012/Winter 2013)
 
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Many doctors specialize in specific parts of the body and specific health care conditions. You will most likely need such doctors at various times in your life. But there is one type of doctor you need right now and throughout your life: a primary care physician—sometimes referred to as a personal doctor. 

This doctor should be familiar with your medical history, your family relationships, and other factors that can help in diagnosing and treating the physical and emotional causes of health problems. You will rely on this doctor to coordinate your care throughout the healthcare system. 

Your primary care doctor should be an internist, family practitioner, pediatrician (for children), or general practitioner—or perhaps an obstetrician/gynecologist (for women) or a geriatric specialist. If you belong to an HMO, you won’t be allowed to get your primary medical care from any other specialty. But even if you have the option, it’s inadvisable to rely on a narrower specialist—for example, a surgeon—for primary care because specialists may see cures for your problems in the procedures they perform—surgery, perhaps, where drug therapy would suffice. 

Using Our Ratings 

Doctors

Our Ratings Tables give ratings of area physicians collected in our surveys of consumers. Our survey asked consumers (primarily CHECKBOOK and Consumer Reports subscribers) to rate their experiences with doctors they had recently used on several aspects of care and service— 

  • Listening to/communicating with you 
  • Personal manner (courtesy, respect, sensitivity, friendliness) 
  • Spending enough time with you 
  • Seeking your input in making decisions 
  • Coordinating your care 
  • Giving prevention/self-help advice 
  • Thoroughness, carefulness, and apparent competence 
  • Arranging to see you quickly when you request an appointment 
  • Giving timely, helpful advice by phone or email 
  • Keeping down office waiting time 
  • Overall quality 

Ratings on all of these questions are reported on our Ratings Tables. These questions are not just about pleasantness or comfort; they go to the heart of quality medical care. For example, research has shown that patients who get care from doctors who listen and communicate well tend to receive more accurate diagnoses, respond better to treatment, and recover more quickly. Certainly, it is hard for a doctor to make a good diagnosis or a good treatment plan without listening to what is bothering you and hearing about any impediments you might have to self care. And you are more likely to do your part in care—for example, taking medicine and making lifestyle changes—if the doctor has successfully communicated what is expected of you, why it is important, and what effects you can expect to experience. 

We have reported what percentage of respondents rated each physician as “very good” or “excellent” (as opposed to “poor,” “fair,” or “good”) on each question. We have reported results for all of the physicians for whom we received at least 10 ratings on our customer surveys. 

Many physicians were rated “very good” or “excellent” for “overall quality” by more than 95 percent of their surveyed patients. But some other doctors received such favorable ratings from fewer than 70 percent of their surveyed patients. 

By clicking on the names of physicians, you can also see the comments surveyed patients submitted with their ratings. Most commenters heap praise upon their committed, caring physicians. But some describe doctors who tend to frustrate their patients more often than they solve their problems— 

  • “Cannot recommend. Has zero bedside manner, spends most of the time with you staring at a laptop typing. Seems in a great hurry to move on to the next patient.” 
  • “One of the rudest doctors we have ever seen. He was condescending and didn’t want to listen—even to answers to questions he asked.” 
  • “Seems totally uninterested in patient.” 
  • “When asking him questions, he doesn’t answer most of them and tells you to go elsewhere. He always seems to be in a hurry.” 
  • “Probably a competent doctor, but she runs the worst office in the area. They are consistently rude, arrogant, and unhelpful. Customer service is completely foreign to her and her staff.” 
  • “Doesn’t return phone calls; takes up to a week to refill prescriptions; doesn’t seem to know much—always referring to specialists.” 
  • “Practice is completely overbooked. Can NEVER get in... Staff is way too busy. Feels like a big factory.” 

While many of the doctors listed on our Ratings Tables are good candidates, keep in mind that often the number of raters is small and that any of these doctors might have scored substantially higher or lower with a larger number of respondents. Also keep in mind that the survey responses are inherently subjective. Because the doctor-patient relationship is very personal, a physician our respondents liked may not be right for you. (Other limitations on our customer survey results and other research methods are discussed here.) 

In addition to finding out how patients rate doctors, you can also consider another CHECKBOOK resource: our list of the area’s “Top Doctors. To compile that list, we asked all practicing physicians in the Bay Area to name one or two physicians in each of 38 specialty fields whom they would consider “most desirable for care of a loved one.” Our list of Top Doctors includes physicians recommended most often in that survey, and our Ratings Tables for primary carecare physicians indicates which doctors also made our Top Doctors list.

Other Information on Doctors 

While patient feedback and recommendations by physician peers provide valuable insight on physicians, other types of information are also important. In particular, you will want wherever possible to have direct clinical measures of physician quality. There is good reason to be concerned. Evidence shows that many doctors don’t consistently perform the basic procedures that have been demonstrated to produce the best medical results, and that many doctors routinely do unnecessary and risky procedures or perform appropriate procedures badly. 

For example, in an article published a few years ago in the New England Journal of Medicine, researchers reported that patients participating in a large-scale study received 54.9 percent of recommended appropriate care. The researchers concluded that “the deficits we have identified in adherence to recommended processes for basic care pose serious threats to the health of the American public.” 

Unfortunately, it has for many years been difficult or impossible to find out whether doctors you are considering have better or worse clinical-care track records than what these studies often found. We are concerned that Medicare, the federal program that has a major influence on physician practice and possesses extensive claims-payment data and the leverage to get more data, has been too slow in using its leverage to improve individual physician practices—including sharing information on individual physician performance with consumers. 

Under the Affordable Care Act, as passed in 2010, the Department of Health and Human Services (HHS) is charged with creating a “PhysicianCompare” website (www.medicare.gov/find-a-doctor) with much information on the quality of physicians. Such a website could include information on physician qualifications, whether physicians follow evidence-based clinical guidelines, whether they achieve good patient outcomes, how they are rated by patients, and other dimensions of quality. But HHS so far has provided very little useful information on this website. And it is not clear that HHS is sufficiently committed to, even in the future, reporting a broad range of quality measures at the individual doctor level, as opposed to the medical group or clinic level—even though most patients want to know about individual physicians and there is big variation from clinician to clinician within clinics and medical groups on many measures. 

Some forward-looking health plans are using data they have to check whether doctors consistently comply with evidence-based clinical guidelines. They are analyzing data from medical claims and other sources for each doctor and identifying doctors who fail to perform recommended procedures (such as eye exams and hemoglobin tests for diabetics), or who perform inappropriate or unnecessary procedures. But because most plans have as members only a limited number of each doctor’s patients, sample sizes for such assessments are often small. Also, anyone attempting to use claims data to judge physicians in this way encounters difficulties, such as problems knowing whether a doctor who did not perform a test had a good clinical reason for not doing the test in a particular case, or whether the doctor knew that the test had been performed elsewhere (for instance, in a clinic or hospital). 

There are also independent programs that enable physicians to seek recognition for quality of their practices. 

The National Committee for Quality Assurance (NCQA) (www.ncqa.org) has a program that recognizes doctors who participate in patient-centered medical homes (PCMH). This is an innovative program for improving primary care. A PCMH is a health-care setting that facilitates partnerships between individual patients and their personal physicians and, when appropriate, the patients’ families. Care is facilitated by information technology, information exchange, and other means to ensure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner. 

NCQA also has programs in which doctors voluntarily agree to have their practices reviewed and seek to be recognized for consistent high quality care of certain conditions—diabetes, heart/stroke, and back pain—and also for practice connections (having practices that use up-to-date information and systems to enhance patient care). For example, the diabetes recognition program checks how well doctors do with patients’ blood pressure control and with giving smoking cessation advice. 

Similarly, Bridges to Excellence (BTE) (www.hci3.org) has recognition programs intended to identify clinicians who deliver high-value care to patients with specific chronic conditions. Recognitions cover all major chronic conditions, such as diabetes care, cardiac care, spine care, chronic obstructive pulmonary disease, congestive heart failure, asthma, and major depressive disorder. 

BTE also has a physician office system recognition program to identify practices that have implemented systematic office processes to reduce errors and increase quality. The program includes three levels of recognition. It assesses, for example, the use of evidence-based standards of care; the provision of educational resources to patients; the use of electronic systems to maintain patient records, provide decision support, enter orders for prescriptions and lab tests, and provide patient reminders; and the use of electronic systems that can automatically send, receive, and integrate data such as lab results and medical histories from other organizations’ systems. 

What Other Lists Are Available? 

Various other lists provide names and addresses and, in some cases, other information about doctors. 

For example, the American Medical Association’s (AMA) “DoctorFinder” (www.ama-assn.org) allows you to search by specialty and location; it offers information on training, hospital affiliations, specialties, and board certification for AMA members—but only name, primary specialty, board certification information, city, and zip code for the many physicians who are not AMA members. At the American Board of Medical Specialties’ website (www.abms.org), you can check whether individual physicians are board certified. 

Most health insurance plans post physician directories online, often accessible to both members and non-members. The better directories list specialties, medical school and year of graduation, hospital affiliation, and other facts. Some even identify physicians who have been recognized for adherence to evidence-based care guidelines or provide patient-survey results, usually for only a limited number of physicians or medical groups, or based on a small number of survey responses. 

Another option is to check with a top-quality hospital for names of physicians affiliated with it. In our Hospital Guide section, CHECKBOOK subscribers have free access to our national ratings of over 4,000 acute-care hospitals in the U.S. You can check to see which doctors are affiliated with top hospitals by calling hospitals or, for most hospitals, checking the hospitals’ websites. Good sources of prospects are teaching hospitals, where you can ask specifically for doctors who have teaching responsibilities. Although the full-time faculty at a local medical school 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 interns—while maintaining their own practices. Doctors who teach part-time at local medical schools are excellent prospects, as are doctors who teach at large community hospitals. 

Questions to Ask Prospective Physicians 

Once you have identified potential candidates, you may want to get answers to some questions about each. Some of these questions can be answered by checking various sources listed above; others will require a call to the doctor’s office; and still others will require asking other patients or meeting—or using—the doctor. 

  • Does the doctor work as a personal, or family, doctor on a primary care basis? For children, for adults, or both? 
  • Is the doctor accepting 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 one or more top-rated hospitals (go to our Hospital Guide section for our ratings of area hospitals for inpatient care). There is a good chance that you will be admitted to one of these hospitals if you need hospitalization—even if you are admitted by a specialist. Your primary care 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 your health history information and recall this health history at each encounter with you? Will the doctor enter lab service orders, x-ray orders, and/or prescription orders into the system; 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 electronically entered into your personal record? 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 recommended procedures? Will it issue reminders to patients? 

There is reason to believe that implementation and use of electronic health record systems represent some of the greatest opportunities for improvements in medical care. But the Centers for Disease Control and Prevention (CDC) estimates that at this time only about one-third of doctors’ offices use electronic health records systems that meet the criteria for a “basic” system. Even in offices that have robust systems, there is great concern that many doctors use only a fraction of the features the systems offer. 

  • Is the doctor “board certified” in his or her specialty? “Board certified” means that the doctor has taken at least two to six years of post-medical school training and has passed a difficult exam. And while a well-recommended doctor who is not board certified may serve you admirably, it makes sense to seek out certification. Our Ratings Tables show board certification status for each physician, according to the American Board of Medical Specialties at the time we checked. The American Osteopathic Association (AOA) declined to grant us permission to provide board certification information for physicians on our list who have osteopathic medicine degrees (D.O.). 
  • Where did the doctor take his or her residency? Hospitals where doctors take advanced post-medical school training—called a “residency”—that have recognizable university ties usually provide good instruction—for instance, Duke University Hospital or Stanford University Medical Center. But the absence of a university connection in the name of the hospital doesn’t necessarily mean the hospital doesn’t have one. 
  • What medical school did the doctor attend? Virtually all medical schools in the U.S. are acknowledged to be of relatively high quality. Medical schools in some other countries such as Canada, the U.K., Switzerland, and Belgium are of comparable quality. So give special consideration to doctors trained in the U.S. or one of these countries. But remember that most experts think the site of a physician’s residency is more relevant than the medical school attended. 
  • When did the doctor graduate from medical school? This tells you roughly the doctor’s age. You may prefer a doctor who has many years of practical experience and has seen firsthand a vast range of medical problems. Or you might want a younger doctor unlikely to retire soon. A recent graduate might also have more up-to-date training, although many older doctors keep current by teaching, engaging in hospital activities, and participating in continuing education programs. 
  • Does the doctor have teaching responsibilities at a hospital? If you found the doctor through a hospital referral service, you may already have this answer. It’s important because a teaching position reflects respect from colleagues and also ensures that the doctor is regularly exposed to new developments and 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 comprehensively incorporate all the specialists’ comments. On the other hand, in a multi-specialty group, 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? Be wary of a doctor who does not have an arrangement with at least one other doctor to share “on call” duties. Where will you turn when the doctor is out of town, ill, or at a meeting? 
  • Does the doctor give regular patients advice over the phone? Does the doctor answer questions by email? Is there a charge for such advice? Phone and email advice can be a great convenience—a partial substitute for the house calls most doctors no longer make. With malpractice liability looming over them, doctors are careful about giving such advice in questionable cases, but most doctors give some advice over the phone, and some are now using email. Very few charge for such advice, as long as patients come in for office visits occasionally and don’t call or email often. 
  • What is the usual wait to get an appointment for a non-emergency medical problem? For a full physical exam? 
  • Will the doctor deal with your insurance carrier? You save time if your doctor bills your insurance company directly. Also, doctors who don’t have relationships with your insurance company may charge higher fees than the insurance company will pay, leaving you to pick up the difference. And your insurance company might expect you to pay a higher percentage of the covered fees than you would pay for care from plan-affiliated doctors. If you have Medicare, it is important to find out whether the doctor participates in Medicare. 
  • 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? The answers will give you a sense of the doctor’s charges for other services also, and of how the charges relate to your health plan’s payment rules. 
  • How convenient is the doctor’s office? Is there public transportation? Parking? 
  • What lab, x-ray, and machine diagnostic tests can be done in the doctor’s own office? It’s convenient to have all these diagnostic services performed in one place. But be aware that doctors who provide these services have a financial incentive for prescribing them, possibly leading to more such tests than necessary. 

When you have gathered all the information you can from calls to physicians’ offices, conversations with friends, and other sources, consider a visit to the physician who looks best. A visit just to meet a doctor should be inexpensive or free. But some consumers find this kind of meeting awkward, a feeling some doctors share. A considerably more expensive alternative is to schedule a physical exam. 

If you do not feel it’s immediately necessary to establish a relationship with a doctor, keep your notes on the doctors you have checked and call your first choice when a medical problem arises. 

If you are not satisfied with your first meeting, or any subsequent encounter, look for someone else and have copies of your records sent there (you have a right to your records). But avoid hopping from doctor to doctor. An established relationship with a doctor you like and trust is a healthful asset. 

A National CHECKBOOK Initiative 

CHECKBOOK’s New Model for Surveying Patients About Their Experiences with Their Doctors Throughout the U.S. 

CHECKBOOK has for many years surveyed patients about their experience of care with their physicians—and published the survey results at the individual physician level. We believe the information you get on individual doctors, based on these surveys, is much better than what you will find at the proliferating websites where anyone can go to rate doctors. But it can be better. And we want to make this type of information available to consumers and doctors throughout the U.S., not only in the seven major metropolitan areas where we publish CHECKBOOK

So we launched pilot projects in four metropolitan areas—Denver, Kansas City, Memphis, and New York City (Manhattan)—to survey patients about their doctors using a questionnaire and survey procedure developed and tested by the U.S. Agency for Healthcare Research and Quality and endorsed by the National Quality Forum. 

Five major health plan organizations agreed with us about the importance of making this type of information available to consumers, and that it makes sense for health plans to collaborate on such surveys, rather than having each plan waste money and survey-respondent time by conducting separate surveys about the same doctors. 

Aetna, Blue Cross and Blue Shield of Kansas City, BlueCross BlueShield of Tennessee, CIGNA HealthCare, and UnitedHealthcare cooperated with us to identify—for hundreds of physicians in each of the four pilot metropolitan areas—plan members who had visited these physicians in the previous 12 months (while strictly protecting the confidentiality of plan members). We surveyed these patients, and made public each physician’s scores. The scores are available free at www.checkbook.org/patientcentral

We hope these pilot projects will inspire health plans, medical groups, government policymakers, and others to work together toward conducting similar surveys and reporting patient evaluations of individual physicians throughout the U.S. 



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