Introduction 

It’s true that the whole is greater than the sum of its parts. Having a top-quality primary care physician who focuses on the whole picture, not just a specialty or certain treatments, is critical to your health. 

A good primary care doctor—sometimes referred to as a personal physician—is your most important link to the whole healthcare system. 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 through the rest of the healthcare system—to refer you to specialists, for instance, or to oversee your care during a hospital stay. 

On our Ratings Tables, you will find a list of primary care physicians who received above-average ratings from their patients when we surveyed CHECKBOOK and Consumer Reports subscribers. (Click here for more information on our survey and research methods and limitations.) In what follows, we will also give you advice on finding a top-quality personal doctor who fits your preferences and needs. 

Your primary care doctor should be a general practitioner, 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 medical 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 trained to perform—surgery, perhaps, where drug therapy would suffice. 

You may want to use the list on our Ratings Tables along with a second CHECKBOOK list: the list of doctors, identified in our "Top Doctors" article, who were most often recommended by their peers when we surveyed all actively practicing physicians in the Puget Sound area and asked them to name one or two physicians in each of 39 specialty fields whom they would consider “most desirable for care of a loved one.” 

Checking Patient Feedback 

Probably the most common approach consumers use to find primary care doctors is to ask the advice of friends and family. That is a valid approach, but only if you ask the right questions. It is not enough to ask: “Who’s your doctor? How do you like the doctor?” You need to push for more information and prod the person recommending the doctor to give critical judgments. Ask, does the doctor— 

• Take a thorough medical history? 
• Remember, or consult records about, your medical history and relevant information you have given before? 
• Seem to be thorough, careful, and competent? 
• Listen to you, make you feel comfortable about asking questions, and not interrupt you? 
• Check your progress, tell you about test results? 
• Explain what is wrong, what needs to be done and why, and what you can expect—and openly discuss any uncertainties? 
• Help you understand your choices and get you involved in making decisions about your care? 
• Refer you to specialists and other providers when needed? 
• Follow up with specialists and other providers—giving needed information to these providers, getting information back, and discussing it with you? 
• Spend enough time with you? 
• Seem personally to care about you and your medical problems? 
• Give you helpful advice about ways to stay healthy, help you find life-style changes that are acceptable to you, and help you find the motivation to do your part? 
• Help you find resources and solutions to deal with sickness, disability, or chronic health problems? 
• Get results as good as you believe you can reasonably expect? 
• Offer reasonably convenient hours? 
• Help you solve problems and deal with worries by calling you back with helpful advice the same day if you call with a medical question—within a few minutes if you have left a message that there is an emergency? 
• Generally arrange to see you within a day or two if you call with a new (non-emergency) sickness or injury? (Surveys show that most doctors do.) 
• Generally not keep you waiting more than 15 minutes past your appointment time before serving you? (Most doctors usually do keep it below 15 minutes.) 

These questions are not just about pleasantness or comfort. They go to the heart of medical quality of care. Being able to communicate and work well with your doctor is critical to your health. Research has shown that patients who have good relationships with their doctors tend to get more accurate diagnoses, respond better to treatment, and recover more quickly. Certainly, you are more likely to do your part in care—taking medicine and making lifestyle changes—if you understand what is expected of you, why it is important, and what effects you can expect to observe. (These questions are important not only when you are looking for a doctor but also when you are considering whether you should switch to a new doctor.) 

The patient-survey information in the list of “Top-Rated Primary Care Physicians” addresses many of the questions you would want to ask another patient about a doctor, and gives you excellent prospects in your search for a personal or family doctor. Our survey asked area consumers to rate their experiences with the practices of the primary care physicians they had used most recently. The patients were asked to give their ratings using the following scale: “poor,” “fair,” “good,” “very good,” or “excellent.” Our list reports for each doctor the percentage of ratings that were “very good” or “excellent” on such questions as “listening to/communicating with you;” “thoroughness, carefulness, and apparent competence;” “giving timely, helpful advice by phone;” and “overall quality.” 

We have listed only those doctors who received at least 10 ratings and received higher-than-average ratings. Many were rated “very good” or “excellent” overall by more than 95 percent of their surveyed patients. For these physicians, we get feedback like the following from their patients— 

“He is experienced and has seen it all. Very calm and reassuring.” 

“Never rushes through her appointments. She listens carefully to what I say and remembers (referring to her notes) information from earlier visits. She is highly professional but also makes me feel I am important to her and she genuinely is concerned about my health and well-being.” 

“A very easy person to relate to. Knowledgeable and decisive. I enjoy talking to her and trust her.” 

“Calls back within 15 minutes. Always has time. Caring and compassionate. She is fantastic.” 

“The best doctor that I have ever had. He listens, gives his opinion and works along with you to a conclusion that you will be happy with. I trust him with all my medical problems and also my three children.” 

“Accessible and responsible, friendly, and helpful. Conservative approach to problems. Good at recommending specialists and coordinating treatments.” 

But at the other extreme, there were some doctors, whom we have not included on our Ratings Tables, who got favorable ratings from fewer than half of their surveyed patients. The feedback we get from these physicians’ patients show that these doctors tend to frustrate their patients more often than solve their problems— 

“Unfortunately, he appears to be under great pressure to see a certain number of patients every hour. As a result, he spent what seemed like the minimum amount of time with me and the other members of my family on our separate visits... His questions were curtly asked and he displayed an unnerving lack of patience when our replies were not quick and accurate. This made me more nervous and less able to answer his questions. He then got even more impatient which made me even more uncomfortable. I felt I could not really talk to him.” 

“Constantly interrupts. Doesn’t hear what you are concerned about. Kept waiting in office for three hours because forgot I was there. Is rude, disrespectful.” 

“Does not listen to you, doesn’t care if the medicine disagrees with you. Doesn’t like questions that would bring into play his judgment.” 

“Does no follow up; never calls or takes calls. Works strictly by the clock. When your 10 minutes are up, your visit is finished!” 

“Appeared to have a significant lack of knowledge about current studies in several areas. Mis-diagnosed four of five issues discussed during the visit. Had no suggestions on possible continued search for solutions.” 

“The staff, particularly on the phone (if you have the time to wait for someone to answer) shows a remarkable lack of organizational competence; mis-scheduling appointments, billing the wrong insurer, all with a surly demeanor.” 

While the doctors listed on our Ratings Tables are good candidates for you to choose among, keep in mind that the number of raters is small and that any of these doctors might have scored substantially higher or lower had we been able to survey a larger number of their patients. Also remember that patients’ ratings are subjective; an experience that you might rate “excellent” might get much less favorable ratings from another patient. 

We hope the pilot projects CHECKBOOK has carried out, surveying patients about their experiences with their doctors, as described below, will eventually lead to having highly reliable patient reports on doctors for most doctors in the U.S. 

Checking on Whether They Order Proper Tests and Procedures 

While patient feedback is one way to get a lot of valuable insight on physicians, you might also want direct clinical measures of quality. There is, in fact, good reason to be concerned. Evidence shows that many doctors don’t consistently provide the basic procedures that have been demonstrated to produce the best medical results, and that many doctors routinely provide unnecessary and risky procedures or do appropriate procedures badly. 

In an article published several years ago in the New England Journal of Medicine, researchers reported that participants 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.” 

A recent report prepared for the Medicare program compared care received by Medicare fee-for-service beneficiaries in 50 states and the District of Columbia to well-established, evidence-based guidelines for what is appropriate care. The report concluded that in the median state— 

• Only 69 percent of diabetic beneficiaries were receiving care that met the biennial eye exam guideline. 
• Only 71 percent of diabetic beneficiaries were receiving care that met the guideline calling for an annual hemoglobin test. 
• Only 56 percent of women ages 52 to 69 had received mammograms during the recommended two-year period. 
• Only 65 percent of congestive heart failure patients were receiving guideline-recommended left ventricular ejection fraction (LVEF) assessments. 

So, you would like to know whether doctors you are considering have a better record with their patients than what these studies often found. Unfortunately, finding out may be difficult or impossible. We are concerned that the Medicare program, the Federal program that could have a major influence on physician practice and that has extensive claims payment data that could be used to monitor physician performance, is not doing enough to improve individual physician practices—including sharing with consumers information on individual physicians’ performance. 

Some forward-looking health plans are attempting to use their claims data to check whether doctors are consistently complying with evidence-based clinical guidelines. They are analyzing their claims data for each doctor and identifying the doctors who are failing to perform recommended procedures (such as eye exams and hemoglobin tests for diabetics) or who are doing inappropriate or unnecessary procedures. But most plans have as members only a limited number of each doctor’s patients, so their sample sizes are small for doing such assessments. 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 in a particular case for not doing the test, or possibly didn’t do so because he or she knew that the test had been done elsewhere (for instance, in a public clinic). 

Keep an eye out for reporting of measures of physician compliance with guidelines. Check your health plan or medical group website to see if such reports are available, or if certain physicians have been recognized for a high level of performance. But availability of information of this kind is still rather limited. 

Checking Recommendations from Peers 

A third approach to learning about physicians is to ask other physicians. Doctors often have opportunities to observe the work of their peers—in hospitals where they work together, in consultations, in feedback following referrals, in professional committees, by reading professional papers, and in other ways. 

If you have a specialist you trust, ask the specialist for recommendations of primary care physicians. Similarly, if you have a primary care physician you trust in another part of the country, ask that physician if he or she has a basis for recommending one in the Puget Sound area. 

We have created a convenient tool for you to review physicians’ opinions of their peers—in our "Top Doctors" article, currently available free to CHECKBOOK subscribers. To create our Top Doctors lists, we surveyed virtually all actively practicing physicians in the nation’s 53 largest metropolitan areas and asked each to name the one or two physicians in each of 39 specialty fields he or she “would consider most desirable for care of a loved one.” On our Top Doctors lists, we simply identify the doctors mentioned most often by their peers, and tell you how many mentions each received—along with basic information about each, such as office addresses and phone numbers, medical schools attended, and board certification information. 

We know a few facts validating these lists. The primary care doctors who make the lists rate higher, on average, on patient surveys than other primary care doctors rate. The doctors who make our lists are almost all board certified (see below), while only about 85 percent of other doctors are board certified. In cardiac surgery, one of the very few fields where it is possible, at least in a few states, to measure the outcomes of medical care (through analysis of by-pass surgery death rates), doctors on the Top Doctors lists have, on average, substantially lower death rates than other doctors. 

We believe health services researchers should do more research on peer ratings. How do doctors evaluate their peers? Are there ways to enhance opportunities for doctors to learn more about their peers? Which types of specialists know the most about which types of other specialists? Are there ways to reduce potential biases like old-boy-network loyalties or business connections when surveying doctors about their peers? 

Given the great credence patients put in physician referrals and opinions, it is striking how little is known about these questions. But from what we know, we believe the peer recommendations you can get from a doctor you trust, and the peer recommendations captured in our Top Doctors lists are a valuable resource. 

Our Ratings Tables also indicate whether the doctor also appears on our Top Doctors list as a result of having been recommended by a sufficient number of peers. 

Checking Other Lists 

There are various other lists to which you can turn for names of available doctors and, in some cases, information on those doctors. 

Several national directories list a few key facts about physicians. The American Medical Association’s (AMA) “DoctorFinder” is available at www.ama-assn.org, and allows you to search by specialty and location; it gives you information on training, hospital affiliations, specialties, and board certification for doctors who are AMA members, but gives you just 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. If you do not have access to the Internet, you can reference ABMS’ board certification information at many public libraries by checking The Official ABMS Directory of Board Certified Medical Specialists, which lists board-certified physicians, and the “American Medical Directory & Physicians Guide,” a CD-ROM-based directory. 

Most health plans have physician directories online, useable by both members and non-members. The better directories give 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 and some give 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. Subscribers have free access to our national ratings of over 4,500 acute-care hospitals in the U.S. You can check to see which doctors are affiliated with top hospitals by calling hospitals or, in the case of many hospitals, by checking 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 the local 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 interns while maintaining their own practices. Part-time teaching doctors at the University of Washington School of Medicine are excellent prospects, but so are doctors who teach at some of the large community hospitals. 

Your Own Checks with Prospective Physicians 

When you have identified a few potential candidates, you will want to ask some questions about each. A few can be answered from the directories discussed above; 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. 

• 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 one or more top-rated hospitals. There is a good chance these are the hospitals you will be admitted to if you need hospitalization—even if it is a specialist who admits you. 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 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 some of 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 in their offices, the systems vary greatly in features and capabilities, many are already 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. Our Ratings Tables show, for each physician listed, the board certification status for each when we recently checked with the American Board of Medical Specialties. We asked the American Osteopathic Association (AOA) to provide board certification information for physicians on our list who have osteopathic medical degrees, but the AOA declined to grant us permission to use that information in our lists. 
• 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 U.S. 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. 
• 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 often. 
• What is the usual wait for 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 will bill your insurance company directly. Also, if the doctor doesn’t have a relationship with your insurance company, the doctor’s fees may be higher 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 fee than you would have to pay for care from a plan-affiliated doctor. If you are on Medicare, it is important to know 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? 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? Being able to get these diagnostic services all in one place is convenient. But you should be aware that doctors who provide these services might have a financial incentive to prescribe the services, possibly leading to use of more such services than patients need. 

When you have gathered all the information you can from calls to physicians’ offices, talks with friends, and other sources, you may want to visit the physician who looks best to you. 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. 

If you do not feel a relationship with a doctor is immediately necessary, keep your notes on the doctors you have checked and simply call your first choice when a medical problem occurs. 

After your first meeting or any subsequent encounter with a doctor, you should feel free to look for a new one if you are not satisfied, and you have a right to your records to pass along to your new doctor. But you will be wise not to shop continually from doctor to doctor. An established relationship with a doctor you like and trust is a real asset. 

A National CHECKBOOK Initiative 

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

CHECKBOOK has surveyed patients about their experience of care with their physicians—and has published the survey results at the individual physician level—for many years. We believe the information you get, based on these surveys, on our Ratings Tables, is much better than anything else put out by other organizations. We have larger numbers of patient reports per doctor and better controls to prevent manipulation of the surveys than the proliferating websites that claim to offer such information. 

But we believe it can be better. And we want to have 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 last year we launched pilot projects in three metropolitan areas—Denver, Kansas City, and Memphis—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 having this type of information available to consumers, and agreed that it makes sense for health plans to collaborate on such surveys, rather than having each plan waste money and survey-respondent time by separately conducting surveys about the same doctors. 

Aetna, UnitedHealthcare, CIGNA HealthCare, BlueCross and BlueShield of Kansas City, and BlueCross BlueShield of Tennessee cooperated with us to identify, for hundreds of physicians in each of the three pilot metropolitan areas, plan members who had had visits to these physicians in the previous 12 months (while strictly protecting the confidentiality of plan members). We surveyed these patients and in July 2009 made the scores of each physician public. The scores are available free to the public (www.checkbook.org/patientcentral) and will also be available through the website of a healthcare coalition in each community: the Kansas City Quality Improvement Consortium, Healthy Memphis Common Table, and the Colorado Business Group on Health. In addition, the cooperating health plans are expected to provide links to the survey results in their provider directories. 

We are working with the health care coalitions and the medical societies in each area to urge the use of the survey results to encourage and guide physicians and patients in improving the aspects of care measured in the surveys, including listening to patients, explaining things clearly to patients, having courteous and helpful office staff, and making appointments and care available when needed. 

We want to build on these pilot projects to move health plans, medical groups, government policymakers, and others to come together to work toward having surveys similar to what we did for the pilot projects take place throughout the U.S. We hope any subscribers who can help in this push will contact us at surveyspread@checkbook.org.