Disclosure- I am married to a practicing physician.

As we enter the great debate of what is quality health care, I worry that most patients don’t know.

From a patient’s perspective, we tend to look at the poshness of the office, how long we had to wait, the doctor’s staff, and the personality of the doctor, before we evaluate anything else.  we might look at his/her credentials- wheere they went to school and did their residency, for example- but few patients know if their doctor is Board Certified in their subspecialty, or even know what this means.

I think the Associations that certify doctors as ready to practice in their subspecialty do a lousy job of making this certification mean anything to patients and consumers.  Being Board Certified is very important to doctors, as being “BC/BE ” (board certified, board eligible) is required to practice and have admitting privileges at most of the best hospitals around the Country.  But as for patients- do you know where your doctor went to school?  Doe sit matter?  Where did they graduate in their class?  Did they win any awards?  What kind of contnuing medical education do they do?  Do they do any cutting edge research?  Does it matter to you at all?

I saw a big flap in the news this morning about doctors seeking to get their patients to agree not to post anything negative about them online.  The article states in part:

“Consumers and patients are hungry for good information” about doctors, but Internet reviews provide just the opposite, contends Dr. Jeffrey Segal, a North Carolina neurosurgeon who has made a business of helping doctors monitor and prevent online criticism.

Some sites “are little more than tabloid journalism without much interest in constructively improving practices,” and their sniping comments can unfairly ruin a doctor’s reputation, Segal said.

What this says to me is that doctors are under tremendous financial pressure, and are having problems being good doctors and good business men at the same time.  The pressure to make enough to keep a practice open, to have it adequately staffed and to see enough patients and do enough procedures to make it all work financially is almost ludicrous.  It means doctors are often treating disease and not patients, and are not allowed the time to spend with patients and make sure they know that they care.  Medicine is supposed to be the caring profession, yet we are trying to make sure everything is profitable, which means time is not a luxury anymore.

Patients know this.  Doctors always seem busy and hurried, and no one likes to feel that they aren’t being heard or listened to.  And in medicine, really hearing and listening to a patient’s complaints may be an important part of the care and diagnosis.

Yet posting a note that you don’t like your doctor’s personality, or his waiting room smells, or his magazines were lousy may or may not help you or anyone else.  You would think a doctor might be responsive to these Consumer Report reviews if he wants to stay in business and be popular, but most doctors I know are less concerned with being popular than they are getting through the day, doing a good job, and making all the finances work at home and on the job.

In fact, some of the best care is delivered in academic medical centers, which see all patients in clinics, regardless of their insurance coverage.  The less than posh waiting rooms and outdated magazines may not make you feel like the Queen of Sheba, but you may still be getting the best medical care available from some of the best doctors around.  Likewise, the most posh offices may be charging you more to keep up those appearances, but in fact, the care delievered may be no better, or even worse than that in less posh surroundings.

I think the public does not have a good idea what constitutes quality health care, and I think we can all fall for the shiny and posh exteriors as proxies for good care, when the exact opposite might be true.  After all, we go to the doctor for a reason, not to window shop (unless you are a hypochondriac.)  We judge the care by the few things we have to judge, and don’t always spend a lot of time evaluating the things that DO matter- how many cases does the doctor do?  What is their experience?  Do they regularly attend Continuing Medical Education classes?  Do they teach others?  Do they do research?  How do their peers evaluate them?  How does their staff feel about them?  Would they send their relatives to see this Doctor?  Would they recommend them to a friend?

Likewise, even doctors are struggling with quality of care issues.  When you are treating patients, there are so many variables- how does this patient respond to the medicine?  Did they call if they weren’t getting better?  Is my staff treating them well?  Is the patient compliant with their care?  Are they telling me the truth?  I may know the latest treatment, but is this patient in need of that, or would some lesser, and perhaps cheaper treatment be better and more cost effective?  Is quality of care always outcome determinative?  Sometimes people get bad  results- they scar more than others, they have complicated anatomy- things that may not be anyone’s fault, but medicine is not a factory where all outcomes are uniform and guaranteed successful.

I agree with these doctors that online rating systems for doctors are probably not good markers for quality of care.  But in the absence of medicine taking a stand in this area- in making things like board certification mean something to the consumer/patient, patients will naturally start taking matters into their own hands.

One last note-We went to a medical insurance system in this Country to try to get doctors out of the “money” part of the business and into the “care” business.  Instead of making all doctors small businessmen  having to worry about collections and business on top of medicine, the insurance system was supposed to act like a guarantee that doctors would be paid, so they gave you the care you needed without worrying about the money.  This had many unintended consequences, including Doctors practicing defensive medicine (leave no test undone- after all, it’s paid for by someone else) and not having to be conscious of  costs or cost containment until very recently.  It also created a whole layer of administrative costs associated with administering insurance, both at the practice,hospital, testing and insurance company end of things, adding to headaches for everyone involved.  (It sure created jobs, though!)

So what constitutes quality fo care for you?  What makes a doctor good? Bad?  how can we make patient feedback meaningful to physicians, but also relevant?  How do we construct a system that doesn’t serve as a way to assasinate a doctor’s reputation, argulably his most important asset, yet have a level of transparency and accoutnability that’s meaningful?

What do you think?