How To Find a Good Doctor

[Guest guest]

How to find a good doctor

It's easier now as physicians provide more info and become more

patient friendly. A key question to ask: How is the practice run?

By Jan Greene, Special to The Times

July 9, 2007

www.latimes.com/features/health/la-he-doctorfind9jul09,1,7591022.story?coll=la-h\

eadlines-health

Consumers have largely been in the dark when trying to choose a new

doctor. They might want someone who is skilled, pays attention to

their concerns and makes it easy to get an appointment. Instead,

with little information to go on, they pick someone out of a

directory whose office is conveniently located.

But a new emphasis in family medicine on providing quality care and

pleasing patients is giving consumers more to go on. They can find

out basic quality information about doctors — such as how well they

provide preventive care — from some insurers, state health officials

and private companies such as HealthGrades. And a few well-placed

questions about the way a doctor runs his or her practice can give

consumers a sense of the type of doctor-patient relationship they'll

have — and, to some degree, the quality of care they'll get.

" Times are changing, and people's expectations of what they want

from their medical care has changed, and we as practitioners are

changing, " says Dr. Klitgaard, a family physician in Iowa

who, like doctors across the nation, has computerized his record-

keeping, made it easier for patients to get appointments and helped

his office staff become more efficient.

Odd as it may seem, simply calling prospective doctors and asking

whether their office is computerized may turn out to be the best

advice for finding a physician committed to patient care over the

long term.

" The average consumer takes it as a given that doctors have these

systems in place, " says Lee, chief executive of the Pacific

Business Group on Health, an employer coalition based in San

Francisco. " They don't know how much medical care today is not 20th

century, let alone 21st century, in terms of how much doctors rely

on paper instead of computers. "

Nationally, only about 20% of physician offices are computerized;

the rest still rely on notoriously inefficient paper charts. But

computers are an easy benchmark for quality. They can help a doctor

not just keep track of files, but also send out prescriptions

accurately and quickly, get lab results inserted into the record

automatically and be reminded what the scientific evidence suggests

is the next best step with a patient.

At the same time, for doctors to get the most value out of

computers, experts say they need to use them as more than word

processors; physicians should use features such as electronic

reminders to prescribe a test or a medication, and change the way

they practice as a result. " I believe it really does translate to

better care, " says Eidus, a New Jersey physician with a

background in business and medical quality improvement. " But it's

not just that I have an electronic medical record, it's how do you

use it and how does it impact caring for patients. "

Oso Family Medical Group in Mission Viejo converted to an electronic

medical record system in 2004, going through the expensive and

painful process of converting thousands of paper files. But it was

worth it, says Dr. Lee Burnett, an osteopath and partner in the five-

doctor practice.

The change improved patient care and stopped the constant and

inefficient search for file folders. " We had two people on staff

whose jobs were just to find paper charts, " he recalls.

But simply asking whether a doctor's office is computerized

shouldn't be the sole determinant in choosing a physician.

Ultimately, in the new doctor-patient dynamic, patients should have

easier access to their doctors when they need them — in person, by

phone or online.

Other aspects of this " new model " of family practice are largely

invisible to patients but just as important: The staff acts as a

team to improve patients' health by making sure they follow up on

medical advice and make it to appointments; the doctors base care on

scientific evidence rather than instinct or habit; patients with

chronic illnesses receive follow-up care; the practice follows up on

test results and visits to specialists rather than waiting for the

patient to track down that information.

" We saw the marketplace evolve to be much more patient-centric, and

insurance companies looking for specific measures of how happy

patients are with your practice, " Burnett said. " We're trying to be

on the cusp of this. "

There isn't a large body of scientific evidence linking family

medicine modernization techniques to better patient care. But some

studies are under way.

Researchers at the Medical University of South Carolina have been

studying health outcomes of patients from about 100 medical

practices that use the same medical record software, along with

several elements of the new family practice model.

In a study of diabetics among 66 of those practices, researchers

found measurable improvement in health status and linked that to

specific techniques used by the practices, including an electronic

medical record, a team staff model and a computerized system that

keeps track of test results and referrals.

Meanwhile, 36 family practices around the country are studying their

performance in a project sponsored by the American Academy of Family

Physicians. It includes computerization, easier access for patients,

websites and a team approach to providing the most efficient care

that involves daily " huddles " among the practice staff. The idea is

to prove whether the concept works in the real world, and whether

it's worth the investment. A report on the project, which ends in

2008, is expected early the following year.

One of the participants is Eidus, the New Jersey physician who spent

a career working in academic medicine, HMOs and healthcare quality

before hanging out a shingle five years ago as a family doctor in

Cranford, N.J. He organizes his practice with an electronic medical

record and offers patients a $30 " online house call " through an

interactive website, along with extended hours on Thursday evenings

and some Saturdays. " I designed the office from the standpoint of

the patient's perspective and what was going to make our practice

best meet the needs of our patients, " Eidus said.

Harlan Clinic in rural Harlan, Iowa, is also among the growing

number of practices betting that overseeing the overall health of

its patients is more effective than providing episodic care. It

keeps a diabetic educator and dietitian on staff and plans to add a

health coach. " We can actively help them manage their disease, " says

Klitgaard, a family physician at the clinic. " That's comprehensive

practice. That can and should happen in all primary care offices. "

That concept has become known as providing patients a " medical

home. " However, a survey released last month by the Commonwealth

Fund, a private foundation focused on improving healthcare practice

and policy, found that just 27% of adults age 18 to 64 reported

having all four elements of a medical home: a regular doctor or

source of care; no difficulty contacting their provider by

telephone; no difficulty getting care or medical advice on weekends

or evenings; and visits that are well organized and run on time. The

survey, conducted in 2006, involved 3,535 randomly selected,

nationally representative Americans.

A 2003 Commonwealth Fund survey found that just 22% of primary care

doctors rated " high " in their use of patient-friendly techniques.

Just 18% used e-mail to communicate with patients. About half said

they send reminder notices about preventive or follow-up care, and

64% said they provide same-day appointments.

Choosing based on quality

Quality " report cards " on doctors can also offer a guideline for

patients choosing a doctor. Although the movement to provide such

ratings has been underway for years, it's thus far yielded mostly

general information.

A 2004 study by the American Academy of Family Physicians found that

patients generally want their primary care physician to meet five

basic criteria: be in their insurance plan, be conveniently located,

offer appointments within a reasonable amount of time, have good

communication skills and have a reasonable amount of experience.

Some of those answers are easy to find — a quick look in a provider

directory can answer the insurance and location questions. But as

more patients use health savings accounts that require them to pay

out of pocket for doctors' visits, they'll likely be looking for

more information about the value they're getting for their money.

The company HealthGrades, for instance, collects public information

such as education, gender and board certification about doctors

around the country and, for 15 states, malpractice payments — and

charges a fee for the report. HealthGrades spokesman Shapiro

says the company does not expect to offer information about practice

design (such as computerization) in the near future.

But the reports do note whether a doctor has received a quality

designation from a private quality organization called Bridges to

Excellence, which offers doctors a review and assessment of how they

handle specific diseases such as stroke and diabetes. In some

places, these ratings can earn doctors financial reward from

employers.

Some insurance plans are also beginning to offer more detailed

quality information about their doctors. A part of the Bridges to

Excellence program, called Physician Office Link, identifies

physicians who use methods considered by national healthcare quality

experts to lead to better efficiency and quality. These include

monitoring patients' medical histories, working with patients over

time, following up with patients and other providers and avoiding

medical errors. Aetna, for one, identifies physicians who have paid

to be evaluated by the program and been found to meet its standards.

Some states collect quality information and report it to consumers

on websites. California's Office of the Patient Advocate offers

quality information online about medical groups developed by the

Pacific Business Group on Health and the Integrated Healthcare Assn.

(www.opa.ca.govreport_card/). The data, based on consumer surveys,

include ratings on timeliness of medical care, quality of

communication and helpfulness of office staff. However, the surveys

apply mostly to large medical groups and include few individual or

small practices.

Such information is becoming more plentiful as doctors, pressured by

employers and insurers, open up more to scrutiny. " We're still in

baby steps on reporting on physician care, " Lee says.

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'Patient experience is key'

This patient-centered approach is considered a new measure of

quality because it means patients will be more motivated to not only

see the doctor but also accept the medical and lifestyle-change

advice dispensed.

Patients who work with their doctors in a collaborative way, for

example, are more likely to take care of themselves, according to a

study of 24,609 adult patients with chronic or serious conditions.

The study, conducted by researchers at Dartmouth Medical School and

reported in the Journal of Ambulatory Care Management in 2006, found

that patients who participated in good collaborative care had better

control of their blood pressure, blood glucose levels and serum

cholesterol than those who were less confident in the information

they received from doctors or their ability to care for

themselves. " We've recognized for over a decade that the patient

experience is key " to good healthcare, says Dr. Carolyn Clancy,

director of the federal Agency for Healthcare Research and

Quality. " Communication in primary care is critical. Eighty percent

of diagnosis is getting a good history, " she says, and that requires

a good relationship between patient and doctor.

Good, basic customer service is part of the package, because it gets

patients in the door. The doctors at Oso Family Medical Group heard

about the " new model " of family practice and that a first step is

surveying patients to find out what they need. That yielded

complaints about long waits and other annoyances.

" I've always loved them, they treat you like family, " says patient

Josh Dryman, a 33-year-old who lives in Laguna Niguel. " But I had to

wait an hour in the lobby and wait in the exam room another half-

hour. Now when you go in, they get you in right away and the staff

seems a heck of a lot friendlier. "

Hearing these and similar comments from the people on whom they

depended, the five doctors changed their — and their practice's —

ways.

Not just computers alone

Of course, a good doctor-patient relationship comes down to more

than a single measure of quality or modernization. And different

people want different things from a doctor. Nevertheless, having a

doctor who takes pains to provide the kind of care patients need and

want is arguably more likely to please them. It will require medical

consumers to be willing to think through what they want, and ask

questions even if that means asking a receptionist to put the call

through to an office manager, nurse or the doctor.

For example, although it's important to know whether a practice is

computerized, Burnett says he wouldn't necessarily avoid a practice

based on that one factor. " Some doctors can't afford it right now, "

he says, particularly practices with just one or two doctors. And

there is debate within the profession about the ultimate role of

computers.

Many argue that their potential for revolutionizing the quality,

safety and efficiency of care is overblown. In fact, a proportion of

primary care doctors will probably never invest in them, predicts

Brailer, former healthcare IT czar for President Bush.

Speaking to healthcare journalists at a Los Angeles meeting in

April, Brailer noted that about 20% of doctors have computerized

their practices, while more than half are debating when, and how, to

make the investment. Another 20%, he estimates, are older doctors

who don't believe the technology is worth the investment and will

retire without having converted their paper files.

A patient can learn a lot about a practice's philosophy by sensing

whether the person answering the phone is open to answering

questions, suggests Dr. Terry McGeeney, chief executive of the

American Academy of Family Physicians' project to study the real-

world feasibility of the " new model " of computerized, patient-

centered family practice.

Some questions to ask of a doctor's medical practice:

• Do you have an electronic medical record?

• Would you use it to follow my care more efficiently?

• Do you use evidence-based practice guidelines to manage patients'

health?

• Can I get a same-day appointment with my doctor (or nurse-

practitioner or physician's assistant)?

• Do you offer extended hours on evenings or weekends if I can't

get off work?

• Does your staff work as a team to improve patients' care?

• Can I get a quick question answered by phone or by e-mail?

• Do you do lab tests in your office or in some efficient way that

won't take up a lot of my time?

• How would I get test results back?

• How do you track patients with chronic illnesses?

Each patient must decide what is important about a potential doctor.

These questions can give consumers a sense of whether the practice

is at least thinking about providing patient-centered, quality care.

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What to look for in a physician

Using quality information to choose a doctor is a relatively new

phenomenon — and one that few consumers are doing, according to a

2006 survey.

• Percentage of people who saw information in the last year

comparing quality among doctors: 12%

• Percentage who used it to make a decision about a doctor: 7%

Source: Kaiser Family Foundation/Agency for Healthcare Research and

Quality phone survey of 1,216 randomly selected, nationally

representative American adults, 2006.

In another survey, people were asked what types of criteria they'd

use to judge a doctor. Those surveyed were asked which of the

following information would tell them a lot about the quality of a

doctor:

• How many times a doctor has done a specific medical procedure

(66%)

• Whether a doctor is board certified, that is, has had additional

training and testing in his or her area of specialty (65%)

• How many malpractice suits a doctor has had filed against him or

her (64%)

• How patients who are surveyed rate how well the doctor

communicates (52%)

• Whether a doctor attended a well-known medical school or training

program (37%)

• Whether a doctor has admission privileges to send patients to a

particular local hospital (35%)

• Whether a doctor has been rated " the best " by a local newspaper

or magazine (28%)

• Whether a doctor charges more than other doctors do (18%)

Source: Kaiser Family Foundation/Agency for Healthcare Research and

Quality phone survey of 2,012 randomly selected, nationally

representative American adults, 2004.