Thursday, April 29, 2010

Choosing a Good Physician

As a practicing family doctor, it's easy for me to figure out how to choose a great doctor. Let me tell you the secrets in finding the best one for you and what I tell my family and friends.

Look for the following:

Board certification
Report card on quality
Licensing / public reporting

As a doctor, I know many doctors who have great bedside manner but aren't particularly reliable in getting the right medical care you deserve and these traits separate the so-so doctors from the truly excellent ones.

If you've found one that meets all of the criteria and you know is in in your insurance plan, has convenient office hours and easy access, then I'll give some tips on what to look for to determine if she has excellent bedside manner.

Importance of Board Certification
Your physician should be board certified in his field of expertise. Think of it as the difference between hiring a certified public accountant (CPA) and someone who just files taxes for you. While you might get the same result, if difficult issues come up, you may not get the best advice. Given how much we are all paying for medical care, why would you opt for someone who wasn’t board certified?

To carry this distinction, your doctor must have graduated from an accredited residency program as well as passed the passed the governing board’s certification exam. The examination may be a one-day or two-day written test. Depending on the medical specialty, test takers may also need to take an oral examination.

To maintain their board certification, physicians are required to devote a certain number of hours per year to additional medical education. Doctors often fulfill this requirement by attending conferences and seminars. In addition, doctors must re-certify with a repeat examination every few years to continue their status. Given all of these requirements, a board-certified doctor will often provide the most up-to-date medical care. Ensure that your doctor is board certified. As a recent article noted, doctors most likely to provide the wrong medical care for colon cancer screening were doctors who were NOT board certified.

Your physician may display his board certificate in the office. Some certificates may not have an expiration date because in the past, physicians only needed to take the exam once. It was good for life. This is no longer true. Current graduates can expect to retake the exam every seven to ten years.

Learn more and research your doctor at the American Board of Medical Specialties.

Report Card on Quality.
Find out if your doctor is practicing the latest most up to date medical care by checking out his report card on quality. Is he doing the right things to keep you healthy?

For example, unfortunately in the United States patients who have suffered a heart attack get drastically different care and many don’t get the life saving medication they need to prevent a future event. Less than 50 percent of heart attack patients in Mississippi receive this medication known as a beta blocker. Yet in Massachusetts, nearly every heart attack patient is taking it. This failure to prescribe the medication simply was whether the doctor consistently followed the guidelines established by the American Heart Association. It wasn’t whether the patient could afford the medication since all the patients received the same insurance, Medicare.

A review of 20,000 patients from 12 metropolitan areas showed that 24 percent of breast cancer patients, 27 percent of pre-natal patients, 31 percent of low back pain patients, 32 percent of coronary heart disease patients, and 35 percent of high blood pressure patients did NOT receive the recommended care developed by expert medical committees.

If your doctor isn’t doing the right things that experts recommend, then what else is he doing wrong?

See if your doctor has applied for the NCQA quality recognition designation in any of the following programs - Physician Practice Connections, Heart/Stroke, Diabetes, or Back Pain. This designation is like the Good Housekeeping Seal of Approval. To have this distinction, doctors must show the National Committee of Quality Assurance (NCQA) that they are doing the right things.

You can only use these aspect on primary care doctors (except for the physician practice connections which can be any doctor), like family doctors or internists, as other doctors don't typically participate in these medical problems or illnesses.

Licensing / public reporting
Although your physician does not need to be board certified to practice medicine, he does need to be licensed. Find your own state medical board by going to the Federation of State Medical Boards or simply Google your state (like Connecticut) and medical board.

Each state provides different public information about its doctors. This typically includes the name of the physician, his license number, when the license was issued, and when it expires. Other states provide additional information like history of malpractice suits, felony convictions, or disciplinary action by the medical board. Some states split up the licensing and disciplinary functions into two different departments or websites. While at the state website, look for a link either for physician profile or credential search.

California State Medical Board
New York State Medical Board

The first three items, board-certification, report card on quality, and licensing / public reporting I know is unlikely things you would have come up with.

Bedside Manner
So now that you've found doctors that fulfill these basic requirements, what really is important for all of us is our doctors' bedside manner. If you have friends who are medical assistants, nurses, or others in healthcare, ask for recommendations. Often they see us when we are the most stressed. If they like working with us, then it is likely that they will recommend us.

Not sure you got the best? Here is how you know.

Does she...
Sit down?
Know your medical history?
Involve you in the decision making process or get your perspective?
Ask you – do you have any other questions?

Finally, most importantly, does she always wash her hands?

Follow this advice and feel extremely confident that you have a great doctor!

Thursday, April 22, 2010

Seventy Five Percent of Primary Care Doctors Provide Sub-Standard Colon Cancer Screening Care

A recent article found that primary care doctors the United States are providing sub-standard care when it comes to colon cancer screening. In the Journal of General Internal Medicine, researchers found that 25% of primary care doctors used in office stool testing to screen for colon cancer. Specifically, doctors do a rectal exam and then swipe the rectal contents off their gloves onto a stool testing card. A positive test result indicates the presence of blood, which can be invisible to the naked eye.

The in office stool testing has not been the standard of care for at least a decade. More importantly, it also misses 95% of advanced colon / rectal cancers. The study found that doctors most likely to do the in office stool testing were those in solo practice.

To confuse matters even further, another fifty percent of doctors did both in office stool testing as well as home testing. This means that essentially 75 percent of primary care doctors are using the wrong screening test.

If one is to screen for colon cancer correctly and wishes to use stool card testing, then it must be done by the patient at home, not in the office by the doctor.

If the stool test revealed occult blood, the recommended follow-up is a colonoscopy. A repeat stool test is not suggested. A sigmoidoscopy is also not recommended for a positive stool test result.

Disappointingly, 17.8% of doctors recommend repeating the stool test. If the second stool test was normal, 28.8% recommended no further workup. This is not only wrong, but now falsely assures the patient that everything is fine. Researchers found doctors most likely to recommend a repeat stool test were those who graduated from medical school before 1978, who were not board-certified, and who were in solo practice.

Though this study surveyed doctors from September 2006 to May 2007 and researchers noted that there was slight improvement in colon cancer screening from 2000, (more doctors did not choose sigmoidoscopy after a positive stool test) the results are still quite disturbing.

The correct options for colon cancer screening for Americans at average risk for colon cancer beginning at age 50 include the following:

Fecal occult blood testing (FOBT) -- stool testing which is done at home, not in the office. Done annually.
above with flexible sigmoidoscopy every 5 years
colonoscopy every 10 years

The authors of the article were too kind when they subtitled their article “serious deviations from evidence based recommendations”. In 2000, when a colleague of mine and I during residency polled our twenty two other family medicine residents and interns, every one correctly knew that in office stool testing was not the standard of care.

The article concludes that “many physicians are continuing to use inappropriate implementation methods [and that] intensified efforts to inform physicians of recommended technique and promote the use of systems for tracking test completion and follow-up are needed.” In other words, if we continue educating doctors perhaps one day they will all do what the standard of care has been for the past 10 years!

Why is this study important?

The only people that can make the healthcare system better is doctors. When we fail, patients get inadequate care.

When healthcare reform proponents recommend patients be given more financial responsibility to get medical care, I wonder if they are too naive. The belief is that the public will choose more prudently when they have more monetary skin in the game. As a result, the thought is that as healthcare becomes more like other markets, consumer goods, purchasing other services, that the healthcare system will be more efficient and drive costs down further.

While I understand that patients should have some cost-sharing, this alone won’t fix the healthcare crisis. Consumer driven healthcare advocates fail to realize that the degree of information needed to make patients truly smart consumers requires a medical degree and training.

Do we expect that patients should be able to recite what are the correct screening modalities for colon cancer screening when doctors can’t do it consistently now even though guidelines have been around for years?

Will patients choose only board-certified doctors or choose quality of medical care based on bedside manner? The correct answer is they should find doctors who have both qualities. If one must choose between the two, patients should opt for board-certification over bedside manner.

This research suggest that perhaps it might be better to find a doctor not in solo practice. Is it possible that doctors are smarter and up to date on the latest research findings because of conversations that occur between patients? Are two heads better than one?

Otherwise, patients have a difficult, but not impossible responsibility to educate themselves. That is why I wrote my book so if our healthcare system truly becomes consumer driven at least there is an easy reference to get everyone up to speed.

You might need to pick up a copy for your own doctor to read.

Monday, April 12, 2010

Can Price Shopping Improve Health Care? Do Pigs Fly?

In a recent Time magazine article Could Price Shopping Could Costs and Improve Health Care, the author suggests as many others have done in the past that forcing patients to more like customers and comparison shop will drive healthcare costs down.

Nothing could be further from the truth.

The theory of consumer driven healthcare goes that if there was more information about the costs of doctors, hospitals, imaging tests, and procedures that people would hunt around to find the best deal, stimulate competition, and drive pricing downward.

Proponents always point to the example of how LASIK eye surgeries have gotten less expensive because of price transparency and increased competition as more eye doctors enter the market in what used to be a very expensive procedure.

But that is always the only example that they give.

They fail to demonstrate how price transparency alone results in decreased costs. Look at elective plastic surgery, which like the LASIK example, has doctors providing a service which isn't medically necessary. Shop around. Get pricing. Has plastic surgery gotten less expensive like LASIK surgery? Of course not. Why?

In the past, LASIK eye surgery required the very skilled hands of an ophthalmologist. Over many years, however, understanding precisely who made a good candidate and the optimal surgical technique to be used become more clear. Consequently the procedure became standardized. As a result, these days LASIK surgery is typically performed by an machine that is essentially automated under the supervision of an ophthalmologist. Because of this standardization and precision, LASIK surgeries are done more reliably and quickly for those who are good candidates. For those of us who have conditions that don't fit into this neat workflow, we will still need to rely on the human doctor's expertise and experience. In those situations, the pricing won't be inexpensive.

It isn't price transparency alone that will drive costs down, but the standardization of treatments for a particular ailment. Specific treatments for bladder infections (urinary tract infections), sore throat, like strep throat or mono, pink eye (conjunctivitis) are fairly clear cut and straight forward. This is why walk-in clinics like Minute Clinic can drive costs downward using less expensive physician assistants and nurse practitioners, rather than doctors. For sore throat, the workflow is pretty obvious (and available at

Note how they avoid back pain and chest pain. It may be for liability issues, but also because the amount of precision needed isn't quite there. Once medical science can determine which tests or interventions can reliably differentiate a symptom or problem into a specific treatment will costs come down. This is probably why plastic surgery won't quite ever become a commodity like LASIK surgery. How would you like to have a standardized nose job or face lift?

Proponents of consumer driven healthcare also believe that having patients pay more of their healthcare expensive or "having more skin in the game", will also drive costs down over the long-term. The thinking goes that if people understood the high costs of having a chronic illness like diabetes or heart disease that they would choose healthy behaviors. They should appreciate that preventive interventions like cancer screenings were less expensive than dealing with a cancer diagnoses and subsequent treatment. Getting a simple vaccination to prevent influenza or pneumonia would be far better in preventing emergency room visits or hospitalizations. People would begin to make rational choices and opt for less costly therapies today to put off very expensive theoretical losses in the future.

Odds this will occur? Highly unlikely.

Simply look at how the American consumer fared when given financial responsibility to make decisions presumably for their best interest, retirement planning, to determine how successful the public might be in embarking on consumer driven healthcare.

Starting in the 1970s, employers started to shift employees from pension plans (defined benefit plans) to 401(k) plans (defined contribution plans), where employees would have more financial responsibility and have "more skin in the game" in determining how much to save and how to invest for retirement. The thinking was that employees, looking out for their best interest, would do research and demonstrate the rational behavior needed to ensure that they retired with a nest egg that suited their needs. After all, who would have more motivation to save for retirement than the individual himself?

Did it work out as planned?

A recent article from CNN Money found that 43 percent of Americans have less than $10,000 saved for retirement. More importantly "the gap between what Americans have saved and what they'd need for retirement is forcing workers to prolong their working years."

In other words, the American consumer isn't doing well to save for retirement even though it is in his best interest. At least in retirement planning, consumers have the option of delaying retirement and working longer.

Consumers as patients, however, won't have that luxury of putting off medical care if they suddenly become ill. It is very likely a large number of Americans instead of losing weight and controlling blood pressure will have a devastating heart attack that requires open heart surgery. Colon cancers will be detected at later incurable stages requiring very expensive chemotherapy for months rather than having been removed years earlier with less costly colonoscopies. It is very likely in consumer driven healthcare, much like defined contribution retirement plans, that the consumer or patient hasn't saved enough to pay for these very expensive future therapies or treatments.

As a graduate of the Wharton School of Business, however, I wouldn't do my education justice if I completely dismissed the concept of efficient markets, consumerism, and competition. If consumer driven healthcare is to work, it will require a few elements, which unfortunately the American healthcare system at this time is ill equipped to deliver on.

I will discuss these crucial elements in a future post.

Wednesday, April 7, 2010

Wanted - Primary Care Doctors ASAP.

In a few years, every American will be required to have health insurance. As a result, the 32 million people currently uninsured will seek out a personal physician. This role typically is filled by a primary care doctor, like an internist or a family physician.

While passage of the health insurance reform bill affirmed the belief that having health insurance is a right rather than a privilege, the legislation falls short on building a healthcare system capable of absorbing the newly insured. Universal healthcare coverage is not the same as providing universal access to medical care. Having an insurance card doesn't guarantee that individuals can actually get care.

One doesn't need to look any further than the Commonwealth of Massachusetts to see what problems lay ahead. In 2006, the state required everyone to have health insurance. It was believed that having universal coverage would have slowed healthcare costs. Expensive emergency room visits would be averted as newly insured individuals would have a personal doctor who could address the problems sooner and at less cost.

Unfortunately, that scenario never occurred. According to the state medical society over half of internists and about 40 percent of family physicians were not accepting new patients. So the newly insured still didn't have a personal doctor to call upon even though Massachusetts has the most primary care doctors per capita than any other state. Insurance coverage does not mean access to medical care.

If a manageable patient panel per full time primary care doctor is about 2000 patients, then the nation would need an additional 16,000 doctors to care for the newly insured. With some evidence that the nation is expected to be short about 40,000 primary care doctors over the next decade, one should wonder if we are training enough doctors to fill the gap.

The answer is no. With the 2010 residency match, US trained medical students have indicated that primary care is not what they want to do. Of the roughly 2300 positions in family medicine residency programs, only 45 percent were filled by students attending American medical schools. While the American Academy of Family Physicians proclaimed the 2010 Match as the most successful ever with 91% of residency positions filled, the sad reality is obtaining this rate required eliminating 600 positions over a decade. In 1999, there were over 3200 family medicine positions available for medical students to match into.

Internal medicine numbers are better, but won't address the primary care crisis either. Though nearly 5000 students are training in internal medicine, the trend has been to use the three year residency program as a prerequisite for more lucrative medical subspecialties like cardiology, pulmonary, or oncology, to name a few. While in 1998, 54 percent of internal medicine residents planned on becoming primary care doctors after training, by 2003, the number fell to only 27 percent.

Solving the primary care crisis can't be done with ancillary clinicians. As Americans are paying more for healthcare, I don't believe that they would willingly choose to have primary care done by nurse practitioners or physician assistants. That is not to say that there are not plenty of excellent clinicians out there, but adding these physician extenders won't bend the healthcare cost curve. Their costs often are comparable even as their knowledge base is less.

Though the healthcare reform legislation tries to maintain the primary care workforce via increased income for primary care doctors providing Medicaid services as well as increase the numbers with grants for more primary care training and loan repayment for doctors working in underserved communities, the reality is medical students won't be signing up. The specialty's relatively low pay, absence of work-life balance, and low prestige compared to other medical fields doesn't resonate with today's students.

That's too bad because the nation and the public needs more primary care doctors than ever. Not only can primary care doctors decrease costs, but also the amount of time wasted getting to the right specialists. One health plan that focused on using primary care physicians to coordinate care discovered use of specialists fell by 14 percent, emergency room use decreased by 16 percent, and prescriptions declined by 11 percent. When patients self-referred to specialists, about 60 percent went to the wrong specialist. More troubling is that on average $1500 was spent on various tests and diagnostic services over an 11 month period before patients were told that the specialist could not help them.

So having a personal doctor is important and can save you time and money, but more importantly get you feeling better sooner. Too bad the nation won't have enough to go around. Hurry and find a primary care doctor you like and trust because it is possible later on you might find yourself without this indispensable advisor and guide for many years to come. Result to you and implications for the nation? Spending more time and money and not getting any healthier.

Want a crystal ball on how this legislation will affect the country? See what Massachusetts does next.


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