Sunday, October 12, 2008

Doctor Shopping - Finding the doctor you need


So I'm sitting in Starbucks near my house with my kids when this group of joggers comes in for a post-run sit around. They immediately get off into some discussion about orthopedic sports medicine and their various injuries, complete with editorials about how their doctor is wonderful, how they were "misdiagnosed", and wondering how different specialists gave them contradictory advice or opinions.

I kind of felt sorry for them. Picking a doctor is tricky, even for doctors. As I work doing surgery at half a dozen hospitals, I have a general idea of the reputation of different surgeons' abilities and personalities in several parts of town.

When I was a resident working with dozens of different attending surgeons, I definitely felt like I could get a feel for who was outstanding or poor. However, when my wife had musculoskeletal back pain, I was left to kind of "guess" at the competence of a neurologist (whom I really respect BTW) who was treating my wife. Some of their field is just too removed from my scope of practice to be fluent in.

Eavesdropping on the joggers reminded me of a letter in the New York Times health section on an article about picking doctors, "You Can Find Dr. Right, With Some Effort". There was a really insightful letter from an ER doctor that stood out to me which I think is worth republishing:


As an emergency physician for 32 years, here is how I would and would not go about finding a personal physician:

1. Chronic medical care: choose primarily based on personality, secondarily on skills. All doctors are smart, in the top 1% of the population, which makes them abnormal to start with. For ongoing care, you need the minority with great personalities. For skills, just make sure they are ABMS (www.abms.org) board-certified.

2. Surgical care: Choose primarily based on skills. Ignore their personality. Here you want the best technician with the best judgment, not Marcus Welby. It will usually be a short-term relationship for a problem that requires invading your body and significant medical judgment issues. It’s not worth trying to find someone who combines both skill and personality; if you get both, it’s a bonus.

3. Acute care: You’re at your most vulnerable and have no time to research. Your regular doctor rarely can see you for acute care: you end up in an urgent care center or ER. Choose based on skill and judgment only, which must necessarily be based on quickly accessible reputation and qualifications.

OK, how do you find someone based on skill/judgment, or based on personality?

1. Personality: Here’s the only place to use friends, neighbors, and trusted acquaintances. These people are qualified to judge this aspect of a physician. This is totally unrelated to a physician’s skill or competence, but this is important for chronic medical care.

2. Skills/judgment: Never use the recommendations of non-medical personnel. They have no basis on which to judge. Avoid online evaluations: they are statistically prejudiced and don’t account for individual practice variances. Instead, use trusted medical acquaintances such as physicians or nurses to make recommendations. They have both the personal experience and medical sophistication to make such recommendations.


I'd agree in general with the insights of this doctor, especially with surgeons. For instance, there were some grade-A sociopaths I knew/know in various specialties whom are outrageously gifted surgeons. I'd be happy to let them do my liver resection, organ transplant, aneurysm clipping, etc... as long as I did not have to speak to them ever again.

Rob

4 comments:

jizo said...

dr oliver: as a patient and the daughter of a doc with 4 specialties, i was with you about personality not counting [in extremis] until you said the great surgeon might happen to be a sociopath. maybe im taking you too literally, but sociopaths are the most likely to have _manipulated_ their [way to a good] reputation. a bad personality mustnt be confused with a dangerous personality disorder. he must not only be known for skill, he must be trustworthy.["first do no harm!]
i think you meant a [nearly] malignant narcissist. i agree- so what if the surgeon even oafishly betrays he thinks he's god.Enroute to the OR we under the knife get a similar impression! Docwilling as an impressionist his performance displays more than a slight resemblence.

jizo said...

dr oliver: as a patient and the daughter of a doc with 4 specialties, i was with you about personality not counting [in extremis] until you said the great surgeon might happen to be a sociopath. maybe im taking you too literally, but sociopaths are the most likely to have _manipulated_ their [way to a good] reputation. a bad personality mustnt be confused with a dangerous personality disorder. he must not only be known for skill, he must be trustworthy.["first do no harm!]
i think you meant a [nearly] malignant narcissist. i agree- so what if the surgeon even oafishly betrays he thinks he's god.Enroute to the OR we under the knife get a similar impression! Docwilling as an impressionist his performance displays more than a slight resemblence.

ciaobella said...

The doc has an interesting point....a study done in Great Britain made note of a greater prevalence and severity of personality disorders noted in "upper management" in the business field than in convicts who are sociopaths. Their study concludes the difference as the "successful" sociopaths are upper management, while the "unsuccessful" sociopaths are convicts. As I know a few, that produced a wry smile from me:).

Willow and Wattle said...

I agree, many surgeons are sociopaths. I have dealt with several, after the first decided that he would do what he liked with my reconstructive surgery, 3 times, never correcting it, but instead making it worse, his personality was definately sociopathic. However when you bring the issues that occured to other surgeons, they simply refuse to believe the situation and cause even more problems to the unsuspecting patient who by this time is suffering from severe emotional trauma. Trauma by the way is not at all understood by surgeons. They simply prefer to believe that its all your (psychological) problem and as such offer no support and certainly not a fix, instead add to the trauma. What surgeons and doctors do not understand is that there are others out there in the real world who are also the top 1% of the population in intelligence and perhaps are even forensic investigators, yet they are treated like less intelligent blots on the earth who have no idea what has actually happened to them. I have had several misdiagnosis, but mostly surgeons simply do not want to listen, the bain of existance to an investigator who is very used to dealing with fine details and piecing together enormous amounts of information into one cohesive, fact and evidence based conclusion. Its a huge source of frustration, enough to bring one to tears over and over again.