Uncategorized

Rating Doctors Like Restaurants, by Bob Wachter

Robert_wachterRobert Wachter is widely regarded as a leading figure in the modern
patient safety

movement. Together with Dr. Lee Goldman, he coined the
term "hospitalist" in an influential 1996 essay in The New England
Journal of Medicine. His most recent book, Understanding Patient
Safety, (McGraw-Hill, 2008) examines the factors that have contributed
to what is often described as "an epidemic" facing American hospitals.
His posts appear semi-regularly on THCB and on his own blog "Wachter’s World."

So Zagat will now be rating doctors, using the methods it perfected helping you find the best sushi in Brooklyn Heights. What’s next, Consumer Reports rating grad schools? Fodor rating auto mechanics?

Whatever you think of Zagat’s cross-dressing, it again demonstrates
the bottomless market for doctor rankings. HealthGrades, the Colorado
company that breathlessly delivers its “200,000 Americans died from
medical errors in 200X!” pronouncements every year (grabbing a bunch of headlines, despite the fact that this report is based on measures that were not intended for this purpose and really aren’t measuring deaths from errors), appears to be doing quite well,
thank you, largely fueled by its doctor ratings. And every metropolis’s
city magazine has its “[Your City’s Name Goes Here]’s Best Doctors”
issue, based almost entirely on peer surveys. Most docs scoff at these
ratings (particularly docs like me who haven’t made their city’s list),
but they clearly move magazines. [I’ll discuss hospital rankings,
especially US News & World Report’s Best Hospitals list, in a future posting.]

Clearly, real people want to know who is a good doctor. But how should we be approaching this task?
have the privilege of serving on the board of the American Board of Internal Medicine. ABIM, and the other specialty boards, have generally taken their charge to be to determine “competence” (with board pass rates generally above 90%, a pretty low bar) and then not to differentiate further. A doc is either board certified or she’s not. End of report.

ABIM’s
recently finalized strategic plan includes a commitment to make public
more information about diplomates if and when it feels such
distinctions are scientifically valid and dissemination would promote
high quality care. Dr. Kevin Weiss, the new president of the American Board of Medical Specialties
(the umbrella organization for all the specialty boards) might go even
further, faster. He recently went on record as favoring having the
Boards enter the doctor ranking business – not just determining
competence, but differentiating excellence from not-so-much. In a
recent talk to the ABIM board in Dallas, Dr. Weiss held a copy of Dallas Magazine’s
Best Doctors issue and dramatically observed that if the Boards don’t
get into this game, others – with far less allegiance to scientific and
psychometric Truth – will. Needless to say, his remarks generated a wee
bit of controversy.

I’m also on Google’s Healthcare Advisory Board. [Note that my
comments about ABIM and Google represent my own opinions, not those of
these fine organizations, and do not divulge any trade secrets. You
decide whether to buy more Google stock on your own.] Anyhooo, it
wouldn’t surprise you to learn that Google is also thinking
about what contribution it can make to the doctor rating “space.” But
how to balance consumer rankings (a la Zagat), which will invariably
tilt toward bedside manner and office amenities (not unimportant
things, but ones that may be quite different from clinical acumen),
with more meaningful assessments of clinical competence? And, as I discussed earlier this month,
even when you add standard process and outcome measures to the brew,
we’re still stuck scratching our heads about how to factor in clinical
knowledge and decision making, things that today’s quality measures
completely whiff on.

The stakes are immense, and a balanced approach is more likely to
bear fruit than any single peephole.
Ultimately, if I’m choosing a doc for me or a loved one, I’d like to
know it all: bedside manner (4 stars from Zagat), structural measures
(is the doctor’s office computerized?), process measures (are diabetics
getting statins appropriately?), surrogate outcomes (what’s the average
hemoglobin A1c?), and hard outcomes (what are the risk-adjusted
mortality or hospitalization rates?). And then I’d like the appropriate
specialty board (ABIM, American Board of Surgery, etc.) to tell me
whether the physician is meaningfully engaged in quality improvement
activities, and how well he or she did on the certifying exam – the
best measure we have of knowledge and clinical judgment. Yes, you heard
me right: I’d like the Board to tell me whether the doc was in 5th
percentile on the certifying exam or the 87th. It doesn’t pass the
smell test to say that we consider both these board certified docs to
be undifferentiate-able. In this new era of transparency, if we
physicians would want that information before choosing a doc for
ourselves (and I sure would), then I believe that patients should have
access to it as well.

And then I’d like Google or somebody else
to put all of this together into an attractive, user-friendly page that
pops up when I type “Best Doctor Diabetes San Francisco” into a search
engine, along with directions to the office, a link to his appointment
calendar… and a parking spot.

Coming soon? The people have spoken, and the people have an uncanny way of getting what they want.

Bob Wachter

Livongo’s Post Ad Banner 728*90

19
Leave a Reply

19 Comment threads
0 Thread replies
0 Followers
 
Most reacted comment
Hottest comment thread
14 Comment authors
Laura SmithStatistics Courses for doctorsultrasound gelHerbert Rubin, M.D.rbaer Recent comment authors
newest oldest most voted
Laura Smith
Guest
Laura Smith

Jamie Zaita is a bad doctor. Don’t go to her! She doesn’t care about patient’s well being. She treat them like cattle.

Statistics Courses for doctors
Guest

Medical Statistics Courses for doctors and clinicians can be downloaded or ordered on DVD from http://www.Learn-Medical-Statistics.com

ultrasound gel
Guest

I think this would have to be handled with great caution. Patients are often inappropriately dissatisfied (“doctor did not prescribe my analgesics that I take daily for headaches

Herbert Rubin, M.D.
Guest

I prefer J.D. Powers ratings to Consumer Reports. The former is based on consumer experience, the latter based on expert opinion. I trust consumers lots more than I trust experts.

rbaer
Guest
rbaer

I am a little surprised that someone as smart as Dr. Wachter (as well as many debaters) want to enhance consumerism in health care. There are (and always will be) patients that are more demanding and make greater efforts to find the doctor they think will be best (for specialty, insurance and area in question). Some patients use reasonable criteria (e.g. recommendations by physicians and/or intelligent friends with first hand experience), others probably not (for instance, one patient told me that my MPH was a major reason to come see me). The criteria listed by Dr. Wachter sound good on… Read more »

Peter
Guest
Peter

“and effectively informs patients about the risks, advantages, and alternatives for a broad range of surgical procedures,”
Is the patient competent enough to make those decisions – or was this written by lawyers for lawyers?
Care to share the five key factors?

Eugene Rosov
Guest

Intriguing. Our company, which runs two insurance companies (one for pediatricians, one for ob/gyns), created an “informed consent” program for ob/gyns. (Incidentally, the program saves our ob/gyns an average of 300 hours a year – worth about $120,000 in billings – and effectively informs patients about the risks, advantages, and alternatives for a broad range of surgical procedures, while simultaneously providing the physician with a comprehensive report on the patient’s listening and reactions.) At the end of our informed consent programs, we ask patients to “rate” their doctors for five key factors. We are collecting (literally) tens of thousands of… Read more »

jay
Guest

Lets not forget that individuals have to deal with 3rd parties – healthcare companies. What role should they play?
Along those lines, if anyone can help support the project at payorwiki.com (a mediawiki) please do add and refer others to contribute.
I’m hopeful with enough community support, we can make a difference.
Thank you
J

Matt Guldin
Guest
Matt Guldin

I wouldn’t dismiss patient satisfaction ratings as a passing fad. This has been done for 20 years in healthcare. Hospitals have collected and used patient satisfaction results for a number of important strategic purposes including service offerings, building decisions, and marketing messages. Couple of interesing ideas on how to make patient satisfaction ratings impactful besides CMS reporting: – Tieing this information into online provider directories and health search results for individual docs. – Use this data along with some other pieces to structure tiered provider networks instead of utilizing on strict utilization numbers sprinkled with a few quality ratings. –… Read more »

Matt Guldin
Guest
Matt Guldin

“Why don’t we get nurses to rate doctors, that would be information from the trenches.”
This is already happening at NursesRecommendDoctors.com. One of at least a dozen companies popping up in the patient satisfaction ratings field for physicians.

Lynn
Guest
Lynn

What a refreshing discussion, how to rate physicians not whether to rate. That’s a big change. When physicians adopted the medical business model, they were warned by Arnold Relman, where this train was headed. In a business model, good/fair customer service is a reasonable expectation. I don’t believe physicians have much to fear because Americans have adapted to poor and bad customer service in a variety of service industries. I feel certain we will adjust to bad customer service in healthcare even when we can document in “science” it is bad service. Patients/customers are smarter than we (editorial not royal)… Read more »

Lynn
Guest
Lynn

What a refreshing discussion, how to rate physicians not whether to rate. That’s a big change. When physicians adopted the medical business model, they were warned by Arnold Relman, where this train was headed. In a business model, good/fair customer service is a reasonable expectation. I don’t believe physicians have much to fear because Americans have adapted to poor and bad customer service in a variety of service industries. I feel certain we will adjust to bad customer service in healthcare even when we can document in “science” it is bad service. Patients/customers are smarter than we (editorial not royal)… Read more »

Barry Carol
Guest
Barry Carol

Why don’t we get nurses to rate doctors, that would be information from the trenches. I agree with you 100% on this one, Peter. I would like a rating system that would speak to the doctor’s clinical ability, communication skills, and the cost-effectiveness of his or her practice pattern. Good bedside manner and not keeping patients waiting too long for their appointments are desirable, but I would trade a lower score on those two measures for a higher score on the first three. Input from nurses, including a suggestion as to whether or not they would go to a given… Read more »

Peter
Guest
Peter

I agree with Matt, satisfaction ratings/surveys are a mine field and once established change those being rated to play-to-the-survey. First you are asking non-medical, non-technical patients, many with little education and communication skills, to rate their experience. Their experience may only be understood by them to be, “he was soooo kind, soooo polite, and surely I felt better when I left the office”. Sorry, but that’s not what I want to know. I think we’ve all seen and done satisfaction surveys, does anyone think the questions make any sense or really allow you to communicate YOUR experience. “Strongly Agree”, “Agree”,… Read more »

Matt Guldin
Guest
Matt Guldin

This conversation misses the point about patient satisfaction ratings. The play in patient satisfaction ratings for physicians is what CMS is pondering. CMS has already mandated that hosptials will have to begin collecting patient satisfaction ratings as of July 2007 through a standardized instrument (the HCAHPS survey instrument). If hospitals fail to meet this requirement, they will be subject to a fiscal penalty of 2 percent of their Medicare payments for fiscal year 2008. Plus, this data will be made public starting in March 2008 on the CMS website. This wasn’t a big adjustment for hospitals since they already have… Read more »