THCB

How Patients Can Assess the Quality of Their Outpatient Care

Even before I launched my geriatric consultation practice, I found myself often pouring over another doctor’s outpatient notes, trying to explain to a patient what the other doctor was doing.

Sometimes these other doctors were specialists to whom I’d referred the patient. But often they were simply clinicians – either previous PCPs or currently involved specialists — whose involvement with the patient predated my own.

Not every patient had questions and concerns about what their other healthcare providers were saying, and doing, but a fair number of them did. And family caregivers, in particular, were often concerned that perhaps their older loved one hadn’t been getting the “right” medical care.

These are, in truth, legitimate concerns patients have. In a busy outpatient setting, doctors often don’t have the time to explain the assessment and plan to a patient and family. And in many cases, the care that clinicians provide may not correspond to best practice guidelines – if applicable to the situation – or to the patient’s preferences and values.

So if you are a concerned patient or family member, and you’re not entirely sure about the medical care you’re getting, what to do?

Should you:

  1. Look up the provider’s quality ratings online, through a government, non-profit, or other website?
  2. Figure that the ACO or payer is on top of it, now that we are moving to pay-for-quality and fee-for-value?
  3. See what other patients have said about the provider’s care?
  4. See how many doctors are referring to the provider in question, and assume that if many doctors refer to this clinician, the clinician must be good?
  5. Look up your medical problems online, and try to determine for yourself whether you’d been getting the right medical care?
  6. Get a second opinion from another doctor?

My guess is that most patients and families end up trying one – or both – of the last options. In this post, I’ll explain why I’ve come to believe that facilitating second opinions is integral to empowering patients, and to improving the quality of outpatient care.

Why seek a second opinion

I don’t know about you, but when I’ve found myself trying to solve a problem in which I lacked adequate expertise, I’ve turned to a professional for help. (I haven’t had to do this for medical reasons in the past decade, but have done it for issues such as home renovation and website design.)

And in many cases, after meeting with an expert for a while, I’ve then turned to yet another expert to get an additional perspective on the issue at hand.

Why? Well, how else am I supposed to determine whether expert #1 is providing me with suitable expertise, especially if after seeing expert #1 I’m left with a nagging feeling that maybe this isn’t quite the help I wanted. In my case, the stakes have been my time, money, and satisfaction with the end product. But if it were a question of health and wellbeing, I’d probably be even more diligent about getting a second opinion.

Incidentally, this is how many patients and families now find me. They have been getting care, but they are either dissatisfied, or they’re worried that perhaps not all the right things are being done.

And so even though I’m happy to be a consultant to other doctors, I’m now mainly a consultant to elders and families. And just as I did when I was a PCP, I find myself spending a lot of time explaining to families what other doctors are doing.

This, I think, is good work to be doing. By looking over records and discussing a family’s medical concerns, here are the specific things I’ve found myself doing:

  • Reassuring families that the current medical treatment plan is reasonable. Often, in looking over the care, I find that the medical care so far corresponds to guidelines and common standards of practice. However, in many cases clinicians have not had time to explain their approach in depth to the patient and family. Families are often relieved to hear this, and appreciate developing a better understanding of their usual clinician’s plan.
  • Pointing out which aspects of the care plan are worrisome. Worrisome, as in really not concordant with guidelines or best practice. These include benzodiazepines for sleep in the elderly (with no discussion of the risks, or plan to avoid indefinite benzo use), or failure to initiate workup for an alarm symptoms such as significant weight loss. This also includes failure to follow-through on a plan; I’ve come across some charts in which the PCP repeats the same plan to get labs or pursue a study, at every follow-up visit. (In one case, the patient’s family had no idea that this was the plan.)

  • Pointing out medications, procedures, or other medical interventions that are likely to be of marginal benefit. This comes up quite a lot in frail elderly patients, because many common approaches in general medicine require time to benefit (i.e. statins, tight glucose control). In other cases, clinicians have developed the habit of referring patients for tests that research has shown to not be so helpful, such as screening for asymptomatic carotid stenosis.

  • Pointing out which aspects of the care plan could be considered choice and preference sensitive. There are some things in medicine that definitely should be done. For example, if an older person has a loud murmur and shortness of breath on exertion, he or she should almost certainly be sent for an echo, to evaluate for symptomatic valve disease. But for many other things, especially when it comes to elderly patients – or patients of any age, in truth – there are many possible ways to proceed, all of which could be considered reasonable. Back pain without alarm symptoms? One could refer for physical therapy, or prescribe analgesics. Or do both. Ideally this would depend on the patient’s preferences and particular circumstances. But in common practice it seems to depend more on the style of the clinician.

Why we should make it easier for patients to get second opinions

The main reason to do it relates to last point above: we should enable patients to get a second opinion because often there is no definite right way to proceed medically, and so how to proceed is essentially a judgement call.

And without access to second opinions, it will be very difficult for patients and families to determine which aspects of their medical care involve judgments calls.

Now, in an ideal world, this wouldn’t be an issue because clinicians would be able to consistently let patients know which aspects of the treatment plan consist of judgment calls, and would always offer patients the option of shared decision-making for these situations.

But the real world is different. Most clinicians are not used to presenting patients with options, and then tailoring the care plan to meet the patients’ preferences rather than a clinician’s habits. If nothing else, doing so takes time, and no clinician has much time these days. So judgment calls proceed according to the clinician’s judgment and preferences, in accordance with our time-honored habits of letting doctors decide because presumably they know what’s best for the patient.

Except, they often really don’t know what’s best, or even better. Among other issues, in many cases clinicians have not had the time or inclination to develop a good understanding of the patient’s experience. To quote from Dr. Larry Weed’s “Medicine in Denial”

“It is the patient, not the physician, who must live with the risks, the pain, the trade-offs, the effort and time that decisions may entail.”

On their own, patients experience pain and effort. But they may not be aware of trade-offs, risks, and alternative options. For that, they need more information, and although some of it can be found through diligent searching online, they should also be able to access an expert who can synthesize information and tailor it to the situation at hand.

In this way, patients and families can be empowered to check on the quality of their care, and can identify other courses of medical treatment may be a better fit for them.

Barriers to second opinions and how to overcome them

There are, of course, some barriers to making high-quality second opinions more easily available to patients. They include:

  • Difficulty accessing patient data and bringing it to another clinician. My own work is often held up by the effort of obtaining records and information from other clinicians. Patients should be able to access and collect their own healthcare data, as this will facilitate care coordination and empower patients to participate more in their own healthcare. (Give ‘em their damn data!) But until this is widespread, the challenges of health information exchange make it hard to have another clinician weigh in on one’s care.
  • Inadequate clinical documentation. Even when one manages to get information from another clinician, it’s usually quite hard to tell what the clinician was really thinking or planning to do. Before templated EHR notes, the problem was that notes were very short and uninformative. (See Larry Weed’s 1971 grand rounds for a hilarious and biting critique of clinical documentation. Sad to say that things have not yet improved much.) Now that EHRs provide templates, I receive notes with lots of text and still have no idea what is going on. Plus some of the information is quite frankly wrong, presumably because the clinician has checked too many boxes in a hurry.

  • Difficulty accessing and identifying a suitable expert. Even when patients have gathered the right medical information, they may often find it difficult to access someone for a second opinion. Academic clinics often have long waits for an appointment. Clinicians who are not subsidized by a larger institution may not offer appointments that are long enough to allow for review of a complicated medical situation.

Summing it up

Second opinions can help patients and families check on the quality of their care, in real-time. This can reduce a family’s anxiety about ongoing medical care, and can help patients better understand the care they’ve been receiving.

Although occasionally real gaps in care are uncovered, in my own experience I’ve found that second opinions mainly help patients and families identify other management approaches which their previous clinician may not have discussed with them. For older patients in particular, care should be individualized and tailored to the patient’s – and caregivers’ — needs and preferences. Historically clinicians have tended to dictate care according to their own habits and preferences, in part because shared decision-making takes more time. Second opinions can help educate patients, and empower them to better individualize their care.

Barriers to faciliating second opinions include difficulty accessing clinical information in the possession of other providers, as well as inadequate information within the progress notes. Last but not least, patients may currently find it difficult to find a provider willing and qualified to provide a second opinion.

Leslie Kernisan, MD, MPH, has been practicing geriatrics since 2006, and is board-certified in Internal Medicine and in Geriatric Medicine. She is a regular THCB contributor, and blogs at GeriTech.

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Afik GalLeslie Kernisan, MD MPHpcbJohn Irvine Recent comment authors
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Afik Gal
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Afik Gal

Hi, Usually I enjoy your posts very much but this time I have to disagree. 2nd opinion is not a solution.The problem with 2nd opinion is that it only accentuates the problem and it does not solve it… not to mention the opportunity for 3rd and 4th opinion…(each physician, unfortunately, has its own flavor of medicine and its sometimes hard for patients to really evaluate these differences). All of this leads to a successful clinical consulting practice but its usually not affordable by many patients and simply bad for the system. This is also a bad temporary solution because it… Read more »

Leslie Kernisan, MD MPH
Guest

hi Afik Thanks for raising these very good points. I completely agree that overall we need better structure and standardization in clinical practice so that patients can more reliably get the right care. And that right care should include providing patients with detailed documentation of what was done, as well as explanations of the options, the risks, the benefits. And then patients should be assisted in selecting and implementing a way forward that’s a good fit for them. The problem is that this will take a long time to achieve. (5 years? 10? Larry Weed has been calling for change… Read more »

Leslie Kernisan, MD MPH
Guest

Thanks for this comment.

In truth, I’m not quite sure why the time issue has to be as intractable as it is. Even if we didn’t give patients and families as much time as they might like, we can still look at the medical problems of the average older person and figure out how much time would be needed…generally on the order of 30-60 minutes.

GroupHealth went to longer primary care visits, so it’s possible that other health systems will follow suit.

But even with longer visits, people will benefit from second opinions. Now who should pay for those? that’s another question altogether.

pcb
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pcb

very nice post.

You referenced doctors not having time to give proper care in our system, which seems to be the crux of the matter, at least from my perspective (and experience).

I find that a sad state of affairs. It’s why you have to practice “outside the system” to give proper care.

I hope we can move the system back to a place where proper time is available for proper care. But I don’t see it happening, and it makes me sad.

John Irvine
Guest

Excellent post Leslie, as always. Congrats on the Times write up.

Story here, if you haven’t read it —

http://newoldage.blogs.nytimes.com/2013/06/26/walking-away-from-medicare/

Some readers were pretty harsh in their reactions. Were you surprised by the criticism? I’ve always been impressed by how much you genuinely seem to care for your patients and the lengths you seem willing to go to provide appropriate care? Do people just not get what’s involved in providing high-level care? How do you respond to the charges that you’re a bad human being for walking away from Medicare?

Leslie Kernisan, MD MPH
Guest

I’m a bit surprised by how so many of the comments referred to my making the decision for financial reasons, even though that’s not a reason that I cited to the reporter. Lots of people also seem to think I am now trying to make as much money as possible! Which is funny because those who know me, know that I’m not much of an income maximizer. Furthermore, I haven’t been making much money because I’ve kept the practice small, in order to have time to write and explore my interest in technology, caregivers, and system improvements. Unfortunately, the reporter… Read more »