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How would you grade your doctor?

February 12, 2011
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Do you ever go to a website to see the satisfaction score your doctor or hospital is getting? If their score is below 4.5 would you stop seeing them? Some pundits expect patients to check out websites with quality ratings such as www.healthgrades.com and www.drscore.com to help them shop for doctors and hospitals similar to a purchase of a dryer or a car.

Posting satisfaction scores may be beneficial in some instances. Businesses like these measurements because it helps them feel like it helps them receive quality care when they purchase health insurance for their employees. In general, businesses like to measure things so this process is well within their comfort zone. Of course there is a complete lack of transparency of how a website generates its scores.

When I’m teaching my family medicine residents, we discuss the tension between the science of medicine and patient expectations. I’ll frequently couch the discussion by saying, “Sometimes you need to wear your scientist hat; sometimes you need to wear your customer service hat.” A common scenario is a patient who is convinced she needs a test, even if the science of medicine says she doesn’t. Most patients are respectful of their doctor’s opinion on the matter, but their attitude is often that they won’t be happy unless they get their MRI.

Imagine I saw an otherwise healthy patient who had been coughing up a little bit of green stuff (the Latin term) for a few days. He wants antibiotics and won’t be happy unless I write the prescription, or even better give him free samples. His vital signs are normal and his lungs are clear, which means he doesn’t have pneumonia. A reasonable diagnosis in this scenario is that he has bronchitis.

The scientific reality is antibiotics don’t really work for bronchitis, which is caused by viruses that aren’t killed by antibiotics. I can offer some symptomatic relief for the cough, but nothing works well for coughs either. The National Institutes of Health doesn’t fund research on new drugs to relieve coughs. It isn’t a sexy problem, and coughing or bronchitis doesn’t have a powerful advocacy group with celebrity spokespeople testifying in front of Congress pleading for more research dollars.

The science of medicine concludes that the average case of bronchitis lasts three weeks and pretty much nothing will change that. If your lungs don’t want something in them, you’re coughing it up, and it takes about three weeks for you respiratory system to heal the damage after the viral invaders are eliminated.

I’ve talked to respected family physician colleagues who practice in the same high-income zip codes where urgent care centers have sprung up like mushrooms. These family physicians know that if they don’t dispense antibiotics like M&Ms, their patients/customers will just go down the street to the urgent care center to get what they want. These patients expect the healthcare system to be kind of like a big medical ATM machine that dispenses whatever they want whenever they want it.

A few years ago, one of my senior residents worked at one of these urgent care centers — we call them doc-in-the-boxes — and he appropriately took the time to educate a patient with a minor cold why she didn’t need antibiotics. When the patient got home she called the urgent care center and complained. The medical director called the resident the next day and fired him over the phone.

Some of my residents still work at these centers. They tolerate it by just accepting they have to “sell my soul” during their shift.

Back to my bronchitis patient, if I educate him on the self-limited nature of bronchitis and decline to write a prescription for antibiotics, what grade should I receive on my doctor quality report card? Will you give me an A for being an excellent physician scientist who took the time to educate my patient about his illness and helped the greater society by preventing the spread of antibiotic-resistant bacteria? Or will you give me an F because I didn’t give the customer what he wanted?

To put it another way, would you rather your doctor be a compassionate scientist or a McDonald’s employee?

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2 Responses to How would you grade your doctor?

  1. Aaron S on February 12, 2011 at 8:37 pm

    For what it’s worth – I practice in one of those high-income ZIP codes.
    And I make sure my patients get what they need… Not what they want.
    I’m sure I’ve lost a few of them over this.
    But I spend a great deal of time counseling and educating, and I think this “countermeasure” probably helps avoid most of those poor reports.
    The problem, as I often complain, is that the counseling takes more time and doesn’t pay. So it’s far more economical to just write the prescription and send the patient on his/her way.
    Physicians are, once again, disincentivized to do the right thing
    Unlike in many trades, “Customer Service” in healthcare is not founded on the often flawed notion that “the customer is always right.” I believe, in fact, that when it comes to diagnostics and therapeutics, the customer is usually wrong.
    Our job is to listen to their story carefully, weed out the red-herrings and irrelevant details, hone in on the clues, and then form our own impression.
    People who insist on getting what they want will never be happy with doctors like me and will find their “home” at the urgent-care doc-in-a-box down the street.
    But I don’t want to be part of the problem.
    I know that when I refuse to write an inappropriate prescription, my patient can go get it elsewhere. I’m sure that some of them do. And some of them will not return to see me again. (Many of them, interestingly, DO come back when the other doctor’s medicine didn’t work, or made them worse)

    It’s a matter of philosophy, and when a patient comes to a doctor, they can present in one of two ways:
    1) “This is my problem, and I want -that- treatment.”
    2) “Here are my symptoms. What should I do?”

    When I was 16 years old, driving my first car, I noticed it was pulling to the right. I took my Oldsmobile to the mechanic’s shop and he walked up to ask “How can I help you today?”
    I replied, “I need the wheels aligned.”
    His response is one that I have borrowed (and adapted) for the exam-room. He said, “Son, you’re the driver. I’m the mechanic. How ’bout you tell me what the car is doing wrong, and I’ll tell you what we need to do to fix it?”
    Turns out, the alignment was fine. He put some air in the tires and the car tracked perfectly…
    That guy get’s an A+ rating from me.

    • Richard Young MD on February 13, 2011 at 11:17 pm

      Aaron,

      Thanks for being one of the high quality foot soldiers of family medicine who does the right thing, even if no one is looking or tallying the right measures. Maybe one day incentives will be aligned so you don’t have to give away your valuable time.

      I loved the mechanic story and will share it with my residents.

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