For years I have bemoaned the fact that there is no accountability for doctors in the way that they treat patients. Make patients wait for 2 hours for a scheduled appointment? Who cares? Offer only clipped, curt answers to questions? Why not? Rush patients through as if they were cattle? What are they going to do about?
I have periodically joked about the need for a Zagat guide to doctors, where patients could contribute evaluations of the doctor’s bedside manner, office policies, and overall treatment of patients. Evidently someone else had the same idea. As a matter of fact, Zagat itself had the same idea.
As reported in today’s New York Times, Zagat has partnered with the insurance company WellPoint to bring WellPoint customers a new guide rating doctors. Predictably, the reaction from doctors has ranged from anger to outrage. As a physician myself, I want to go on record as applauding the move. It is long over due.
The doctors’ criticism can be summed up as the claim that patient evaluations do not take into account the diagnostic and clinical skills of the doctor. A patient with an excellent bedside manner can be an incompetent practitioner, and a nasty doctor can be an excellent clinician. That claim is true, but it is beside the point. Patients are not being asked to evaluate their doctor based on his clinical skills; they are evaluating the doctor on how he treats patients as human beings. The Times quotes Nina Zagat:
Ms. Zagat, who founded the Zagat Survey company with her husband, Tim, said the reviews were not meant to be the main factor in the choice of a doctor. Rather, she said, they could help a patient choose among specialists recommended by her primary physician.
“One patient might say I care more about communications skills,” she said. “To somebody else, having a very modern, attractive office may lead to a different choice.”
The doctors’ whining is depressingly predictable:
“It is curious that they would go to a company that had no experience in health care to try to find out how good a doctor is,” said Dr. William Handelman, a kidney specialist in Torrington who is president of the Connecticut State Medical Society. “It certainly is very subjective.”
In addition, the doctors preemptively blame patients for bad ratings that a physician might receive:
“Patients notoriously ignore their doctor’s advice to eat well and exercise,” he said. “Often they quit taking their pills when they’re feeling better. They usually don’t understand the technologies and skills needed for treatment.”
Those complaints are, in the words of a classic expression, “true, true and unrelated.” Yes, Zagat has no experience in healthcare, but they have tremendous experience in collecting, collating, and disseminating customer opinions. Yes, patients often ignore the advice of doctors, but that has no bearing on whether they are entitled to have an opinion about the manner in which the doctor treated them.
The sad fact is that at this moment, patients currently have no way to evaluate doctors. Internal evaluations by insurance companies and rating agencies tend to be useless for everyone involved. Evaluating doctors by whether they order enough Pap smears, but not too many doesn’t tell us who is a good doctor and who is incompetent. It also doesn’t tell us who is a compassionate caring physician, and who is a mean SOB.
The Zagat rating system will not provide much information about the diagnostic and clinical skills of physicians, but then it is not designed to do that. It will provide information about the other factors that matter a great deal to patients and often seem to be of no consequence to physicians.
Make patients wait for 2 hours for a scheduled appointment? That’s inexcusable and reflects and complete disregard for the value of the patient’s time. A Zagat guide to doctors will let patients know who cares enough to create a realistic daily schedule and who has no idea or interest in how long patients wait.
Offer only clipped, curt answers to patients’ questions? That’s simply unacceptable, and it has a major impact on whether patients comply with their treatment, not to mention a major impact on how patients experience their care. If doctors knew that their behavior would be broadcast to all potential patients, they would give more thought to their responses.
Rush patients through as if they were cattle? Now they will be able to do something about it; they will be able to tell other potential patients. For the first time ever, there will be real consequences for physician actions.
I have a great deal of sympathy for the terrible time pressure under which doctors operate, and I understand how that leads to long waits and short tempers. But there should be consequences for doctors in how they treat their patients. At the very least, it will cause them to take notice of something they now routinely ignore.
A Zagat Guide for doctors? This doctor says, “Bring it on!”
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Comments
"but it would be nice to see one that multiple insurance companies used, so that there was a broader pool of reviews and comments."
I'm hoping that this will be just the beginning. I desperately want to see some accountability brought to bear on doctors who never think twice about the patients' time, feelings, or experience.
I am an RN and I am very comfortable seeing one of the two NPs who work at the clinic I frequent. You don't wait as long to see them and their assessments are generally thorough.
Last time I went for an annoying sinus infection I signed up to see the NP and saw the MD by accident. He was irritated when I cheerfully admitted I preferred the NPs because of the above reasons. I was honest: I said dude I work 12 hour shifts myself I don't have time to wait forever, get over yourself.
"they'll enter the examination room with their heads down, scanning the chart, as if I were the chart, and they'll introduce themselves as Dr. X while addressing me informally."
It's frustrating that many have no motivation to change, or don't have an awareness that they are doing something wrong. Ratings would concentrate their attention.
"I was honest: I said dude I work 12 hour shifts myself I don't have time to wait forever, get over yourself. "
Yes!! Good for you.
"I would love that but some of the blame has to go to the managed care system."
Some blame does indeed go to the managed care system. However, it costs no time or money to address someone formally and politely, or to explain when the doctor will show up and why he or she is delayed.
Obstetricians offices often advise patients to call before leaving for their appointment. Then they can tell the patients whether the doctor is on time, or if he is delayed, when they should come in, or if he is delayed for hours, they can reschedule the appointment.
I am a cancer survivor, I spend a lot of time in waiting rooms and more often than not I wait 1-3 hours to see my surgeon and my oncologist. However, I am okay with the wait because I know that my doctors are dealing with issues that cannot be made to conform to time limits. When I was in chemo, the time I needed from my oncologist was very different than what I tend to need from her now (although she still never rushes me). I also understand that she has patients who need more time than me now. Even before I was diagnosed, there were many times where I would get terribly annoyed with other patients in the waiting who would begin to complain to me, bully the staff and just make everyone uncomfortable and more aware of the time we were all spending in the waiting room. Often I would say to these patients, "I am perfectly okay with the wait. There are women who have just been diagnosed with breast cancer and Dr. A needs to spend a lot of time with these women on what is perhaps the worst day of their lives." Then I would add, "If I am ever in their position, I hope that Dr. A will spend this much time with me too..." Eventually I did find myself in their position and I am so thankful that my surgeon, and later my oncologist, did not rush me. They took hours to explain what was happening, going to happen and to answer my questions and also address my fears. If a healthy patient had to wait because of these needs, so what. I would rather wait hours, taking hell from the boss, than be diagnosed with cancer or some other devastating disease.
I am afraid that this Zagats guide might result in doctors rushing patients when they need them the most. Medicine is not the same as waiting for a table. There are many reasons why patients often must wait hours to see the doctor, but I believe for the most part, these reasons have more to do with patient care than a disregard for patients' time.
"I am afraid that this Zagats guide might result in doctors rushing patients when they need them the most."
My hope is that ratings will alert doctors to a problem many don't even know exists. They literally have no idea how long their patients wait for them
It is definitely possible to schedule patients so that waiting time is minimal. If a doctor is finishing office hours two hours late every day, either he is scheduling too many patients, or not telling them to arrive at the time he will actually be able to see them. That is not acceptable if it occurs on a daily basis.
"I think I'm one of the fortunate few who have wonderful, thoughtful doctors (and staff) who I love. Across the board - Primary, Gyn, Hematologist, Cardiologist, and Psych. But I've spent years getting here."
I'm glad it finally worked out. It is so comforting to be able to rely on providers to be both competent and kind.
"Zagat has a fine idea, but may find that it's easier to get a table at a hot restaurant on Saturday night than it is to change doctors."
I think the idea is simply to provide patients with more information. It could be especially helpful in the case of specialists whom you might need to pick on short notice.
"But he doesn't seem to pay attention to me when I tell him about side effects - I'm telling him that I spent two days lying on the floor vomiting after chemotherapy and he says "well, just keep taking the drug I gave you". (You mean, the drug that's obviously not working?) I don't think that's something you can express in a 1 to 5 star rating, but it's something I wish I'd known before I picked him."
They are going to have to work hard on determining just what questions to ask.
My internist is being re-certified and she recently sent me (and other patients) a questionnaire that included rating the doctor on whether she listens attentively and responds.
I mean, attentive is good, but when it boils down to it, I can't afford too many $80 appointments and my health is going to suffer. I'd also be very happy to see in ratings which care providers--doctors or nurse practitioners--are prone to prescribing whoever they're advertising. My current nurse practitioner is reasonably good on the time thing, but my brand-name copay is high and I can't afford to pay $60 for an antibiotic when I've had Augmentin-generic-not-XR plenty of times for my sinus infections. Value matters; it means the difference between getting care and not getting care for a lot of us. To say that these things don't have an impact on the actual quality of care is to ignore the fact that most Americans have only a limited amount they *can* spend on health care.
I'd only by a book titled like that if Greg Palast wrote it.
"To say that these things don't have an impact on the actual quality of care is to ignore the fact that most Americans have only a limited amount they *can* spend on health care."
That's right, and doctors need to be aware of this.
"But in the now, A Zagat's Guide for Doctors might as well be subtitled: The Best Healthcare Money Can Buy"
True, it is only meaningful for people who can afford healthcare, and have a degree of choice.
However, it increases transparency in the healthcare system and that is a good thing. Right now, healthcare is essentially a blackbox. No one knows what they are really paying for, no one knows what they are really getting, doctors are thoroughly insulated from the patient experience, and doctors don't even know what they are going to get paid for what they do.
To me, the need for a Zagat Guide to doctors is directly proportional to the vehemence with which doctors are opposing it. They don't want potential patients to be held accountable for the way that they treat existing patients.
When I was in college many years ago, a dear friend was the moving force behind a new college guide that surveyed students (all, not just some) at the end of every course. They used sophisticated statistical techniques to analyze the data. Then they published the results as a guide. The professors opposed it vociferously; fortunately the college administration was willing to allow it.
Now, decades later, the professors are entirely on board. First, it expresses in the most obvious possible way, that teaching is valued almost as much as research. Second, it turned out that they got feedback that was valuable to them. Instead of hearing from only the dissatisfied students, they heard from everyone, even those who would have been too shy to speak in public. They learned what was effective and what was not, and they adjusted accordingly.
Similarly, a Zagat Guide to doctors expresses in the most forceful way possible that compassionate care is expected, not optional. Most doctors are completely insulated from the patient perspective. They have literally no idea how long patients wait, or how they feel. All doctors assume that they are doing a great job, or at least the best job that anyone can do under the circumstances. It will be incredibly beneficial for them to learn how they come across, and to know that there are consequences to certain types of behavior.
"I'd love to see a consumer rating system for health insurers."
Me, too.
When you have a month of such data then you can start to understand how the system works and the root causes of long waiting times. When you've identified the root causes then you can address them and reduce waiting times. You also then have a system by which you can monitor waiting times to ensure that they aren't creeping back up.
This isn't rocket science, but it does require time and effort on the part of the office staff, nurses, and physician.
if i'm left waiting too long, i leave. and too long is 30 minutes unless there's literally an office emergency.
and if the dr doesn't pay attention to me, i won't go back. a dr like that will make mistakes because they're not listening, and i'm not a gambler.
"Check out Angies List for another doc rating system."
Thanks.
"When you have a month of such data then you can start to understand how the system works and the root causes of long waiting times. When you've identified the root causes then you can address them and reduce waiting times. You also then have a system by which you can monitor waiting times to ensure that they aren't creeping back up."
It can be done. As you point out, all that is needed is the will to do it.
"and if the dr doesn't pay attention to me, i won't go back. a dr like that will make mistakes because they're not listening, and i'm not a gambler."
Excellent point.
We seem to agree that a Zagat Guide, as of now, will only really be useful to people that can already afford the highest echelons of care. So who is looking to choose healthcare anyway right now? Well people in a medical crisis who need primary care or secondary opinions and then there are folks looking to get one of the many optional medical services we provide such as cosmetic enhancements or prescriptions for little blue pills.
Now the doctors (many ultra specific specialists) who are already serving high end patients have placed themselves to treat them on purpose, not some accident. We have already seen the reality of high cost medical school drive individuals away from Family Practices and into specialties.
So many of these medical professionals already work in a market where patients have choice....and thus they must compete. So this is where the Zagat Guide comes in right? Just like for restaurants Zagat will be a wonderful marketplace for physicians who have previously honed their marketing skills on the open market. They will now have a concentrated audience.
Opening up doctors to a kind of Zagat rating system would be fantastic. But it's only one step. I'd like to see information about medical error rates also.
"My source of good advice about medical providers are the nurses in hospitals and nursing services. Those have proven reliable and excellent."
Definitely. The nurses know a great deal about the doctors with whom they work.
"Just like for restaurants Zagat will be a wonderful marketplace for physicians who have previously honed their marketing skills on the open market. They will now have a concentrated audience."
I suspect that will not be a serious problem. Doctors don't hone their marketing skills because they don't need to. Most patients come by way of referral from other doctors, generally in exchange for referral in the other direction.
"Opening up doctors to a kind of Zagat rating system would be fantastic. But it's only one step. I'd like to see information about medical error rates also."
I agree. Patients should have access to all relevant information.
Having taught communication skills at a health sciences college, I've become acutely aware of how imbalanced these students' training continues to be, giving them a (usually) solid technical skill set but giving short shrift to learning how to talk with patients. And yes, it is a skill that needs to be learned! The traditional medical education model tends to push interpersonal/communication training off to the side, with an assumption that students will "pick up the basics" in residency (or somewhere...maybe...).
This is starting to change, thankfully; I've found that many of my students do value the ability to communicate well and are often quite honest in voicing their fears of inadequacy in this area. Hence the need for better and broader training.
College instructors get evaluated by students these days. Do I love it when a student criticizes something about my course? Not really. Has their feedback pushed me to grow as an instructor? Often. Am I glad to have the input? You bet.
Seriously? I mean I realize you are trying to make a point here....but too ignore the grossly commercialized aspect of the medical system, as it exists today, is going a little too far. And to just, ad-hoc dismiss the reality that medical professionals do actively and aggressively market themselves is surprising to see.
Maybe the absolute onslaught in tv/print/radio advertising for doctors, clinics and newly formed medical groups are just some honest attempt to get referrals for hair replacement, breast enhancement and erectile dysfunction.
I am sure good doctors like yourself would welcome a rating. For good doctors it would be something to prove to the public at large that they do not get sued annually for malpractice. But man o man....just wait until the OBGYN and Family Practice lists are quickly eclipsed in the future version of "The Best Healthcare Money Can Buy" by a bunch of docs who can best sell themselves to the public or the Guide itself. If the other Zagat guides are any roadmap for the how an industry will respond, align and utilize such a marketing tool...jeez.
Dang now I have a bee in my bonnet about this...
Really, the more I think about it the worse this idea of a Zagat Guide for doctors sounds to me. We need solutions that address cost for healthcare, plain and simple. Not some elitist handbook for one-percenter's who want an extra added bonus status symbol of going to the "Top Rated" Zagat doc....
They could sway me to the idea if they offered the Zagat Guide for Doctors- Free Clinic Version. But there wouldn't be any money in that...See what I'm sayin?:)
"That said, if I had to chose (and I recognized that maybe we shouldn't have to), I would rather be treated by an obnoxious, annoying brilliant neurosurgeon or anaesthesiologist than one of those "fatal doctors" who make us feel good about ourselves while they cut corners and make mistakes."
Me, too. I've had a brain tumor, so I know exactly what you mean.
Giving patients more information about doctors' bedside manner does not mean that patients are going to use that information as the sole criterion in choosing a physician. It just gives them more information than I had otherwise.
For example, as a doctor, I have access to much more information about doctors than most lay people have. That's how I was able to choose a neurosurgeon who was both extraordinarily skilled and a kind person, too.
"If I operated as inefficiently and rudely as so many doctor's offices do (doctors should be rated along with their support staff), my ass would be canned."
Exactly. They do it because they can. They would still be able to behave that way if they were rated, but there would be consequences.
"College instructors get evaluated by students these days. Do I love it when a student criticizes something about my course? Not really. Has their feedback pushed me to grow as an instructor? Often. Am I glad to have the input? You bet."
Thanks for your perspective. Maybe I'm hopelessly naive, but I believe that doctors will eventually feel the same way.
"hair replacement, breast enhancement and erectile dysfunction"
Hair replacement and breast enhancement are not medical procedures. They are cosmetic procedures and are paid for out of pocket.
I still don't really understand your point. Even if doctors marketed themselves to get patients, why would having more information on a doctor's behavior be harmful?
Last year when I blacked out in a gas station and was taken to the ER by the parameds, the cardiologist associated with my medical group showed up in 30 minutes and turned out to be a great physician, as far as I can tell. My heart still beats, my pacemaker paces, what more could I ask for?
But when you are flat on your back on a stretcher, scared shitless, you don't ask you wife to use the Blackberry to consult Zagat's.
My own psychiatrist, who never runs more than 5 minutes behind and that's ususally due to a phone call, complains about going to his opthalmologist and his primary care physician because he has patients scheduled to be in HIS office when the other guy keeps him waiting
"My own psychiatrist, who never runs more than 5 minutes behind and that's ususally due to a phone call, complains about going to his opthalmologist and his primary care physician because he has patients scheduled to be in HIS office when the other guy keeps him waiting"
There are a lot of books and articles written by physicians who were totally shocked when they became patients. They had simply never considered what it might be like. A rating system might at least get doctors to think about it before they get sick.
Here's one of the problems I keep coming up against: The biggest complaints I hear from patients are 1) I can never get in to see my doctor and 2) He doesn't spend enough time with me. With the shortage of primary care physicians, my panel is fairly big right now and I have one of two choices when patients call to make appointments 1) tell them I'm already busy with scheduled patients and make them go to urgent care (they don't like that) or 2) squeeze them into my schedule for a few minutes in which case I get complaints that I rushed their visit (which they also don't like). My other option is to just close my patient panel which would be great but that would leave patients without a primary care doc which I also have a problem with. Yes, the solution would be to have more primary care docs, but that isn't going to happen anytime soon. After much thought, I've basically decided I just need to run my practice the way I think it should be run and I can't fret over every little worry.
The other problem I've realized is that any disgruntled patient can put anything they want on these reviews. If I have some narcotic seeking patient and I don't give them narcotics, they are free to write about what a bad doctor I am, etc. I've had many patients walk away upset with me because they wanted me to do something that was against normal medical care (one patient has fired me because I kept talking to her about quitting smoking, another fired me because I wouldn't prescribe testosterone when he didn't need it). I think for a lot of the docs "in the trenches" we're busy enough that we won't focus too much on some of the bad reviews that get posted.
"The biggest complaints I hear from patients are 1) I can never get in to see my doctor and 2) He doesn't spend enough time with me. With the shortage of primary care physicians, my panel is fairly big right now and I have one of two choices when patients call to make appointments 1) tell them I'm already busy with scheduled patients and make them go to urgent care (they don't like that) or 2) squeeze them into my schedule for a few minutes in which case I get complaints that I rushed their visit (which they also don't like). My other option is to just close my patient panel which would be great but that would leave patients without a primary care doc which I also have a problem with."
I can understand completely because I have faced the same problem. However, the patients can't possibly understand unless someone explains it to them. Most people are very accepting of waiting if they know it is because someone else needs medical attention immediately, but they can't be accepting unless someone tells them.
Moreover, it is not fair to all patients to schedule more people than you can possibly see in the time available. They need and deserve to know when they will be seen, and they deserve to be seen in a timely fashion. If patients are being booked into ten minutes slots when appointments routinely averages 20 minutes per patient, the doctor or the staff is overbooking for THEIR convenience without regard for the patients.
"The other problem I've realized is that any disgruntled patient can put anything they want on these reviews."
That should not be a problem if statistical methods are used to eliminate outliers. The Zagat Guide is not going to be unfiltered patient reviews. The reviews will be collated and analyzed to make sure they are as accurate as possible.
The bottom line, really, is that patients should have access to the same information about doctors that you and I have. Why should they know any less? You and I wouldn't go to a doctor that we knew to be rude and inconsiderate unless it were absolutely medically necessary. Why shouldn't other people have the same options that we do?
I have lived with cancer for the last eight years, in my late 20s and now mid-30s. My surgeon is a royal ass. The wait is always three hours or more. Why? Because people have flown around the world to see him and if he limited the number of patients he took, I’d be seeing the doc down the hall with half the skills. None of this is an excuse for his arrogance, but this is my body; I can get nice décor and good customer service at a restaurant, though I would like it, I don’t need it from my doc.
Thanks for your post. Refreshing to know that doctors like you do exist.
"None of this is an excuse for his arrogance, but this is my body; I can get nice décor and good customer service at a restaurant, though I would like it, I don’t need it from my doc."
I understand. The doctor who diagnosed my brain tumor (benign) was obnoxious, but he diagnosed it when other could not.
The reason I like the idea of a guide is that it allows everyone to have the same information that doctors have. I know in advance who is nice and who is arrogant, so I figure that you should, too.
Amy, many doctors already know they're providing lousy service, and simply don't care. My father complained to his doctor after being forced to wait for over 2 hours on multiple occasions (and having office staff ignore his requests to find out how much longer it would be). When he complained directly to the doctor, his response was "Blame managed care." That's passing the buck. No one makes him pack far more patients into his schedule than he can possibly see. Blue Cross isn't ordering his staff to be rude and unhelpful.
(Ultimately, my father switched to another practice, under the same insurance, which treats its patients respectfully.)