Yesterday WellPoint announced
that as of early 2008, a “new online tool” “will allow consumers to
share their physician experiences with others” a la Zagat surveys.
Zagat in fact is partnering with WellPoint on this initiative, and the
format of ratings will be similar to other Zagat products, where
customer anecdotes accompany ratings of different criteria on a 30
point scale. The rated criteria for doctors will be trust,
communication, availability, and environment. Measurements of quality
of care and health outcomes are not included in this rating system, an
omission that Jane Sarasohn-Kahn points out over at HealthPopuli.
Jane is kinder toward this announcement than I am. Neglecting crucial
information about quality misses the point about medicine—that it is
devoted to improving health. As Jerry Flanagan of the Foundation for
Taxpayer and Consumer Rights told USA Today yesterday,
“the fact that a doctor might have a friendly administrator at the
front desk is meaningless if they have a high medical-error rate.” It’s
a bit like having car ratings only address color scheme and seat
comfort: these are nice facts to know, but at the end of the day you
want a car that you can rely on, a consistent performer that does its
job and does it well.
In the partnership press release, WellPoint’s chief marketing officer
says that the Zagat initiative is indicative of a “commitment to
provide members with the data and tools necessary to help them take a
more active role in their health care decision making.” But a truly
empowered patient would be one who knows the quality of care and
outcomes that he or she can expect.
In theory there’s nothing wrong with knowing the experiences of others
at doctors’ offices. But practically speaking, we run a very real risk
that a Zagat-style survey distorts our understanding of the
doctor-patient relationships. Already, some medical professionals have said but that “there’s a place for this [Zagat system] because as physicians we do need to become more patient-centered.”
This is dangerous thinking because these rankings are not
patient-centered—rather, they’re consumer centered. Even WellPoint is
clear on this fact, asserting in its press release that “peer-to-peer
interactions are a critical component of our consumer engagement
strategy."
The standards of the rating system reveal a preoccupation with the
euphoria of consumption rather than meaningful patient satisfaction.
The emphasis is on convenience—did you have to wait for the doctor
(“availability)”? Did you like the office decor? (“environment”)
It’s not clear what “communication” means. Are we talking about
explanation or dialogue? Some doctors might score high because they
explain what they are doing, others because they ask for patient input.
The latter approach might actually improve care by giving the doctor
information he needs to make an accurate diagnosis, yet the difference
between the two approaches is not likely to show up in a five-word
comment from a respondent.
And how helpful a metric is “trust” if rankings are not tied to
expertise or specialty? The threshold for trust is much lower for a
physician telling me to take Aspirin than it is for a specialist urging
me to have surgery. Our expectations change with our needs. This is not
reflected in the ranking system, concerned as it is with convenience
and enjoyment.
A more credible version of what the Zagat system purports to be—a
system that empowers patients to understand and manage their
relationship to doctors—is the paradigm of shared decision-making.
(Maggie has written about shared decision-making here).
Very briefly let me just say that: “shared decision making” is a
process which allows doctor and patient to share valuable information.
First, the doctor describes the relevant risks and benefits of all
treatment alternatives, and the patient shares with the physician all
relevant personal information that might make one treatment or side
effect more or less tolerable than others. Numerous studies indicate
that when patients have the opportunity to participate in medical
decision making with their physician, the patient-physician dialogue
improves, and patient well-being improves as well.
This is the real deal when it comes to empowering patients to take
control of their “health care decision making.” Presumably a doctor who
engages in shared decision making will score high on the metrics of
trust and communication—no conflict there.
But from a long-term perspective, the reduction of medical care to
Zagat snippets may be counter-productive with regards to moving toward
shared decision making, because it reinforces the notion of health care
as consumption. Treating doctors like restaurants perpetuates the
notion that health care is like any other commodity: we want it fast
and we want it now. In reality, real empowerment demands active
engagement and a certain measure of personal responsibility.
The danger is that in relying on superficial measurements of service,
patients will get comfortable with the quick fix approach, and we take
two steps back with regards to truly integrating patients into health
care as active participants.
Somehow, I’m reminded of a M*A*S*H episode, in which Hawkeye recommended a patient have an operation.
“I want a second opinion.”
“OK, don’t have the operation.”
Maggie and I have discussed the issue of the knowledge gap in clinical decisionmaking, and not come to an ideal conclusion. Most patients don’t spend hours routinely reading physician-oriented material, nor have studied the underlying basic sciences. At some point in any discussion involving a complex subject, there is often a point at which going deeper requires some specialized knowledge. Think of an issue such as nuclear nonproliferation, and how compliance is verified.
I’m not sure how they could be determined for a Zagat’s, but some behavioral things come to mind, as things that mark a good physician to me.
A good physician isn’t nervous about checking a reference book in front of the patient. I’d rather not have a guess at the right dose.
A good physician finds the right balance of formalism to encourage discussion. I’ve been formal with some physicians and on a first-name basis with others. It’s when it’s “Doctor” and “Howard” when I get warning flags — this is also something to observe between nurses and physicians.
If you can get a frank opinion from nurses that see a physician practice, that can be enormously helpful. Unfortunately, with the trend to hospitalists, hospital nurses simply don’t know how someone practices.
Not a totally reliable clue, since many physicians do their reading at home, but seeing recent textbooks and journals is a good sign. Oddly, I’ve never known a physician who collected old medical books and equipment to be anything other than excellent — as long as they get new ones as well.
These are just a few ideas, when it’s not practical to have a detailed discussion, or find out what your doctor thought of the [foo] trial or the article by Dr. Flubber in last week’s NEJM. In fairness, I know a lot of very good doctors that are 3-4 weeks behind on current journals.
I would value a rating system like this at close to zero. I’ve had doctors tell me that most patients will rate doctors based on the three A’s – affability, availability, and last AND LEAST, ability.
Who do doctors go to when they or a family member need services? That would be valuable information to me. The same information from nurses might also be helpful. I’m told that sub par doctors generally have no doctors or nurses as patients. I would love to know that information as well. While I don’t appreciate being kept waiting a long time as though my time has no value, what I really want most is competence and decent communication skills.
Barry and Howard,
I think you’re both right on the money: reducing health care to Zagat-speak distorts what we should be expecting from our doctors.
And Barry, you’re right too in suggesting that issues like availability and comfort aren’t completely irrelevant–but as I think we all agree, a rating system like this might actually keep patients in the dark more than they already are because it shifts attention away from meaningful measures of quality.
The more we reinforce that the most important component of medical care is enjoyment, the easier we lose sight of what really matters:ability, expertise, rigorous fact-checking and verification (a good point, Howard), and all the rest.
The metrics you both suggest–the level of confidence that medical peers have in each other and comprehensiveness/compliance–are good examples of how there are creative ways to develop ratings that actually matter. Unfortunately, it’s much easier to package and market a ratings system like Zagat’s than it is one immersed in the actual nuts and bolts of medicine…
Thanks for your comments!
The medical profession is such a quandry sometimes. A mix of science and art, one objective the other subjective. When I was practicing, I reccomended three things to assess your doctor (however, you can only assess for yourself). Are you comfortable enough with this person to tell them things you may otherwise keep to yourself due to embarassment or shame (this is very important, knowing grandma was a schizophrenic or grandpa was an alcoholic is important)! Next, is the visit directed by your goals, (I often opened with the question, What are you hoping to achieve here today?) otherwise I may prescribe a bunch of meds to help you live longer and really you just want to enjoy what you have left (this question also helped me define realistic expectations for the patient). Finally, there is a set of questions I gave people to ask when going to a new doctor or specialist, this tests the doctors knowlege, communication and willingness to say those three little words, “I dont Know” (hopefully followed by “I will find out”).
DrMatt,
I think you make a good point noting that the experience of engaging with a doctor is important, but only if we dig down deep and connect the experience to dynamics that we know matter to medical outcomes.
Curious to see if this was a possibility with Zagat, I registered as an online voter for Zagat.com this morning. Never having participated in Zagat’s ratings, I was curious to see if there was some back-end, complex tally system from which the final reviews were derived.
My thought was that even if the final product is only a cursory review, maybe it was the distillation of a more rigorous, comprehensive survey process–as opposed to a survey system as superficial as the review itself.
But alas, to review something for Zagat you just pick one number out of four to rank the designated categories. Then, if you so choose, you can write whatever comes to mind in a blank comments box that gives no direction and asks no specific questions.
I think our fears of a ratings system that doesn’t connect subjective perceptions to objective concerns (as drmatt suggests) are pretty well-founded.
Thanks for the information on topic.I would value a rating system like this at close to zero. I’ve had doctors tell me that most patients will rate doctors based on the three A’s – affability, availability, and last AND LEAST, ability.
I’m not sure how they could be determined for a Zagat’s, but some behavioral things come to mind, as things that mark a good physician to me.