Nine years ago, my career started when I launched my first practice. I got 7 million hits on my site that month, and more press than I knew what to do with. Here’s one from the time capsule. My, what nine years has done to this old man.
I had a pediatrician when I was a kid. Dr. Keefe. He was my mom’s go to. He was in a solo practice in St. Charles, MO where I spent the first 22 years of my life. Then I moved to Pennsylvania to go to med school. Ever since, I’ve never had a “relationship” with a primary care doctor. Granted, I’m a doctor. I can prescribe my own meds or go see my doctor friends. But, in talking with friends and family, I occasionally stumble across someone who uses the term “my doctor.” It’s like they’ve somehow seen and befriended a mythical creature.
If you do a literature search for “how many people in America have a relationship with a primary care doctor” you get zero results. First of all, nobody would benefit financially from the results of the study, so nobody would spend time and money on this issue. We know what people are. We know what primary care doctors are. But we don’t know what “relationship” means.
So what the hell is this mythical thing?
First and foremost, a relationship is loyalty to someone you respect, trust, and jives with your personality. In order to find that one person, just as you find a spouse, you’ve got to shop around and experiment to find the one that actually personally fits with you. This is a rare find.
Second, we’re a mobile society, both doctors and patients.
Doctors move neighborhoods. Doctors move jobs. And doctors move health insurances they take. Doctors are increasingly no longer solo entities. They’re now part of group practices that have been bought up by local large hospital networks. Doctors are becoming employees, not entrepreneurs. They’re abandoning the personal responsibility felt when you’re emotionally, professionally, and financially beholden to the group of patients you’ve been building relationships with for years.
And people move neighborhoods. People move jobs. People move health insurance companies. If they move too far away from “their” doctor, they have to find a new one. And when their doctor takes a job at a large group practice, the group has to provide a better experience and benefits than the solo doctor. If not, the patient will likely lose loyalty. They’re often forced to lose loyalty because the average person changes jobs every two to three years. And when they change jobs, they are almost guaranteed to change health insurance plans. Even when they stay in their job, companies change health insurance plans every few years because health insurance has become a race-to-the-bottom commodity. And every time you change your plan, there’s a good chance “your” doctor won’t take your new plan.
Compounding all these logistical issues, the way different age groups consume healthcare has more to do with the demise of the old-fashioned doctor-patient relationship than anything. As children, we get sick and hurt all the time precipitating many acute visits. We also have a very set schedule for why and when we’re supposed to visit the pediatrician to keep everything all up to date. Then, blam, high school and college happens. Then our 20’s. We don’t need much healthcare in our 20’s and 30’s except for the same kinds of issues we had when we were kids- acute sickness and injuries. But we’re too old for our pediatricians and we also feel out of place sitting in waiting rooms with 90 year olds. For the most part, 40’s and 50’s are the same, except some of us start having an early onset of old people diseases. Then our 60’s happen and the diseases we get tend to mimic more of a 90 year old than a 10 year old. And that’s when we again start looking for the old-fashioned close relationship with an internist similar to the one we used to have with our pediatrician.
All relationships, both personally and professionally, are built over time with consistency and mutual dedication. Does it qualify as a relationship if you’ve seen a doctor 3 times over 3 years? How about if when you make an appointment at your doctor’s practice and her colleague sees you because your doctor had to leave early that day? How long must the loyalty and consistency exist before we can call it a relationship? One year? Two? Ten? How many visits? And does it matter what those visits were for?
Kids need a consistent pediatrician. The elderly need a consistent internist. The chronically ill, no matter the age, need a consistent team and place to receive care. But for the rest of us (around 75% of the population) the likelihood of wading through today’s nearly impossible logistics of maintaining consistency and mutual dedication makes this old-fashioned thing called a “doctor-patient relationship” unrealistic in today’s society. And honestly, how much of a relationship can you build with a doctor when the interaction is a harried 8 minute conversation in which your doctor is constantly interrupting to focus your answers to her questions. Not only is it unrealistic, it’s of questionable value. I’ve heard it said that the value of longitudinal healthcare data, which is what a relationship is supposed to maintain, is less valuable the older the data. Data that’s 5 years old is less valuable than data that’s 5 weeks old. Since from your 20’s and into your 60’s most people need more transactional fixes than ongoing routine management of issues, the value of the data and the emotional connection you have with your doctor simply isn’t there.
Going forward, we need to update the definition of the doctor-patient relationship. We need to view it as a tool meant to solve a certain constellation of problems for a certain kind of person. But as we all know, there is no one tool to solve every problem. And we also need to stop assuming that everyone has a relationship with a primary care doctor. Our data here at Sherpaa suggests that only 10% of the working age population does. And we also need to stop saying that everyone needs a relationship with a primary care doctor. Not everybody does. Anything that’s threatening to the concept of the old-fashioned doctor-patient relationship doesn’t need to be feared. A relationship with a singular doctor is a wonderful tool to solve a certain subset of health problems for a certain type of person. Not everyone has that subset of problems. Marcus Welby was a wonderful invention for a certain time when things were less complicated and less mobile. Times have changed and he’s no longer the perfect tool for every single healthcare problem.
Another reason for the medical community’s initial resistance to anesthesia was that it threatened to upset what had always been considered “normal” surgical procedures. Surgery was traditionally performed on a conscious patient, one who was able to communicate and express pain to his or her surgeon. Surgeons and doctors would use their patients’ reactions—either by asking them questions or listening carefully to their wails and cries—to help guide their surgeries. Removing this element from the act of surgery seemed strange and unnatural to some—like removing one of their senses.
Mütter was dismayed that something he considered a gift from God could be seen as an evil by his peers and contemporaries. The strong feelings against the use of anesthesia went much deeper than just a gentleman’s disagreement about its use. Institutions began to take public stances against it. The board of Philadelphia’s Pennsylvania Hospital—the main hospital with which Jefferson Medical College had a working relationship—successfully voted to ban all use of the surgical anesthesia for seven years. Even worse for Mütter, one of anesthesia’s most outspoken critics would emerge among his own faculty: Charles D. Meigs.
Change is glacial in healthcare. Anything new always, always meets resistance. To learn more about this, please read the biography of Thomas Mütter, Dr. Mutter’s Medical Marvels, which includes that passage. It’s one of my favorite books of all time. Mütter was one of the fathers of modern medicine. Simply a fascinating man, mostly for his desire to push the profession forward while being known as one of the great medical lecturers of all time.
I’ve seen this resistance firsthand multiple times. Since 2007, I’ve been doing everything I can to update how doctors and patients communicate. I spoke about this many years ago in this TED talk. In 2016 the resistance has lightened, but it surely hasn’t stopped. Persistence and rational, vocal arguments builds coalitions. But it takes time. Hang in there everyone. While slow, we’re building something far better. Please don’t forget that.
What does quality mean in healthcare and how do you find it?
During my preventive medicine residency at Hopkins I worked in Dr. Peter Provonost’s Institute for Patient Safety and Quality. In addition to leading all safety and quality issues at Hopkins, he’s also credited with creating the concept of the surgical checklist, a tool that’s proven to save a significant number of lives and best described in Atul Gawande’s book, The Checklist Manifesto. Peter taught me that everything is a process, and if you don’t design the process with intention and outcome in mind, the process evolves into the easiest, rather than the safest. That being said, in healthcare, I deify process mostly because the data on individual physicians isn’t plentiful enough to be statistically significant (by the way, the photo above is a shot of Sherpaa’s process maps, the first thing you see as you walk in the office). For example, a surgeon who does 32 tonsillectomies a year isn’t enough data to be scientific. It’s meaningful because it’s common sense that you almost always want to go to the surgeon/facility who does the most of the exact thing you need. But, you need much, much more volume than that for the outcomes to be scientifically statistically significant.
Physicians are also always taught that the practice of medicine changes every 5 years. New evidence comes out and gold standards change. This also throws a wrench in the concept of studying doctor quality. If the gold standard is a moving target, there’s again not enough time to generate sufficient data/volume. It’s also relatively common knowledge that the older the physician, the further they are from state of the art training. As humans, we all get set in our ways. Older physicians, unless they take it upon themselves to learn new procedures through curiosity and continuing medical education, will likely be doing an exceptional job with out of date procedures. Younger physicians will be doing state of the art procedures with less experience.
All of this takes us back to the concept of process. What is a surgeon’s process and what is the hospital’s process for following best practices? Without standardized processes, things quickly get ugly.
Without super reliable data, people are left to compile a list of soft data points and hope for the best. I’m not a huge fan of patient reviews mostly because the volume and quality of those reviews are quite low. Amazon has stated that about 1% of purchasers actually review their items and that’s with a very clear and promoted single source to easily and quickly leave a review. 1% of a doctor’s patient panel is way too low to be hard data. Of course, you can often still get a decent feel for the doctor’s personality. In order of priority, I’d say this is how you make the decision:
- Rule out the terrible doctors with malpractice reports. 6% of doctors are responsible for 60% of malpractice cases. Don’t go to that 6%. That’s mostly incompetence mixed with being an asshole.
- Once you’ve ruled out the incompetents, research to find out who does the most cases of the very procedure you need
- Schedule a meeting with this surgeon to understand the priority they place on process before, during, and after the procedure. Healthcare is simply problem solving powered by communication. So clearly understand the surgeon and their team’s process for communication post-discharge. I’d also ask if this was his/her kid, who would they take their kid to for this procedure?
- In addition to other physician recommendations, nurse recommendations are way more valuable. Nurses seriously know everything. They keep the healthcare train running and they know who’s a good doctor and what their patients are saying about the doctor. They also know who to stay away from.
- Time since completing their residency. I’d say the ideal time is more than 5 years and less than 15. If it’s more than 15, ask the name of the procedure they plan to use to see if it’s up to date.
- Where were they trained? Medical school is relatively meaningless. It’s essentially studying books and shadowing residents and just getting exposed. American medical schools are superior because best practices/doctor culture vary wildly in different countries. What really matters is where they did their residency/fellowships. Was it a well regarded academic medical center here in America or a community hospital?
- Surgical facility. And what is the hospital/facility’s statement on process/patient safety?
- Admitting privileges to what hospitals? High quality doctors tend know each other and cluster together.
- Academic appointments/publishing. I think this correlates to how passionate and interested you are in the field and is a soft metric that you’re doing everything you can to be relevant and push boundaries. It’s a far stronger metric than board certification.
- Yelp/Healthgrades/ZocDoc/etc. There’s no clear winner here so you’ve got to combine them all. We’ve found that for most specialties, Yelp is most valuable. ZocDoc is good for specialties that depend on churn like dermatology and dentists. Those specialists are all competing for patients. If you’re an in-demand physician, you don’t need ZocDoc.
- Personal website. I actually think this is meaningful. If it’s well designed and articulate, it’s a soft data point that the doctor emphasizes the patient experience and good communication.
- Board certifications. Honestly, these things are not difficult to pass. The vast majority of doctors are good standardized test takers, so when I see board certification, it’s pretty meaningless to me. These are mostly just revenue for the speciality associations.
- Cost. There’s no correlation to quality. And most doctors aren’t even the ones determining their actual costs. It’s mostly in the facility’s billing department.
Unfortunately, this isn’t an easy process that can be automated.