Rating Doctors Like Restaurants, by Bob Wachter

Robert_wachterRobert Wachter is widely regarded as a leading figure in the modern
patient safety

movement. Together with Dr. Lee Goldman, he coined the
term “hospitalist” in an influential 1996 essay in The New England
Journal of Medicine. His most recent book, Understanding Patient
Safety, (McGraw-Hill, 2008) examines the factors that have contributed
to what is often described as “an epidemic” facing American hospitals.
His posts appear semi-regularly on THCB and on his own blog “Wachter’s World.”

So Zagat will now be rating doctors, using the methods it perfected helping you find the best sushi in Brooklyn Heights. What’s next, Consumer Reports rating grad schools? Fodor rating auto mechanics?

Whatever you think of Zagat’s cross-dressing, it again demonstrates the bottomless market for doctor rankings. HealthGrades, the Colorado company that breathlessly delivers its “200,000 Americans died from
medical errors in 200X!” pronouncements every year (grabbing a bunch of headlines, despite the fact that this report is based on measures that were not intended for this purpose and really aren’t measuring deaths from errors), appears to be doing quite well,
thank you, largely fueled by its doctor ratings. And every metropolis’s city magazine has its “[Your City’s Name Goes Here]’s Best Doctors” issue, based almost entirely on peer surveys. Most docs scoff at these
ratings (particularly docs like me who haven’t made their city’s list), but they clearly move magazines. [I’ll discuss hospital rankings, especially US News & World Report’s Best Hospitals list, in a future posting.]

byClearly, real people want to know who is a good doctor. But how should we be approaching this task?
have the privilege of serving on the board of the American Board of Internal Medicine. ABIM, and the other specialty boards, have generally taken their charge to be to determine “competence” (with board pass rates generally above 90%, a pretty low bar) and then not to differentiate further. A doc is either board certified or she’s not. End of report.

ABIM’s
recently finalized strategic plan includes a commitment to make public
more information about diplomates if and when it feels such
distinctions are scientifically valid and dissemination would promote
high quality care. Dr. Kevin Weiss, the new president of the American Board of Medical Specialties
(the umbrella organization for all the specialty boards) might go even
further, faster. He recently went on record as favoring having the
Boards enter the doctor ranking business – not just determining
competence, but differentiating excellence from not-so-much. In a
recent talk to the ABIM board in Dallas, Dr. Weiss held a copy of Dallas Magazine’s
Best Doctors issue and dramatically observed that if the Boards don’t
get into this game, others – with far less allegiance to scientific and
psychometric Truth – will. Needless to say, his remarks generated a wee
bit of controversy.

I’m also on Google’s Healthcare Advisory Board. [Note that my
comments about ABIM and Google represent my own opinions, not those of
these fine organizations, and do not divulge any trade secrets. You
decide whether to buy more Google stock on your own.] Anyhooo, it
wouldn’t surprise you to learn that Google is also thinking
about what contribution it can make to the doctor rating “space.” But
how to balance consumer rankings (a la Zagat), which will invariably
tilt toward bedside manner and office amenities (not unimportant
things, but ones that may be quite different from clinical acumen),
with more meaningful assessments of clinical competence? And, as I discussed earlier this month,
even when you add standard process and outcome measures to the brew,
we’re still stuck scratching our heads about how to factor in clinical
knowledge and decision making, things that today’s quality measures
completely whiff on.

The stakes are immense, and a balanced approach is more likely to
bear fruit than any single peephole.
Ultimately, if I’m choosing a doc for me or a loved one, I’d like to
know it all: bedside manner (4 stars from Zagat), structural measures
(is the doctor’s office computerized?), process measures (are diabetics
getting statins appropriately?), surrogate outcomes (what’s the average
hemoglobin A1c?), and hard outcomes (what are the risk-adjusted
mortality or hospitalization rates?). And then I’d like the appropriate
specialty board (ABIM, American Board of Surgery, etc.) to tell me
whether the physician is meaningfully engaged in quality improvement
activities, and how well he or she did on the certifying exam – the
best measure we have of knowledge and clinical judgment. Yes, you heard
me right: I’d like the Board to tell me whether the doc was in 5th
percentile on the certifying exam or the 87th. It doesn’t pass the
smell test to say that we consider both these board certified docs to
be undifferentiate-able. In this new era of transparency, if we
physicians would want that information before choosing a doc for
ourselves (and I sure would), then I believe that patients should have
access to it as well.

And then I’d like Google or somebody else
to put all of this together into an attractive, user-friendly page that
pops up when I type “Best Doctor Diabetes San Francisco” into a search
engine, along with directions to the office, a link to his appointment
calendar… and a parking spot.

Coming soon? The people have spoken, and the people have an uncanny way of getting what they want.

Bob Wachter

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