Physician, Rate Thyself

An editorial entitled “Rating your Doctor, Fairly” (The New York Times ([NYT)], December 8, 2007) discussed consumers’ need for reliable sources to rate physician quality. At present, insurers do much of this rating and apparently focus on costs, awarding grades or stars on the basis of expenditures. According to the editorial, physicians who are most “cost-effective” get the top marks. The NYT advocated a more encompassing set of rating criteria that would include measures such as adherence to guidelines or national standards (whatever they are). They also suggested posting physician scorecards on a single Web site to facilitate consumer choices.

The NYT has intelligent and trenchant editorials, but, in this case, I think that the paper has mistakenly oversimplified a complicated and contentious subject. Sure, there is an enormous amount of data on physicians out there, but creating a meaningful consumer guide will be a heroic undertaking, if possible. Furthermore, while a ratings system (a Zagat’s guide, in other words) may work for restaurants or movies, I am far from convinced that it would work for healthcare. After all, restaurants are a matter of taste and deciding that the food is a 26 or 27 has the same precision as deciding who has the prettiest face or the most talent in a beauty pageant.

‘Best’ Is a Matter of Perspective

On a recent flight, I was surprised to see an advertisement for the “Best Plastic Surgeons in America” in the airline magazine. The doctor pictured looked sharp in his crisp white coat and he had the straightest and pearliest teeth you have ever seen (no doubt crafted by his buddy who is one of the “Best Cosmetic Dentists in America”). While the basis for calling any doctor the “best” is questionable, I have to admit that the impression was strong. If I ever need a facelift or tummy tuck, trust me, I am going to fly to the smiley surgeon in that ad.

I have been thinking more about quality ratings in medical care since I have presented cases in this column. As you may remember, in a previous column I wrote about managing a hospitalized patient with gout when all the usual therapeutic options are problematic because of co-morbidities (July 2007 TR, p. 6). I asked readers what they would do, and the responses ranged from intra-articular steroids to intravenous colchicine. As pleased as I was with the enthusiastic response, I was amazed by the diversity of opinion.

In another case I discussed an elderly woman whose giant-cell arteritis was discovered during pathological examination of her aorta following grafting for an aneurysm (October 2007 TR, p. 6). The question was whether or not to give steroids in the post-op setting. In this case, while the rheumatology team favored their use, the surgeon wanted to hold off until the graft had healed and the risk of dehiscence had abated. My question to the readers was “What would you do?” Thank you to everyone who wrote in and I very much appreciate your thoughtful answers, which we’ve published on page 9.

The problem, of course, is that there was no agreement on the treatment recommended. Clearly, as in sports, there are those who use steroids and those who don’t, although in rheumatology drug use does not reflect cheating but rather preference and a reasoned assessment of the risks and benefits in situations where choices are murky and the data sparse. For those of you who said to use steroids, I know where you are coming from. The same is true for those of you said to keep the Medrol safely in its vial and far away from the fragile veins of a nice old lady.

For my part, I probably would have waited on the use of steroids until the surgeon gave me the green light. I would, however, have exhorted the rheumatology service to check on the patient every day and query her—indeed, pester her—with questions about vision loss, fever, and other symptoms of arteritis, recognizing that after surgery just about every patient feels lousy, has a skyrocketing sed rate, and gets headaches from everything that goes on in a hospital—including her physician who keeps asking her whether she has a headache.

You Be the Judge

For today, I have two sets of questions. The first question concerns rating the responses we received (I promise we will not post grades on a Web site). In response to my question about steroid use for arteritis, who should get an “A” and who should get an “F”? Who should get the gold stars and who should get none—those who recommended steroids or those who did not? Should I be the judge or should we take a vote?

The second question is more practical and concerns how consumers could use a physician rating system. Let us consider a hypothetical patient called Mrs. Jones. Like the other patient with arteritis I described, Mrs. Jones has an aortic aneurysm. At her computer at home, she scopes out surgeons on a Web site called PhysiciansRatings.com or something like that. Mrs. Jones types in vascular surgeons and gets a list. She chooses Dr. Smith at St. Elsewhere General and goes off confidently, anticipating a successful outcome because Dr. Smith has the top rating among patients of her insurer. (Alas, he was only the third best with another insurer, but no one is perfect.)

What happens, however, when, after the surgery, Mrs. Jones’s arteritis is discovered and the rheumatologist must be consulted? Should Mrs. Jones just trust Dr. Smith’s recommendation or, through the fog of anesthesia and post-op pain, should she request internet access and log back into PhysicianRatings.com to find the best rheumatologist? And—egad—what happens if she finds that the consultant at St. Elsewhere General turns out to be number 10? What should this sick lady do?

As an academic, I have spent most of my career rating things and I believe strongly in the overriding importance of quality in medical care. But if the basis of the rating system is flawed, any ratings that emerge will not be worth a dime. To my colleagues at the NYT, I would like to say that the ratings system you advocate will not be reliable, feasible, or useful.

Also, the next time you write about healthcare, please consult your physician. That way, we can work together to forge a system that we can all rate as fair.

Dr. Pisetsky is physician editor of The Rheumatologist and professor of medicine and immunology at Duke University Medical Center in Durham, N.C.