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Who has wide experience with procedures you need?
A. Doctors Reviewed by Doctors
Angioplasty or Pacemaker Surgery
Aortic or Endovascular Surgery
Endarterectomy/Head or Neck Muscle Angioplasty
Femur Fracture Surgery
Gallbladder Removal Surgery
Heart Valve or Heart Bypass Surgery
Hip or Knee Replacement Surgery
Hysterectomy and Cystocele/Rectocele Repair Surgery
Major Bowel Surgery
Prostate Removal Surgery
Spinal Cord Exploration or Spine Fusion Surgery
ProPublica almost simultaneously with Checkbook in 2015 released death and complication rates for all surgeons with at least 20 surgeries during 2009-13, in the categories below. They count deaths during the same hospital stay as the operation, and wisely do not exclude hospice deaths (p.5). As "complications" they count readmissions within 30 days if these are for diagnoses considered likely to be related to the original surgery. These are 46% of all 30-day readmissions (p.6). They count a surgeon as having a "high" complication rate, based on their best single estimate, even if his/her confidence interval extends all the way into the "low" range.
ProPublica limits the data to elective surgeries, which usually involve healthy patients, but can include patients with other serious conditions, as long as these do not prevent the operation, conditions such as diabetes, dialysis, weak immune systems, etc. They say they adjust data based on the sickness of the patients, but they tried only one summary measure of all health conditions, and it had little effect (pp.10-11, with column heads defined on p.4). Age has the most effect, but they group it into 5-year categories, instead of using exact years of age (maybe because of data availability?). They do not provide summaries of their equations' power, but do acknowledge that their adjustments for surgeons' differing patients make only a "small difference" (p.13). For each equation they provide the standard deviation of the random effects (ranef sigma), which they interpret to mean most of the variation is among surgeons, not hospitals (p.15). They cover (definitions on App.1-3):
- Knee Replacement-Replace diseased knee joint with an artificial knee.
- Hip Replacement-Replace diseased hip joint with an artificial hip joint.
- Cervical (Neck) Spinal Fusion-The fusing of two or more vertebrae of the neck, using orthopedic devices to hold them in place.
- Lumbar Spinal Fusion, Posterior Technique-The fusing of two or more vertebrae in the lower back, performed on the back portion of the spine.
- Lumbar Spinal Fusion, Anterior Technique-The fusing of two or more vertebrae in the lower back, performed on the front portion of the spine.
- Prostate Resection-The resection and removal of a portion of the prostate through the urethra.
- Prostate Removal-The removal of the entire prostate gland via the open or laparoscopic or robotic method.
- Gallbladder Removal, Laparoscopic-Minimally invasive gallbladder removal.
Levy says the profession keeps secret a better scorecard, NSQIP.
Chest surgeons show 3-star ratings on about 500 hospitals and 500 group practices (typically the group of surgeons operating at a hospital), for
- Coronary artery bypass grafts (CABG) and
- Aortic valve replacements (AVR).
Cardiologists show 4-star ratings for use of recommended drugs by a few hospitals after
- Implanting Cardiac Defibrillators, and
- Diagnostic Catheterization and Percutaneous Coronary Intervention (PCI/Angioplasty)
California has a rating system for doctor groups with HMO members:
- colorectal cancer screening of adults 50-75
- lower back pain patients who had X-ray, MRI, or CT scan within 28 days of the diagnosis (fewer is considered better)
- diabetes/blood: kidney function screenings, HA1c blood sugar testing, HbA1c <8.0%, blood pressure <140/90, cholesterol screenings, cholesterol LDL-C <100
New York shows deaths within 30 days after a procedure for individual heart surgeons and cardiologists. You can filter by name of doctor and/or hospital, and region of the state. They describe methods and definitions for the surgeon and cardiologist data. Another NY site has profiles of all doctors, but does not link to the death rates.
CMS Qualified Entities are allowed to use Medicare claims data, in order to provide quality measures on doctors, but it is not clear if any have yet released quality measures.
C. DOCTORS REVIEWED BY PATIENTS
- "Choose someone who makes time to listen to you and answer your questions... and who engages you in a discussion of your diagnosis. By the same token, watch out for doctors who display signs of impatience, intolerance, condescension, or inflexibility" (p. 211).
Wen's and Kosowsky's book goes on to describe in detail how patients need to prepare before seeing a doctor.
Patient reviews tell you the style of different doctors, especially in the written comments.
- The most widespread written comments are: RateMDs, AngiesList and Vitals.
- There are fewer written comments at Wellness, Yelp and eHealthScores. EHealthScores shows amount of experience for each doctor, but their data are old, and you cannot search by amount of experience. As of January 2017, they still use 2012 Medicare data, while 2014 data are available on the Specialists tab.
- There are votes, but few or no written comments at HealthGrades, LifeScript and UCompareHealth.
- There are some comments at Yahoo and Google, but patients' friends see those postings, so most patients do not want to discuss their medical situation frankly there.
- Checkbook has votes (often 10-70 per doctor) for many doctors in 11 metro areas (listed below), on communications, advice, accessibility, courtesy, etc. No written comments.
- AngiesList gives more weight to reviews by paid subscribers, so stuffing would be expensive or impossible. AngiesList offers a national subscription which lets patients check doctors far and near. However doctors are told the real name of each reviewer on AngiesList, so there are few negative reviews.
- Checkbook's ballot box is even harder to stuff. They send questionnaires to:
- subscribers of Consumer Reports and Consumer Checkbook, in 7 metro areas: Primary care doctors in: Boston, Chicago, Delaware Valley, Puget Sound, San Francisco Bay, Twin Cities, DC. $34 for 2 years of results.
- people insured by Aetna, Blue Cross/Blue Shield of Kansas City, BlueCross BlueShield of Tennessee, CIGNA HealthCare, and UnitedHealthcare, in 4 metro areas: Primary care doctors in Denver and Kansas City; Memphis also has cardiologists and obstetricians / gynecologists; New York has all these and gastroenterologists and orthopedists. Free results.
Some doctors have required patients to sign contracts which prohibit negative reviews or let doctors remove negative reviews. The "Consumer Review Fairness Act of 2016" makes those clauses unenforceable. 3,000 doctors had these contracts available in 2011, though not all used them. These doctor-patient contracts are not mentioned by any of the review sites as a reason for removing reviews, but one assumes they do it, or doctors would not bother with the contracts.
Before patients choose any doctor based on positive reviews, it is important to ask the doctor's office: Do patients have to sign a contract controlling patient reviews?
Rules about the reviews they keep are important. Here are rules at the 3 biggest sites:
Allowable reviews: They have few restrictions: "post only truthful, non-libelous, and relevant ratings and posts."
Removing reviews: "We remove ratings for a number of reasons, but it is usually due to one of our automated spam filters thinking there were multiple ratings coming from the same rater... We generally do not remove ratings. This site is for people to report on their experiences...
- [If doctor says:] "I have no choice but to sue you!
- [Website answers:] "Think twice. The Communications Decency Act (the "CDA") is a complete bar to our liability for the statements of others on this website...
- [If doctor says:]"I'm going to sue you anyway. Taking down the review is cheaper than paying a lawyer.
- [Website answers:] "Sounds like a Strategic Lawsuit Against Public Participation (SLAPP.) Twenty-eight states, including our home state, have passed strict anti-SLAPP laws, authorizing expedited motions to dismiss and giving rise to counterclaims seeking attorneys’ fees and liquidated damages. If you want to drag us into court, bring your checkbook with you, because you'll be paying our attorneys to defend us."
Are reviews anonymous? Possibly. They keep patients' names anonymous unless subpoenaed, but they let advertisers and social media companies track which pages you see, so those companies can see your IP address when you post reviews. You can be anonymous if you post your reviews from someone else's computer, like a library, and don't identify yourself on that computer (eg. logging in to Facebook or email). Using your computer at a coffee shop gets you a new IP address, but your computer probably has persistent identifiers which their advertisers can track.
Are searches anonymous? Only if you use someone else's computer. Their advertisers track IP address and every page visited, so they can see what you're searching for. To foil advertisers you can turn off cookies, but not necessarily beacons. Buttons for Facebook, Twitter, and Google+ on every page presumably report every page visit to those companies.
Multiple ratings and updates: They limit patients to one rating "for the same doctor from the same computer or user." "If you were logged into your account when you submitted the rating, you can edit your star rating in your profile. Comments are not editable, but you can leave a new comment... If you were not logged in when you submitted the rating, the only thing you can do is to try to remove it and then enter a new rating."
Can patients report why they didn't go to a doctor? Yes.
Allowable reviews: They have woolly restrictions: "accurate, truthful and complete in all respects" (10) and not offensive, harmful or distasteful, among many other criteria (16).
Removing reviews: They pose the question and answer it several different ways: "Angie's List may modify, adapt, or reject Your reviews if they do not conform with Angie's List's publication criteria, which may change from time to time at Angie's List's sole discretion" (10g). "we never remove reviews unless the member who posted the feedback contacts us to delete it." "If ever we question the legitimacy of a review, we take it down."
Are reviews anonymous? No. They reveal the author of each review to the doctor (10f), though not to other members. Writing any review waives privacy and lets doctors publicly post "Your private or confidential health information in response to Content You submit" (15). "Angie's List may in our sole discretion share your User Generated Content with others."
Are searches anonymous? No. They disclose personal information when "permitted by relevant law," and they have four tracking companies on their search pages (see a table at the bottom of this page), so those companies know what you're searching for. They allow themselves to "link the information we record using tracking technologies to Personal Information we collect."
Multiple ratings and updates: "You have the right to share your honest opinions at any time."
Can patients report why they didn't go to a doctor? Yes. Reviews by people who checked out a doctor but did not go there are posted, but not weighted as heavily as people who did choose the doctor. So good or bad experiences before getting care can be read, though the doctor's average rating is not much affected.
- "(a) any violation of this Agreement by You;
- "(b) the inaccurate or untruthful Content... or
- "(c) any intentional or willful violation of any rights of another or harm You may have caused to another." (27).
Allowable reviews: must be "true and accurate" and not offensive, harmful or "otherwise objectionable," and not "deemed confidential by any contract or policy," among many other criteria.
Removing reviews: They say they provide "The complete list of all reviews from patients just like you." However they'd suppress reviews that violate their lengthy criteria, so it is not really "all." They sell to doctors a service called: "Reputation Management." It "enables providers to append responses to specific reviews [and] Opportunities to encourage patients to write additional reviews." Vitals' CEO is quoted in Buzzfeed saying the site can remove an "outlier" negative review at the doctor's request.
Multiple ratings and updates: "post only one (1) Submissions regarding the same Healthcare Provider, entity, procedure or subjectduring any thirty (30) day period."
Can patients report why they didn't go to a doctor? No. "By clicking Submit, I... verify that I have received treatment from this doctor."
D. PATTERNS OF COMPLAINTS BY PATIENTS
DOCTORS CHARGED BY INVESTIGATORS: What Their Reviews Look Like
The first list below summarizes consumer reviews for 8 doctors who have faced charges (and citations for the charges). All the doctors denied the charges. The second list shows there have been fewer complaints for a control list of doctors who have not been charged, and who do many knee replacements, a risky procedure. So consumer complaints do show a difference between the two groups of doctors.
- LA Times Jan.2012. License now revoked so consumer reviews no longer available
- LA Times Jan.2012. Complaints about poor work, starting in 2009; many other patients praise him
- NY Times Aug.2012. Complaints about poor or unnecessary work, starting in 2009; several other patients praise him
- NY Times Aug.2012. Complaints about poor or unnecessary work, starting in 2009, along with other good reviews
- NY Times Aug.2012. Two good reviews and no bad ones.
- Washington Post Oct.2013. Many good reviews, and 1 complaint in April 2010 about lack of care in a hospital.
- Medicare May 2013. Many good reviews, but also a complaint from June 2012 about poor communication with the patient's primary care doctor and poor service when the patient did not change his insurance as requested by the surgeon. The surgeon was charged with billing Medicare for work not done, so even if true, the alleged activity would not create consumer complaints about poor or unnecessary work.
- Justice Department Jan.2015. Complaints about unnecessary tests, starting in 2008. Many other patients praise him. RateMDs rates him lowest among 26 cardiologists in his city.
DOCTORS WHO DO KNEE REPLACEMENTS: What Their Reviews Look Like
The following shows the range of consumer reviews for 5 surgeons who do high volumes of knee replacements. These have not been the subject of investigations and may be considered "normal" high-volume doctors:
- Several good reviews; one complaint about delays getting a cortisone shot
- Two of 12 written reviews on Vitals and one of 20 on AngiesList describe failed surgeries; the others describe successful outcomes or consultations
- Several complaints about long waits for appointments, but no complaints about outcomes and much praise for results
- One complaint about the brevity of an appointment and the doctor's approach, so the patient went elsewhere; but no complaints about his work, and much praise for it.
- 14 of the 31 reviews complain about rudeness or long waits in the office to see assistants, and about little contact with the doctor, even in the hospital. Some of the positive reviews also say contact is generally with assistants; several express happiness with his surgery.
E. NO PRIVACY ON THE WEB: TRACKING YOUR SEARCH FOR DOCTORS
Click to enlarge table
Nurses also get payments and meals from drug companies, but only Massachusetts tracks these payments.
Drug companies also have constant access to doctors and give them biased information. A 2012 summary found (emphasis in the original):
- 61% of physicians reported that their own behavior was immune to influence by industry, but only 16% thought that other physicians’ behavior was equally secure
- sometimes the suggestion that such influence exists can be infuriating to them
- The frequency of meetings with pharmaceutical representatives varied across specialties, ranging from two per month for anesthesiologists to 16 per month for family practitioners
- representatives presented only selected, usually positive, information about their products
- In one of the few studies of specific [training] content, 11% of statements in formal lunch presentations by pharmaceutical representatives were found to be inaccurate, all favorable toward the promoted drug, yet only 26% of medical residents attending those presentations recalled hearing any false statement. All statements about competing drugs were accurate, but none favorable
- research supported by industry is more likely to report positive results—3.6 times as likely, according to one meta-analysis
- One study of industry-sponsored review articles and Cochrane [academic] reviews on the same medications found that all of the former recommended the drug in question whereas none of the latter did
- 85% of [US medical students] who thought that accepting a small gift or lunch was inappropriate reported accepting them anyway. This may be partially explained by the fact that 93% of the students had been asked or required by a faculty member to attend a sponsored lunch
- In one survey of internal medicine residents, 100% of those who thought interactions with industry were inappropriate accepted at least a lunch or a pen
- In a random sample of physicians in six specialties in the United States, 94% reported some relationship with industry (18). Eighty-three percent reported receiving food or beverages in the workplace; 78% received samples
- Clinicians often describe the role of samples as helping those who cannot afford medications to receive treatment... Physicians themselves report that samples influence them to prescribe drugs that differ from their preferred choices (32). Although the initial reason may be to avoid cost to the patient, most samples are of the newest and most expensive medications, which patients may not be able to afford after their samples run out. Further, the side effects of newer medications are usually less well established
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