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A. Financial Conflicts of Interest
Doctors get many pressures which affect patient care. The Journal of the American Medical Association (JAMA) May 2 2017 summarizes a lot of research and has a proposal that doctors be paid by salary, to avoid:
Practices with 2 or more primary care doctors were analyzed in a July 2015 study in Annals of Family Medicine (632 practices surveyed 2012-13):
B. DOCTORS REVIEWED BY DOCTORS
Average incomes (after expenses) by specialty range from $200,000 per year for Pediatrics to $440,000 for Orthopedics, with wide variation. Wealth averages $1-2 million, depending on specialty. Half of some specialties would not choose medicine again if they had the chance, including Orthopedics, Plastic Surgery, Radiology, Urology and Dermatology.
Most doctors at hospitals work for large groups which contract to provide hospitalists, radiologists, emergency doctors, etc. Some companies provide doctors to hundreds of hospitals.
Payments from industry to doctors are discussed on the drugs page.
Patients can use published surveys to find doctors recommended by other doctors.
Consumer Checkbook surveyed 375,000 doctors in 2009 in 53 metro areas ($25 online, $1 used). They list 24,000 doctors who received the most recommendations, and show the number of recommendations each received. Their research says that in general these doctors also:
A 1999 study found that doctors were more likely to be in such lists "if they trained in prestigious residencies (P<0.01) or fellowships (P<0.05), or if they had an academic appointment (P<0.05) or 15 or more years of experience (P<0.001)."
Referral services also select doctors they think are high quality, and you pay for the referral.
Malpractice and disciplinary cases (rare) are another place where some doctors are reviewed.
C. DOCTORS REVIEWED BY STATISTICS
The best statistics are:
Groups which report outcomes often say they adjust for initial health to put all patients on a level field, but the adjustments are very weak. They have low explanatory power, and few variables: "the most assiduous work on risk adjustment has produced tools of only moderate power. The prospects for solving this problem with improved risk adjustment are not promising.,"
Consumer Checkbook rates individual surgeons on death (within 90 days) and total bad outcomes, SurgeonRatings.org. They use Medicare patients 2009-12, and only report surgeons with results significantly above average. Unlike their hospital data, they unwisely exclude hospice patients from the surgeons' results (p.3). Few patients would have these surgeries if they were on hospice, so they must have gone on hospice after surgery. These deaths are no more or less attributable to surgery than any other deaths in 90 days. They acknowledge a random level of deaths in any population, unrelated to surgery, and exclude it with statistical tests.
Surgeons' total bad outcomes for Checkbook include deaths within 90 days, atypically long hospital stays (indicating major complications), and readmissions within 90 days of initial hospital discharge. They seem to include all readmissions, even unrelated to the surgery, so they penalize surgeons who take on patients sicker than average. They say they adjust for patient riskiness, without details about which variables they use. They do list the "c statistic" for each adjustment, ranging from 0.626 to 0.913 (pp.14-39). The c statistic ha a scale of 0.5 to 1, where 0.5 means their equations do no better than chance, and 1 means their equations are perfect. So some equations are little better than chance, and they still rate surgeons with them. They cover (definitions on pp.9-13):
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):
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
Cardiologists show 4-star ratings for use of recommended drugs by a few hospitals after
California has a rating system for doctor groups with HMO members:
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.
D. DOCTORS REVIEWED BY PATIENTS
Patient reviews tell if a doctor speaks clearly and listens, as well as giving early warning of problems. Dr Wen of George Washington U and Dr Kosowsky of Harvard say doctors need to communicate well with patients to get information for a good diagnosis:
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.
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...
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.
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."
E. PATTERNS OF COMPLAINTS BY PATIENTS
Consumer sites carry complaints about doctors, justified or not. Also, some doctors are formally charged by authorities or investigative reporters, correctly or not. The complaints on consumer sites often give early warnings about doctors who are later investigated. Second opinions are almost always a good idea, and especially in any of these situations where others have reported concerns.
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.
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:
F. NO PRIVACY ON THE WEB: TRACKING YOUR SEARCH FOR DOCTORS
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