In my last post about using the healthcare system, I talked about patient satisfaction surveys as a way to measure its quality.  But measuring satisfaction is only part of health care quality.  You may be satisfied with the care your physician provides, but is it medically appropriate and up-to-date?

Another kind of measure looks at how well all the doctor’s patients with certain common characteristics stack up against some specialty recommendations.  This approach works well for preventive measures for patients of a certain gender and age, such as, immunizations for children or mammography rates for women.  It’s also used to measure care delivered to patients with certain chronic conditions, such as diabetes or heart failure.  These measures cover whether certain tests have been performed on a regular basis and whether certain medications proven to be effective in managing the condition are being taken by the patient.  They also may include what percentage of the patients with the condition are under control by attaining certain standards, such as blood pressure or the A1C level for the diabetic.

There are certain problems with these measures.  First, sometimes more than one medical organization releases conflicting recommendations for the same test or procedure.  For example, the United States Preventive Services Task Force (USPSTF) recommends screening mammograms for women every other year after the age of 50, whereas the American Cancer Society (ACS)  recommends that it be done every year after the age of 40.  Which should be used?  Another problem with some of these measures is that they don’t always accurately reflect the physician’s practice.  With most of them, the physician may order a test or a medication, but the patient must follow through and have the test done or fill the prescription and take the medication.  Another weakness of these measures is that while they can work for primary care and some specialties, they can’t be applied to all specialists.  With time more specialty-specific measures may be developed.  Finally, gathering the data to do the calculations can be a problem, though as more and more practices adopt an electronic medical record, that problem may be reduced.  More about that in the next post, when I discuss clinical pathways.

Some health plans publish some of these kinds of measures for their physician network.  Have you ever seen them or used them?  Please share your experiences with healthcare quality by leaving a comment.

For Your Health – Dr. Bob

This is a complicated question since it goes beyond your satisfaction as the patient.  Certainly your satisfaction with the services you receive is extremely important, but since you are probably not an expert in every aspect of medicine, you may not know whether the test or treatment you receive is the most appropriate for your condition.  In most instances, you are reliant on the physician to give you the correct diagnosis for your medical problem.  Today, I want to talk about the importance of satisfaction in assessing the medical care you receive.

Over 20 years ago, in 1990 the Institute of Medicine (IOM) gave a definition of quality of care that has been useful ever since.  In their publication, Medicare: A Strategy for Quality Assurance, they defined “quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”  Though referencing Medicare, this definition works for all healthcare.  I feel that if you are not satisfied with your experience, whether it is an office visit with your PCP, an x-ray procedure or a surgical procedure, it can lead to your questioning the appropriateness of the other aspects of your care where you aren’t the expert.

I would suggest you measure each part of your healthcare experience by asking this simple question: “Did this encounter meet or surpass my expectations?”  When evaluating your experience, for example a PCP office visit, consider everything about it:

• Courtesy of the front desk staff
• How long you waited in the waiting room
• Courtesy of the person who escorted you to the examining room or doctor’s office
• How long you waited to see the doctor
• How well the doctor communicated with you
• The thoroughness of the examination
• The clarity of the diagnosis and treatment plan
• Your comfort level of being able to communicate with the physician should you have any questions

Please submit your comments, such as, how would you rate your satisfaction with your physician and other health care providers you’ve seen?  How can things be improved from your perspective?  I’ll talk more about other quality measures in my next post on Using the Healthcare System.

For Your Health – Dr. Bob

Recently a friend of mine, I’ll call him Ed, had a surgical procedure to treat his gastroesophageal reflux (GERD) which intense medical therapy could not control.  He was having severe, almost continuous heartburn and nausea.  The procedure was done by means of an endoscope that went down his mouth, through his esophagus and into his stomach.  Ed experienced considerable relief after the procedure. But several weeks later he started having a different kind of pain that started in his mouth, went down his chest and down through his abdomen below his navel.  When Ed explained this to his surgeon, I’ll call him Doctor Adams, the doctor said it couldn’t be due to the surgery and he was stumped.   He could only suggest Ed continue his pain medication for the time being.  My friend felt the doctor didn’t take him seriously, and so he went from doctor to doctor.  It wasn’t until his pain became more localized to his right upper abdomen that he felt one doctor who believed him, ordered tests that showed the problem was his gallbladder.  Ed then had his gallbladder removed and now is recovering smoothly.  What happened?  What went wrong?  Why did Ed have to search for another doctor to help him?

The answer is that the pain Ed first experienced didn’t match any pain Dr. Adams expected.  In fact, it sounded weird.  While Dr. Adams  may have thought the pain was all in my friend’s head, let’s give him the benefit of the doubt and assume that Dr. Adams believed Ed but didn’t know what was going on and decided to wait to see whether the pain would go away on its own or become more identifiable.  But, if that’s what he was thinking, this is where his communication with Ed broke down.  He didn’t explain his thinking to Ed and tell him that even though it wasn’t clear what was going on at the time, he wanted to keep in touch with Ed especially if any of his symptoms changed.  Instead Ed left the doctor’s office feeling like Dr. Adams didn’t believe him.  So, even as his symptoms became more localized, Ed was not inclined to go back to Dr. Adams.

The lesson to be learned is for both physician and patient to maintain open lines of communication in challenging cases like this one.  The physician needs to encourage the patient to report any new, changing or worsening symptoms.  Just as important, the patient needs to understand that the initial symptoms of a condition may be vague and confusing but with time they become better defined and point more clearly to the ultimate diagnosis.

How comfortable are you with your communications with your doctors?  Have you ever had problems similar to Ed’s?

For Your Health – Dr. Bob

When you need elective surgery, make sure you evaluate your treatment options.

This includes not only how you will be treated, but also where you will receive the treatment and by whom.  Here’s how I viewed my situation – In my case with my multinodular thyroid with an especially large nodule on the right, I was given the option of just having the right side of the thyroid removed.  In that case there was a good possibility I would not have to take daily thyroid hormone replacement, but there was also a small possibility that there might be a cancer in the remaining thyroid.  However, most thyroid cancers are very slow growing.  If I kept the left half of my thyroid, I’d need periodic thyroid ultrasounds and follow-up.  At some point in the future I might need the left side to be removed as well.  Realistically with my cardiac history and advancing age I figured that my risk for surgery will only get worse as time goes by, so I chose to have the whole gland removed.  This way, I will know definitively if this is any cancer in any of the thyroid.  The only downside is that I now have to take thyroid medicine every day, but, since I already take daily medications for my blood pressure, that didn’t seem like such a negative.  Your potential treating physician should be able to help you understand the pros and cons of your treatment options.

Just as important, especially if you are having surgery is how much experience has your surgeon had with the procedure as well as the outcomes of the hospital for that kind of procedure.  I was initially evaluated by specialists at a local community hospital about 20 minutes away from my home.  I considered having my surgery there until I learned that the surgeon does only about 25 of these procedures a year and the hospital had a higher mortality with this kind of surgery than average.  Fortunately I live only 30 minutes away from a national center which also participates in my health insurance network.  Their mortality is better than average, and I had surgery by the chair of the department who does 300 of these a year.  Often your health plan will have some quality information about the hospitals and physicians in their network.  I used the information compiled on www.health.usnews.com to help me make my decision.

I hope these last four posts will prove useful if you are faced with new symptoms that might require surgery.  Please share your experiences with us!

For Your Health – Dr. Bob

When you go to your doctor for some new symptom, realize that there will be a clinical process for your workup that could involve many steps, so think ahead!

I’m not suggesting that you will know exactly what tests will be necessary to evaluate your condition, but you can still think ahead.  In many instances, your PCP will have a pretty good idea what kind of treatment your symptoms will require.  In most cases, the tests he orders are done to confirm his suspicions.  With that in mind, if surgery is a strong possibility and you have a history of a chronic condition such as diabetes or heart disease, you may wish to schedule a pre-op evaluation by the specialist who cares for you for that condition.  Why?  Because these doctors are often very busy and you may have a long delay to get such an appointment.  At the very least check with the receptionist how quickly you can be seen if you need clearance before surgery.  In my case because of my heart history I knew I needed to be cleared by my cardiologist.  I also knew because I hadn’t had a recent stress test, he would probably want me to have that done prior to his giving me clearance. I was correct & getting these done added about two weeks to the process.

Next time I’ll discuss evaluating your treatment options to make sure you get the best care you can!

For Your Health – Dr. Bob