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An internist and cardiologist tells you what others may be afraid to-and what can save your life: where to look, what to ask, and what to avoid when you need quality health care for yourself and your family.
Dr. Evan Levine, a New York cardiologist, believes he has a responsibility. The practice of medicine in America today has deteriorated and everyone must look harder to find good health care. Dr. Levine wants to give people the facts that can really help them-the truth about ...
An internist and cardiologist tells you what others may be afraid to-and what can save your life: where to look, what to ask, and what to avoid when you need quality health care for yourself and your family.
Dr. Evan Levine, a New York cardiologist, believes he has a responsibility. The practice of medicine in America today has deteriorated and everyone must look harder to find good health care. Dr. Levine wants to give people the facts that can really help them-the truth about the scams doctors, hospitals, and drug and insurance companies are running, all in an effort to put profits ahead of healing patients; and the vital tips we need to find the appropriate general physician, specialist, and hospital in our area.
How do you choose a good doctor? Check for his or her board certification, medical schools, and rankings; and never accept a doctor assigned automatically by a hospital. How do you find the right hospital-where things will be done professionally and correctly? Go to a university hospital, especially during an emergency; make sure an ER doctor calls your primary physician; and always question a test being administered. Levine's book is chock-full of essential information on second opinions, clinical studies, and the tricks of the trade that doctors, hospitals, and drug and insurance companies use to maximize their profits-at the expense of your health-and your wallet.
How to Choose Your Doctor
How do you choose your doctor? It's not a very easy question to answer. However, I can tell you how not to choose your physician and, if nothing else, give you a tried-and-true set of guidelines as you make one of the most important decisions of your life.
I have been told many times by my patients and even my friends that when they are suddenly in need of medical attention or advice they simply open up the Yellow Pages and pick the physician with the largest advertisement. Needless to say, this is not a good way to find an excellent doctor. Or a plumber, for that matter. Others have told me that they close their eyes and pick their physician from the pages of their HMO book. Think about that for a moment: putting your life into the hands of a stranger picked at random out of the Yellow Pages or from some health-care provider's booklet. Would you buy a car or appliance using this method? When you purchase a car, don't you go automatically to Consumer Reports to check out the reviews and ratings and then give it a test drive first? One of the most important things you can do after reading this chapter if you do not yet have a primary doctor is to go find one before you get ill. Looking for a physician when you are sick with a fever or, God forbid, a much more serious ailment is not an opportune time to start.
The first thing to consider is the qualifications of the primary-care physician or specialist. Although medical credentials do not always guarantee a physician's knowledge and expertise, they are a good place to start. So find out where the doctor went to medical school and where he or she did his or her residency. This information can be obtained by looking in books like Who's Who in Medicine and Health Care, by calling your local hospital, or simply by calling the doctor's office.1 You can also use the U.S. News & World Report website (www.usnews.com), for example, to find out a great deal more about medical-school rankings. I know my staff is always eager to answer these questions. Yet when I called a handful of offices in the five boroughs of New York City, I found that some of them were reluctant to answer my questions. In such instances, one can only surmise that these offices were staffed by physicians with second-rate training and dubious skills. Again, good-quality physicians with quality staff should be not only able to answer these questions but happy to do so.
Call a few offices, especially in large medical centers, and see if you get a headache listening to the phone ringing endlessly without an answer. If you can't get through to an office to set up an appointment or to ask a simple question, imagine how you will feel when you really need to speak to the doctor. I'm sure there are patients and doctors reading this who have experienced this: no answer or an abrupt forward into a byzantine voice-mail system (often the black hole).
If you end up in an emergency room with a real medical problem, you may be given the doctor on call. The physician to whom you are assigned might be a poor doctor, indeed. The nurses in the ER are almost certainly aware of his deficiencies and are sympathetic to your dilemma, but no doubt they would be unwilling or afraid to tell you. I cannot stress enough the importance, if at all possible, of going to an ER in a large teaching hospital. You will be assigned a medical resident, and after seeing him, if you are able, you can ask him to call a physician he trusts.
While we are on the subject, perhaps the best people to ask about which doctors are super and which ones are not are the medical residents and the nursing staff in an academic or teaching hospital. They know which physicians are bright and caring. They see which physician comes to see the patient in a timely manner and orders appropriate tests and consults. Or which stops by on the weekend to see what's up. But there is still that terrible code of silence I mentioned previously. It exists in all the hospitals where I have worked and studied. The staff knows which physicians to avoid yet they cannot advise the patient or his family. They could, however, if asked, suggest a physician whom you could see once you come to the hospital. Or perhaps you could prevail upon one of the nurses for her recommendation as to which physician she would see if she were in your shoes.
Being an absolute iconoclast and a true patient advocate, I have in many circumstances, and behind closed doors, told patients seeing particular specialists to get a second opinion. Or, in other words, I've told them to seek care with a doctor better qualified than the one they were seeing.
As incredible as this will sound, you also must make sure that the physician is board certified. Board certification means simply that your physician has passed a standardized test given by the nationally recognized specialty board. Frankly, in my opinion, physicians who cannot pass their board exam should not be allowed to practice their specialty. The exam is quite easy, and only 20 percent of doctors fail on their first attempt to pass it. And yet I know physicians who specialize in cardiology and pulmonary medicine, for example, who have failed their board exams several times before finally passing or who have never passed the exam at all. Statistics like these are not available, unfortunately, as I can imagine there are few potential patients who would happily submit to care by one of these frequent failures. Perhaps the simplest way to determine if your physician is board certified is to go to the site www.abms.org. There is no cost to register, and you can look up as many as five physicians per day.
In general, a physician must renew his certification every ten years, although many older physicians do not, probably due to some sort of grandfather clause that gives them special dispensation.
If the doctor is not board certified, then obviously I recommend that you go elsewhere, since this usually means the physician in question lacks the aptitude to pass an exam. Once again, just because the physician specializes in a particular field does not mean he is board certified.
If you walk into a physician's office and you notice that it is dirty or shabbily furnished or poorly lit or that the staff is not courteous, attentive, and professional, then I would suggest you turn right around and leave. Use your instincts, as you would in any number of situations. If you meet the physician and he looks in any way less than presentable, or seems overworked or distracted, or doesn't seem to be listening to you when you are talking to him, then I would not go back. You would be surprised, for example, to know how many MDs can be found day-trading stocks in the back office while not seeing patients. Meeting people and forming opinions about their integrity and competence is a crucial skill for us all, needless to say.
I would also take a look at the doctor's stethoscope. This is the tool of his trade. A top-of-the-line stethoscope costs less than $200. So if you see a stethoscope with pink tubing or perhaps a drug logo on it (usually a $5 stethoscope given to the physician by a pharmaceutical rep), I would be very wary. In fact, if you don't know what kind of stethoscope your doctor is using, ask him. I'm troubled by the number of physicians, even cardiologists, who use cheap and inferior stethoscopes in order to save a hundred bucks. Can you imagine such a thing? But a seemingly insignificant detail like this might save you from going to the wrong physician.
I recently came across a neurologist who did not have a blood-pressure cuff in his office. He called me to tell me that my patient was complaining of a headache during his exam. When I asked him to take her blood pressure, he replied, "I don't have a BP machine in my office." Any physician you see should be able to take your blood pressure, and most should take it as part of their exam. If you see a physician who cannot take your blood pressure I would question whether he is truly capable of taking care of his patients-or you.
Lots of us hear about doctors from our friends, but I would not rely on a friend's recommendation of a physician unless he has done his homework and you trust him implicitly. Just because someone you know has been using the same doctor for a decade does not mean that he or she is getting good care. People see doctors for twenty years and have good relationships with them but may be receiving the worst sort of care. Perhaps the only exception to this rule would be a recommendation of a good plastic surgeon, since you can at least judge with your own eyes the results of his or her work.
If you need to be referred to a specialist, all of the previous suggestions still apply. Unless it is an emergency, however, I would suggest that you ask your primary-care physician to give you the names of two physicians he would consider sending you to and then ask him if he would recommend one over the other, and if so, why. I am no longer shocked when I ask a patient why his doctor sent him to me and he tells me that he has no idea. There is an uncanny degree of blind faith at work here. Over and over again, I see the same tacit assumption made by patients of both sexes, of all ages, of all levels of education, and from all walks of life, namely that every individual with a physician's shingle hanging out in front of his or her office is equally talented, insightful, and trustworthy. Do you make the same assumption about lawyers? Or accountants? Even your electrician?
When you do choose a doctor you should also consider who your doctor works with or who covers him (takes calls in his absence) when he is not working. Since it's impossible for your doctor to work every single night and weekend, most physicians arrange what is called cross-coverage. In other words, competing doctors agree to work and cover their competitor's patients and vice versa. Sadly, there are instances (rare, one can only hope) when a bright, hardworking physician might be involved in a coverage agreement with one who is inept and unqualified. In one hospital where I attend, for example, specialists who are board certified are sometimes covered by some less-than-astute physicians who have never passed their board exams. My partners and I were involved for a very short while with another cardiologist who approached us for a coverage arrangement. One night when he was covering for us, he refused to go to the hospital to take care of a very sick patient who was having a life-threatening heart attack. At 2:00 A.M. I was tracked down by the patient's internist, who told me that the physician covering refused to go see the patient. I went in myself and took care of him. The next day, of course, we told that physician we would no longer be involved in a cross-coverage arrangement with him. As I understand it, this character is no longer practicing medicine in the United States.
So remember, when you do choose a doctor of any kind, ask him if he is involved in some sort of coverage arrangement with other physicians. Ask him for the names of those doctors and then find out if they are board certified. You might also ask your doctor if you could call him in special circumstances when his associate's coverage is not helpful. Or, to avoid this cross-coverage issue altogether, you could find a doctor you trust and respect who works in a larger group of affiliated physicians and then become familiar with all the doctors in that practice.
If you are also a patient of a specialist, like a cardiologist, your other choice if your primary-care physician is away or unavailable, or if the cross-coverage falls through or is unsatisfactory, would be to call the specialist who knows you. Many patients call me when their family doctor is not available.
There are times when your doctor, dentist, or podiatrist might sell his practice. In fact, it is illegal for a physician to "sell" his patients, and in any event, the buyer understands that the patients can always decide to leave him when the deal is made or at any time thereafter. Sometimes, however, the physician who is leaving is paid a percentage of the monies the new doctor collects over the next year. With this financial incentive in mind, the retiring doctor has a great incentive to keep you from leaving the practice. So if your doctor decides to leave or retire or to sell his practice, don't stay if you think the new doctor is not the right one for you. In fact, I would evaluate him or her just as I have suggested you evaluate every new physician. If you decide to leave, remember to get your old records, or at least a copy of them, no matter what the charge may be. (I believe it can be no more than 75¢ per copy, but most offices will charge you far less.)
There are any number of common situations I would urge you to avoid. Doctors with different areas of expertise who share offices often (but not always) have some sort of incentive to send patients to their colleague down the hall. So, unless you trust your doctor implicitly, I would avoid these situations. Frankly, in the interests of complete disclosure, one of my partners happens to be a gastroenterologist. But in order to avoid even the slightest possible appearance of bias, I tell my patients that he is a partner of mine and, if they wish, I will be more than happy to send them to another highly qualified and respected stomach doctor. In order not to influence them in any way, I do not even tell them that I send members of my own family to see him.
Husband-and-wife teams present essentially the same problem. And if your primary-care doctor tells you that a number of different specialists rent space one day a week in his offices, I would caution you that this often means some sort of shenanigans are going on.
Never call an 800 number advertised by your hospital. These advertisements remind me of the ones politicians put forth every election year, full of half-truths at best. Hospitals do this to get their physicians, most of whom are on salary at the hospital, more patients, by which I mean more business. I would be especially careful of small community hospitals that advertise in this way. The hospital may purchase time on a local station and make all sorts of dubious claims: We have a heart center, or wound center, or perhaps a special sleep or cancer center. Yet there is no special certificate or prestigious award to back up their claim that their center is one of excellence. Once the listener calls in, an operator gives him or her the number of a physician affiliated with that hospital. Often these doctors are picked at random from a list and again only because the hospital hopes to profit from them. I am embarrassed and outraged by these sorts of lies and distortions I hear every day on the radio as I drive to work.
The truth is that almost every hospital advertises, and even the more prestigious ones are not opposed to painting a picture of excellence even when that may be far from the case. Very often this advertising centers on the formation of a new heart or cancer center, for example, or draws attention to the arrival of a much sought after and very highly paid new physician who, the ads suggest, virtually walks on water.
On December 15, 2002, the New York Post ran an article titled "Hospital Heartache" that illustrates precisely the point I am trying to make. The author begins by describing how aggressively Mount Sinai Hospital marketed their new "world-renowned team" of top cardiothoracic surgeons.
"The best just got better," the ad boomed in large type.
After reading the Post article, however, you might conclude that Mount Sinai would rather not have had to endure this latest round of free publicity, for it went on to state that "the state Health Department is investigating complications in 28 heart procedures, including bypass surgeries and valve replacements, at the hospital earlier this year (2002)-including 21 deaths." According to the Post, one of the cases under investigation involved Mount Sinai's new chief of cardiothoracic surgery, Dr. David Adams, and whether he incorrectly had placed a prosthetic heart valve in a patient, who died shortly after.2
In November 2002, in a letter obtained by the Post, "the State asked Mount Sinai President Larry Hollier to explain the hospital's 'unusually high' 6.12 percent mortality rate for bypass surgery in the first half of this year." Pointing out that this mortality rate (while not adjusted for risk factors) was "substantially higher than the statewide average" (2.24 percent in 1999), the state also asked the hospital to take "corrective action."
When the Post reporter asked the hospital about these results, they replied that their surgical outcomes were getting better and mentioned that out "of 130 bypass operations since July, no patients have died." But Mount Sinai didn't mention that 130 bypass cases is an unusually small number of cases to have occurred in such a large medical center during that period of time. So while I'm not sure how they lowered their surgical mortality, they might have turned away the high-risk cases instead of doing a better job.
"'They're still a great team,'" Gary Rosenberg, executive vice president of Mount Sinai Medical Center, said of the heart surgeons, adding that "it takes a while" for a new group to get established.3
This investigation has not been concluded as of my writing, but Mr. Rosenberg's statement says volumes about the arrogance of such an institution. When a hospital or medical center recruits a highly paid doctor to join its staff, that institution very quickly has to justify the large cash outlay it has made. Therefore other members of the faculty are encouraged, and in some cases pressured, to send patients to him, even though those doctors may not know if he's a good doctor or not. Recently, a very highly paid doctor, José P. García, and his team were recruited to run a new heart transplant program at Montefiore Medical Center in New York City. With millions of hospital dollars invested in this new program, it won't surprise you to learn that the hospital did not publicize the doctor's surgical mortality rate when he practiced in another state.4 (You can rest assured that if it had been low, it would have been publicized.) You might assume, though, if you were a trusting sort of person and given all the hoopla, that his mortality rate was stupendously low. But here's the thing: For the year 2000, the doctor's in-house mortality rate, as reported by the Pennsylvania Health Care Cost Containment Council, was 10.3 percent, when the average or expected percentage of deaths is 4.3 percent (or 2.4 times the expected death rate from cardiac surgery).5 Fancy that.
So never trust a stranger (or, in this case, any of the medical centers with their big ad budgets and prima-donna program directors). Do your homework and find out everything you can about a doctor's record. It may be hard to determine if a physician who is new to an institution or a neighborhood is a high-quality one, so I'd go to a physician who has an established record.
As you conduct your search you may be surprised to find that some physicians do not accept insurance. Period. Some of these doctors are indeed very skilled and highly qualified professionals who can afford to take this position (thereby avoiding the hassle of all the forms and the price limitations set by the insurance companies) and feel entitled to earn a seven-figure salary, John Q. Public be damned. Many others with this policy are not so well qualified. Either way, I do not approve of these physicians' shameful way of doing business. Actually, these folks infuriate me. The credo of a physician is to heal the sick, not to take advantage of them by charging outrageous prices, turning those who cannot pay away from the door, and not accepting insurance. Luckily, many of the best doctors are participants of health maintenance organizations (HMOs). Don't believe any rumors to the contrary.
There will almost certainly be times when you are confronted with an urgent medical crisis, though not quite a dire emergency-room visit. Perhaps a member of your family has just been diagnosed with cancer or a neurologic disorder like ALS (Lou Gehrig's disease). In such an instance, it goes without saying that you need to find a compassionate, knowledgeable physician in a hurry. Situations like this are often intensely difficult to manage, particularly if the disorder that you or your loved one has is unlikely, in the long run, to be cured. Stress, panic, denial, a feeling of the walls closing in or of one's worst fears suddenly becoming an inescapable reality-all these mind-numbing emotions converging at once can make for a hellish experience. But one must rally to make sure that logic, coolheaded thinking, and common sense prevail at precisely this most terrible moment.
My suggestion in this case is that you actually see as promptly as you can not one but two physicians, both specialists in the field, but one involved in research and the other involved in patient care. This way you will benefit, in theory, from the state-of-the-art knowledge of the former and the highly expert but still hands-on, sympathetic people skills of the latter.
I'll give you an example. A dear friend recently received news that she has ALS-a life-threatening neurologic disorder. When she first began experiencing troubling symptoms she went to see an excellent and compassionate neurologist of sterling reputation. He diagnosed her condition, took all the time needed to explain the ailment to her as carefully as possible, scheduled the tests my friend needed, but also suggested she consult with a physician involved in clinical research just to see what he might have to say about the very latest treatments, state-of-the-art research, etc.
She did see that research clinician, and though his manner was off-putting and somewhat cold, he did at least give her an education about the most current lines of research and treatment. Thus both physicians had their merits, and both visits were worth it. The research doctor, though far too callous as a human being, did have access to the latest study protocols. The real "doctor" took care of the patient.
The problem with many physicians who are involved in research, by the way, is that they sometimes lack the human touch and are often preoccupied with their specific goals: to get funding, to begin and conclude studies, and, yes, to find an answer, or in this case a cure, to a dreadful disease they surely hate with every fiber of their body.
I almost always have my staff help the patient make an appointment for the studies I have suggested, especially when they are complex studies. In addition, my staff always tries to send the patient to a lab that accepts his or her insurance. So if you see a physician, regardless of his status, who ignores you during your interview and simply sends you on your way for exams without helping you, I would suggest you tell him (and his superior) that you are not satisfied with his care.
In the past few years there have been any number of books, magazines, and news articles listing the "best doctors" in this or that field. I am not altogether sure how these lists are compiled, but I have made a point of reading all of them. They are actually rather entertaining, or they would be if this was not such serious business. Some of these physicians have been studying lab animals for years rather than seeing patients. Others are just administrators. My favorite publishers sell their book (I happen to be listed in this one) to the public, but they also do a lively business selling a plaque to every doctor listed in that book for $200. And how do they sell it? In my case a salesperson dropped it off in my office and told the office manager to either send it back (at our cost) or to send a check. I told him to come pick it up or accept a small fee. It's now hanging on my wall.
In my opinion, the most dangerous such list is the one focusing on the "best" cardiothoracic surgeons, which is compiled by the New York State Department of Health (many states have similar lists, which can usually be obtained on the state's website) every year6 and published in most of the New York newspapers, including the New York Times.
This list ranks cardiothoracic surgeons and the hospital centers in which they work based upon their "operative mortality." There are different patient "risks" (essentially "high-risk patients"-a sick elderly female, for example-versus "low-risk patients"-a healthy young male, for example) placed into an equation to weigh a surgical death, but nevertheless a death is a death. What this has created is something I call the "New York Times syndrome." This deadly syndrome actually is responsible for hundreds of deaths in New York State each year.
Let me explain. Three major studies conducted about twenty years ago that compared operative (bypass surgery) to medical treatment (CASS, VA Trial, European Cardiac Society Study) all reached similar conclusions.7-11 Sicker patients, meaning those with the most disease, have a greater chance of survival when they are operated on rather than treated with medications. Yet the sicker the patient, the more likely he or she is to die during surgery. Self-serving surgeons are thus often confronted with a dilemma: Whether or not to operate on a patient with a 20 percent risk of surgical mortality who has a 50 percent risk of dying anyway within a year and thus risk having their "best surgeon" status tainted by a death on the operating table and then published for everyone to see. (In their defense, surgeons never like to lose patients. And, thanks to the rise of the 1-800 SUE YOUR DOCTOR television ads, they always run the risk of a lawsuit in such cases.)
But here is what often happens as a result of this ridiculous and unintentionally dangerous list. A patient is admitted to the CCU with a large heart attack and recurrent angina (chest pain). The angiogram shows a severely enlarged heart with an ejection fraction (percentage of blood ejected from the heart in a single beat) of 20 percent (normal is 50 percent), and severe triple-vessel disease, including a proximal area of the major (left anterior descending) artery. The patient is also diabetic, female, and seventy-five years of age.
Here's the catch. In my opinion, there are many list-conscious surgeons who would refuse this case because of the significant possibility that the patient might die during or shortly after the operation, even though they are aware that the patient would be more likely to survive with surgery than with just medical therapy. I've interviewed many cardiologists in New York State, and most of them agree with this.
Many surgeons have confided to me other ways in which a senior cardiothoracic or CT surgeon diminishes his mortality data (other than by being a very good surgeon). These tricks include the following: The senior surgeon places his junior surgeon as the primary surgeon on the case and places himself as the assistant on the operative report, thus eluding responsibility for the death if the patient expires.
Since only pure bypass surgery is surveyed and tabulated by New York State, and not, for example, surgeries involving valvular disease, it has been suggested to me that some surgeons, as a precaution, will put a few unnecessary stitches in the mitral valve during an operation (so now the patient had valvular surgery as well) and thus escape the burden of a tabulated death, should a high-risk patient die on the table. I know of an even more egregious episode in which a heart surgeon who probably realized that his patient was going to expire and that he was going to have a reportable fatality on his hands went ahead and placed a mechanical aortic valve in the patient possibly to avoid tarnishing his statistical standing. To the best of my knowledge (this was confirmed by several of my colleagues), the patient did not have enough disease present in his aortic valve to justify the replacement.
I am aware of one hospital that was known to transfer patients who were expected to die to its affiliated nursing home next door to avoid a tabulated death. These days, thankfully, all deaths within thirty days of surgery are reported, whereas previously only those patients who died inside the hospital were considered operative mortalities.
You may find, therefore, that some of the surgeons boasting the lowest surgical mortality may have in fact caused more deaths than their colleagues because they have turned down cases like the ones mentioned above. Perhaps they even manipulated the thinking of the cardiologist and of the family as well in order to convince them to decline the surgical option. How do they do this? The surgeon tells the family that it is very likely that the operation could lead to (let's say in this case) Mom's death or a devastating stroke. After painting a gruesome picture, he might add, "I'll still go ahead with the operation if you want me to," but he already knows that in 99 cases out of 100 the family will decline the procedure.
This may not be for the faint of heart, but I have known of surgeons who crack open their patient's chest and begin the operation but then decide it's too risky and close the patient up. Many of these surgeons have a very low surgical mortality rate, but at what cost? Can you imagine waking up in pain from surgery and with great apprehension about your prognosis and the course of the healing process only to find out that you had your chest cut open for no reason? Nothing was repaired, and all you have to show for it is a new scar. Needless to say, it would now be impossible to find another surgeon to operate on you not only because a colleague had walked away from trying to save you but because you have a huge, freshly healing scar. Believe me, things like this happen all the time. But there's almost no way of knowing which surgeons do this, and it is almost impossible to report.
It should come as no surprise that there is an unwritten rule among surgeons in most hospitals that says never take a case from another surgeon who refused it because of the high surgical mortality potential. Or in their own words: Don't take on someone else's problem, and above all, don't get dumped on.
To illustrate what I mean here, in the spring of 2003 I did something unheard of among doctors. A cardiothoracic surgeon suggested to a hospitalized patient of mine that coronary bypass surgery was too tricky and risky for him and thus essentially turned him down. Yet after consulting with other cardiologists and another cardiothoracic surgeon I was convinced that the patient needed surgery. The only catch was that it was very difficult to convince another heart surgeon at my hospital to perform the surgery because his colleague had turned the surgery down. So I transferred the patient from Montefiore Medical Center to Columbia Hospital and a team of surgeons who thought the patient would do better (and live longer) with bypass surgery. Not the right thing for me to do politically, but the right thing to do for the patient.
Let's imagine then that there are 1,000 patients turned down every year in New York because they have a likely surgical mortality rate of 20 percent (the average surgical mortality rate in New York state from 1997 to 1999 was about 2 percent and perhaps a one-year mortality of 25 percent). Instead of going to surgery, if these 1,000 patients are treated with medications, their one-year mortality rate may be as high as 50 percent. At the end of one year, then, the New York Times syndrome has likely been responsible for the deaths of 250 patients who might have lived longer lives.
Thus it is possibly the case that at least a few of the surgeons who rank at the top of this list, that is, those with the lowest mortality rates, are there because they turn the tough cases away. (Having noted this regrettable fact, I suppose I should concede that if one of these surgeons does agree to perform a procedure on you or on one of your loved ones, then you can take it for granted that you have a low-percentage chance of surgical mortality, which is important.)
Moreover, the list is important for two reasons. First, it tells you how many operations a surgeon performed that year. You don't want to let a surgeon near you unless he has performed at least 200 operations in the past year. Second, it tells you which surgeons are to be avoided: those with the very highest surgical mortality. In fact after New York State's bypass-surgery profiling, some of the smallest hospitals with the highest mortality rates closed their bypass programs, thus saving many lives. But these worthwhile contributions are outweighed, I would insist, by what the list does not tell you about the surgeons who simply don't accept the tough cases or about those who perform some sort of valvular surgery on a dying patient to keep that mortality from entering the database. Needless to say, I could name names of surgeons who manipulate the data in order to give themselves a very low surgical mortality.
A few years ago I read a paper published in The Journal of the American College of Cardiology (October 1998). In their study, the authors, Eric Peterson, MD, et al., claimed that they "found no evidence that New York's provider profiling limited procedure access in New York's elderly or increased out-of-state transfers."12 What that means in plain English is that in spite of their higher risks of mortality, the study suggests that high-risk patients in New York were still operated on.
Yet, you did not even need to look at the fine print to learn that this study was conducted on patients who had bypass surgery between the years of 1987 and 1992. However, it is only since 1992 that the New York State Department of Health has released their mortality statistics to the public and thus to the press, and it has taken a few more years for this annual news release to influence patient selection. Thus, only after Dr. Peterson's study was concluded could you find surgeons' mortality rates in the New York Times! And so I stand by my claim. Many surgeons won't operate on very high-risk patients if they know those deaths will be published in the local papers.
While we are on the subject of these lists, I have to say I find it hard to trust any of them, unless we are talking about a list of doctors who are guilty of criminal misconduct. You can look this up on the web at www.fsmb.org. That site lists each individual state's medical board site. There you can search under professional misconduct to see if your doctor has been listed. You might be surprised by what you find.
Finally, what should you do if you've got no insurance or you have Medicaid? One of the best-kept secrets is that most large hospitals have clinic systems that provide some sort of discounted care to the uninsured or free care for Medicaid patients (since they must accept Medicaid outpatients and in fact get paid quite well for treating them). These centers are staffed by medical residents in training who are often smarter and already better doctors than many of the second-rate doctors out in the community. In addition, all the resident doctors must have an attending physician in the clinic in case they have to consult with him or her. What's more, some of the hospitals even supply discounted medications to clinic patients.
The downside to all of this is that your doctor will not be taking care of you when you are admitted to the hospital. Instead, you will be admitted as a service case, and other residents in training will care for you. But again, if you chose a top-notch hospital, you could end up with better care than if you paid thousands of dollars out of pocket for care in a mediocre community hospital at the other end of town. The clinic is likely to be a bit crowded, and it may be a bit more difficult to get special tests or consultations, but again, the care could end up being quite good. Finally, since residencies only last a few years, you won't have the same doctor for more than three years.
So how do you choose a good doctor? Here is a list of tips I would suggest you follow.
1. Call the physician's office. First, you'll see if the staff picks up the phones in a timely manner, and you'll find out if they are attentive and cordial. The quality of the doctor's staff is often a reflection of the doctor. You can ask the staff where the doctor trained in residency, went to school, and whether he is board certified. Check out the medical school rankings. You can also find out which hospital he admits to. If you're not happy with the staff's response, then you should go on to the next office.
2. Meet and talk to the doctor. Just because you made a trip to the doctor's office or a doctor came to see you at the hospital doesn't mean you're stuck with him. If you're unhappy with his demeanor or mannerisms, if he is unkempt, or if you just don't feel comfortable, then either go see or ask for another doctor. If the office is dirty, walk out before meeting the doctor.
3. Disregard all advertisements.
4. Do not call 800 numbers at the local hospital in your search for a doctor.
5. If you end up in a hospital where your physician does not work, do not automatically accept the physician assigned to you. Have the staff call your doctor and see if he can suggest someone.
6. Only accept someone else's advice about their physician if you feel your friend has done his or her homework.
7. When your doctor sends you to a specialist, always ask him for two different recommendations. Unless you have the greatest trust in your doctor, avoid doctors who rent space from him. Also, avoid the doctor's spouse or a relative of the doctor. (I would ask him if you think that might be the case.)
8. Never wait in an office for more than an hour. You shouldn't feel like you're part of a herd. Having to wait for hours often means your doctor is too cheap to get another partner.
9. Make sure the physician accepts your insurance. Why pay for a service if there is an excellent physician who is in your HMO or insurance plan?
10. If you have no insurance or only have Medicaid, go to a clinic at a university medical center.
NOTES FOR CHAPTER ONE
Chapter 1. How to Choose Your Doctor 1. Who in Medicine and Healthcare, 2002-2004, 4th ed., Marquis Publishing.
2. Edelman, S. "Hospital Heartache," New York Post, December 15, 2002. 3. Ibid.
4. http://www.phc4.org/idb/Cabg/default.cfm. Pennsylvania Health Care Cost Containment Council. Pennsylvania's Guide to Coronary Artery Bypass Graft (CABG) Surgery, 2000. 5. Ibid.
6. http://www.health.state.ny.us/home.html. New York State Department of Health.
7. "CASS principal investigators and their associates: Myocardial infarction and mortality in the Coronary Artery Surgery Study (CASS) randomized trial," New England Journal of Medicine 1984; 310:750-758.
8. "The Veterans Administration coronary artery bypass surgery cooperative study group: Eleven-year survival in the Veterans Administration randomized trial of coronary bypass surgery for stable angina," New England Journal of Medicine 1984; 311:1333-1339.
9. Varnauskas E. "Survival, myocardial infarction, and employment status in a prospective randomized study of coronary bypass surgery," Circulation 1985; 72(Suppl 5): 90.
10. Yasuf S, Zucker D, Peduzzi P, et al. "Effect of coronary artery bypass surgery on survival; Overview of 10-year results from randomized trials by the Coronary Artery Bypass Surgery Trialists Collaboration," Lancet 1994; 344:563.
11. Eagle KA, Guyton RA, et al. "ACC/AHA Guidelines for coronary artery bypass graft surgery. A report of the American College of Cardiology/ American Heart Association task force on practice guidelines," Journal of the American College of Cardiology 1999; 34(4): 1262-1347.
12. Peterson, ED, DeLong ER, Jollis JG, et al. "The effects of New York's bypass surgery provider profiling on access to care and patient outcomes in the elderly," Journal of the American College of Cardiology 1998; 32(4): 993-999.
— from What Your Doctor Can't (Or Won't) Tell You by Evan S. Levine, M.D., copyright © 2004 Evan S. Levine, published by G.P. Putnam's Sons, a member of Penguin Group (USA) Inc., all rights reserved, reprinted with permission from the publisher.
|Ch. 1||How to choose your doctor||13|
|Ch. 2||How to survive your hospital stay||36|
|Ch. 3||Tricks of the trade - how some doctors are taking advantage of you and the system||102|
|Ch. 4||Should I get a second opinion?||139|
|Ch. 5||Should I take part in a scientific study?||152|
|Ch. 6||The pharmaceutical industry||167|
|Ch. 7||Medicine in crisis||216|
Posted March 22, 2004
This book should be required reading for anyone interested in getting the best possible medical treatment. Dr. Levine is clearly a honest, caring, very competent cardiologist who objects to many facets of America's medical business. He points out, in clear language and with very scary examples, many of the pitfalls that a medical consumer faces, and gives practical advice on how to assure that you and your family get the competent treatment and human decency every patient deserves. I recommend this book without reservation.Was this review helpful? Yes NoThank you for your feedback. Report this reviewThank you, this review has been flagged.
Posted January 22, 2004
Posted February 22, 2004
He never backs away from run-ins with the hospital administrators or doctors who aren't doing the right thing. We all know him at the hospital for someone who sticks up for his patients! This is not a con- artist or some self-serving doctorWas this review helpful? Yes NoThank you for your feedback. Report this reviewThank you, this review has been flagged.