How to Choose Your Doctor

In this issue of HONOLULU Magazine, you’ll find a list compiled by Best Doctors in America. The organization asks doctors in the United States and Canada whom they’d want to treat them if they were sick. While popular with health consumers, the Best Doctors list is, at best, regarded by Hawai‘i doctors with suspicion.

“This list is a popularity contest, like American Idol,” comments Dr. Stephen Arnold, despite being selected for the list for four years running. He adds modestly, “I know plenty of doctors in town who are smarter and kinder than I, and who are not on the list.” At the same time, “there is at least one doctor on that list who I think should not be there.”

One might say that Arnold protests too much. Indeed, he is widely regarded in the medical community as a “doctor’s doctor,” caring for many doctors and their families. Why is Arnold, and other doctors on the list, so respected by their peers?  Is it because he starts seeing patients at 6:30 in the morning and stays until 8 or 9 p.m. in his office dictating notes? Is it because he trained at Cornell? Or is it because he has been practicing for more than 25 years in one location?

How does one become a doctor’s doctor? It is interesting to note that, while marketing experts, health plans and even the government have extensively studied how patients choose doctors, how doctors choose doctors has hardly been studied at all. Is there something patients can learn here?

How Do Doctors Choose Doctors?

At first glance, it seems that doctors are not particularly choosy when it comes to selecting their own doctors.

“I chose Dr. Pien because he worked right next door,” remembers Arnold.
“I chose Dr. Arnold because he was my wife’s doctor,” Dr. Robbins says.

When pressed further, though, my colleagues added that, “Dr. Pien has a brilliant mind, and is also very thorough.”

“Dr. Arnold is easy to communicate with.”

Most doctors focus on the technical aspect of medicine: being as shrewd and thorough as Sherlock Homes, making the right diagnoses and keeping up with new findings. As Dr. Edwin Cadman, dean of the University of Hawai‘i Medical School, puts it, “A doctor must have an outstanding base of knowledge. Patients do not know disease processes. They relay the information to the doctor. The doctor must then analyze the data and make the right diagnosis.”

How Patients Usually Choose Doctors

On the other hand, patients seem to assume that the doctor is competent and focus instead on the doctor’s ethics. Patients want doctors who put the patient’s interests  first, not the doctor’s interest, not the hospital’s, not the HMO’s interest. In this age of “managed care” (managed by whom?), 90 percent of patients still believe that their doctors put the patient’s interest first. However, more than 40 percent of patients believe that their doctors’ decisions are partly influenced by HMOs, whether the patients are enrolled in managed care or not.

This tarnished reputation was earned by doctors in the 1990s when they signed up to be “gatekeepers” for HMOs. In the past five years, managed care has been rejected by a popular revolt of patients. Fortunately, doctors still rank second-highest in the most recent Gallup poll of professions in terms of honesty and ethics, right behind nurses who did not sign up to be gatekeepers. In the same Gallup poll, HMO managers were ranked last for honesty and ethics.

It irks economists, marketing professors, government agencies and HMOs that patients do not behave as these experts think they should. Calling them “irrational” and “passive,” health experts would like patients to become “health consumers,” using “quality information” and “examined behaviors” to make “knowledgeable and informed choices.” However, in survey after survey, more than 50 percent of patients rank family and friends as their most important sources of referral for doctors. Newspapers, magazines, yellow pages, radio, brochures and free health seminars are ranked by fewer than 1 percent or 2 percent of patients as their most important sources.

As doctors know from experience, patients are not only smart, but also proactive. In one survey, more than 80 percent of patients have changed, or have thought about changing, their doctors over the past five years. The most common reason was their doctors’ personalities. As one patient put it, patients expect “competence, caring and courtesy” from their doctors. On average, a patient decides within three minutes of meeting a doctor whether or not the doctor cares for her.

Until patients trust statistics over their friends and family, lists such as the one in this issue will remain popular with consumers. On the other hand, hard data might also help to dispel the popular Island belief, that, “If I really sick, I go Mainland.”

Are there good doctors in Honolulu? Cadman, former chief of Yale-New Haven Hospital and director of UCSF Cancer Center, says, “Since I have been here, I have been impressed with the hospitals and the physicians. I think it is more a question of size. For example, Yale has 10 heart surgeons, and here in Honolulu we might have four or five. Yale has 800 beds, and Queen’s about 400.”

The quality of care in Honolulu will certainly improve with the completion of the new UH medical school campus in Kaka‘ako. Of the more than 2,000 doctors in Hawai‘i, more than 1,000 of us are volunteer faculty with the medical school.

How Patients Should Choose Their Doctors

First, you should make sure that the doctor does not have a bad record; and second, that your and the doctor’s personalities are compatible.

You can find out if your doctor is in good standing with the State Professional Licensing Office at www.ehawaii.gov, under Online Services. This Web site will tell you if your doctor is under suspension for any reason and if the doctor has any lawsuits pending against him or her. Because more than 60 percent of doctors will be sued sometime during their careers, having one or two suits on record should not be an automatic strike against the doctor.

You should know that because Honolulu is such a small town, it is hard for a doctor not to have a bad reputation if he or she is incompetent. As an internist, I would not refer a patient to a specialist unless I had confidence in the specialist, because, if things went wrong, I would be named in the lawsuit.

Can “quality information” and statistics really help patients choose doctors and hospitals? Heart surgeon Mark Grattan thinks so. “Unfortunately, here in Hawai‘i patients have no access to quality information, such as mortality rates of surgeons.”

When statistics on heart surgeons were first published, people were quite shocked to see the wide variation among them. “I think the numbers generally improved the overall quality of care. When New York State first published its numbers, several surgeons had to stop operating, because their numbers were just way off the chart.” One can find hard numbers from the National Healthcare Quality Initiative, Health Plan Employer Data and Information Set (HEDIS) and Consumer Assessment of Health Plans (CAHPS). Through Healthgrades.com, one can find if a Honolulu doctor is board certified, where he or she went to medical school and if he or she has been sanctioned by the state or the federal government.

There is a downside to relying on numbers. For example, because heart surgeons are judged according to how many of their patients die during or after operations, they are naturally more reluctant to take on sicker patients. “Does this mean that if your 90-year-old father has a heart attack, and now has a severe heart valve problem and bad heart failure, you will have a hard time finding a surgeon who is willing to operate on him?  You bet,” cautions Grattan.

After your doctor’s competence has been vouched for by another doctor and the state licensing board, you should also check if you and the doctor can work well together. This is where your friends and family can be helpful, by letting you know if they have been treated by the doctor and the doctor’s office with courtesy and good service.

The ability for you and your doctor to communicate well is crucial, and you can find this out only by talking to the doctor face to face. When I was in medical school, our professors kept telling us that there is an “art” and a “science” to medicine. Since it has been proven that 90 percent of communication is nonverbal, the “art” of medicine is the verbal and nonverbal interplay between the patient and the doctor. Patients don’t always tell doctors what they really want: a million-dollar work up, a prescription or information and reassurance. Picking up on such subconscious communication is how doctors develop a positive relationship with patients.” 

Ultimately, when you choose a doctor, you are choosing someone you can trust. You trust that your doctor is competent. You trust that he genuinely cares for you. You trust that he or she will have the courtesy to see you and return your phone calls promptly. In short, patients deserve competence, caring and courtesy.

Author’s Note: Dr. Robert Yih-jen Shaw is an internist at Straub Clinic and Hospital. He trained at Albany Medical College, the University of Hawai‘i, and Oregon Health Sciences University. His last piece for HONOLULU Magazine was “18 Questions While You’re in the Dentist’s Chair,” February 2004.