If You Trust Your Doctor, Tell a Friend

A doctor leaving medicine is not like a vendor posting a going-out-of-business sign--patients just don’t move on to the competitor down the street. Replacing the trust and confidence that are key to a good doctor-patient relationship isn’t easy.

Yet millions of people face this dilemma every year as managed care, moves and other factors uproot patients from long-standing relationships with their doctors.

When it comes to choosing a new doctor, there are few places to look for good advice. In the future, objective facts and figures may be able to help, but for now most people wisely turn to recommendations of family and friends who, in effect, are saying, I trust my own doctor, and he or she may be good for you.

That’s how I chose my gynecologist 22 years ago. But now he has given up his practice because of poor health, turning it over to a very personable female doctor. Essentially he is telling his patients that she is good enough to care for them and that they will be treated well.

This doctor delivered my daughter and followed me into middle age to help me confront the need for mammograms and hormone replacement therapy. I didn’t always agree with him. When he said he was a believer in hormone replacement, I knew the evidence that this would protect me against heart disease was thin, and when he advocated Pap smears every six months, I knew there wasn’t much evidence supporting their value either. Yet I stayed with him because I valued his communications skills and openness.

So when it comes to his replacement, I will trust his judgment and look no further. Trust is not easily broken, so something will have to go horribly wrong to make me change.

“If you’ve had many good experiences and a long-term relationship, you allow for the occasional difference of opinion or the troubled appointment and maintain your loyalty,” says Dr. Bart Wald, president of Physician Associates of the Greater San Gabriel Valley, a large medical group.

However, if trust is not there to begin with, care may suffer. A new study from the Commonwealth Fund, a health care research foundation, underscores the importance of relationship and trust. In a 2001 survey of almost 7,000 adults, one in four people said they did not follow a doctor’s advice or treatment plan or get recommended tests or referrals in the last two years largely because they disagreed with their doctor or because the advice ran counter to their beliefs or was impractical for them.

Even more astonishing, the survey found that 23% of respondents did not have a regular doctor, and only one in three had had the same physician for more than five years. It’s hard to build much trust when you don’t regularly see the same practitioner. Trust and confidence are only one aspect of getting good medical care. Doctors must correctly diagnose your ailment and prescribe the right treatment.

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Here’s where the facts-and-figures crowd comes in. If people had objective data on the performance of physicians, such information might replace recommendations of family and friends and maybe even the less tangible things such as quality of personal interactions with doctors, which are pretty important. Medical outcomes--did the patient improve, did quality of life improve?--would better identify real physician performance, some argue.

“I’m incredibly optimistic about Americans having objective quality information about performance of different doctors to help them make better choices in the next 10 years and not having to rely on what their neighbors told them,” says Peter Lee, president of the Pacific Business Group on Health. “They will be able to know that Dr. Jones does a better job of hip replacement or Dr. Smith does a better job treating diabetics.”

Eventually Lee’s group, a coalition of employers that buy health insurance, hopes to measure how well each of the 70,000 doctors in California scores on a variety of measures. So far, they are working on measures for medical groups and will publish results this fall that compare how groups stand based on their patients’ experiences.

But research is a long way from giving us measures that say, for example, whether Dr. Jones is good at hip replacements, and it’s not likely that such numbers will ever replace relationships and the gut-level trust people need to obtain good care. Nor should they, especially when it comes to primary care or family doctors, even gynecologists.

With specialists it might be different. You want your cardiologist to follow standard treatment protocols and your back surgeon to be technically competent and achieve good results. Some objective guidance might be helpful.

To that end, the American Diabetes Assn. along with the National Committee for Quality Assurance, a group that accredits managed care organizations, is giving a kind of seal of approval to more than 1,500 doctors across the country who have met certain benchmarks in treating diabetic patients. Doctors voluntarily submit patient records that indicate whether appropriate care has been given, such as eye and foot exams, plus blood sugar tests showing results in a certain range. If doctors meet standards, they win recognition.

Sixty-one doctors in California, but only six in Los Angeles, have stepped forward to participate. Obviously only doctors likely to meet the standards submit their records, although, according to Lisa Joyner, who directs the program, about 2% of the applicants fail to meet the benchmarks. To see which doctors do, visit www.ncqa.org/dprp or call (800) DIABETES.

Programs such as this have merit. So far the diabetes program is unique, but in the next few years there may be similar programs recognizing doctors who treat patients for cardiac disease and other common, high-cost illnesses. With only about 20% of diabetic patients receiving the important blood sugar tests every six months and thousands of heart attack victims failing to get lifesaving beta blocker drugs, someone should be looking over the doctor’s shoulder. If you are referred to a specialist, it would help to have some data that show you have a shot at a good outcome.

In the end, care circles back to the intangibles of good medical practice. One New York City doctor who treats diabetic patients says his most important role is to convince them to take the necessary steps to control their disease. If they don’t, he adds, his technical skills and knowledge mean very little. That ability is not always reflected in the numbers.

It gets back to the trust and confidence that are implicit when your friends recommend their doctor.

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Trudy Lieberman can be reached by e-mail at trudyal530@aol. com. Health Matters appears on the third Monday of the month.