To Find the Best
Doctor for an Office Visit, Click
Here
To Find the Best Specialists for Any Procedure, Keep Reading:
Contents
STEP
A - Find Names and Codes for Procedures You Need
STEP
B - Find and Talk to Specialists in These Procedures
Other Lists of Experienced Doctors
Checkup Sites for Specialists:
STEP
C - Other Information for Choosing Doctors
An
Example of Eyes - Macular Degeneration
An Example of Knees
Medical
Costs Specialists'
pay
Unnecessary
Work
Legal
Cases
Reviews
of Doctors
Research on Doctor Volume
Doctors' Training
Steps A and B show you how to find the most
experienced specialists. You can also find the most experienced hospitals. Usually several experienced doctors
practice there, and can learn from each other. You can do this on a small
mobile screen, but a large screen will be easier, and finding the best doctors
is important enough to go find a large screen if you can.
A lot of research shows that doctors who do a
procedure most are generally the best at it. They get the most referrals from
other doctors, who see good results, and from satisfied patients. Also,
constant practice makes these specialists even better. Here are some examples:
The
first steps are always to consider what care is needed, what the alternatives
are, and what questions to type out for the specialist. For alternatives, you can subscribe to UpToDate
from Wolters Kluwer for a week; it has the most
detail on medical options. And you can see reviews of the doctors by patients and other doctors, which
tell you what to expect.
Doctors who refer many patients to a particular specialist
could have their staff check the specialists in some of the ways listed here,
and even compile fact sheets, but they don't. Referrals are usually based on
personal acquaintance, not on reviewing all doctors in an area.
Medicare’s
Physician
Compare includes on a page for each doctor, the number
of times that doctor did a few procedures.
It does not let you search for the doctors who do these procedures the most.
To
find specialists who do a procedure most, you need to know the technical name
of the procedure in the comparative files. Step A finds this name. Step B finds
the specialists.
The specialist files are too big to download easily, with 9-10 million
records per year. To select the records you wish, which you can download
if you want, click below. When you get there, the menu in upper left): lets you
choose 2013-2022
If more and more referring doctors and patients search for
high-volume specialists, then larger numbers of doctors will be able to get
highly experienced in their specialties. Researchers
use the analogy of choosing a restaurant in a strange city: most people will
choose a busy restaurant over an empty one, and most people prefer a doctor who
does a procedure every day, rather than once a month. When other doctors see
bad results after referring a patient to a specialist, they stop referring to
that specialist, so the less successful ones get fewer patients.
The files are based on the Medicare
fee-for-service program. They include doctors and other medical
professionals who did any procedure 11 or more times on Medicare patients in
2014. Patients can use the data whether they have Medicare or not. Medicare has
a brief description of the data
Thus they cover most
shocks that flesh is heir to, but they don't reflect other years, treatment of
younger people, or Medicare HMOs. Patients can ask doctors' offices how much
they treat younger people or HMOs, so that they may have experience beyond what
these files show.
Occasionally a
provider code covers several doctors, and it always covers the residents and
fellows training under the named doctor, if any. The doctor's website usually
says if a doctor teaches, or patients can ask the doctor's office.
HealthGrades offers an easier, approximate, way to find experienced
surgeons for 6 surgeries: Hysterectomy, Bariatric Surgery, Pacemaker
Procedures, Hip Replacement, Total Knee Replacement, Coronary Artery Bypass
Graft. Their risk calculator shows the nearest hospitals with low rates
of death and complications, and highly experienced doctors in these procedures
at those hospitals. They also list many other procedures, conditions, and
symptoms,
and offer experienced doctors. Their definition
of highly experienced is a mix of high volume on the procedure you need
along with total volume for all procedures. They name all the conditions and
procedures each doctor has experience with, but not how much volume s/he has on
each. You can find those volumes above. EHealthScores
shows amount of experience for each doctor, but their data are old, and you
cannot search by amount of experience. As of January 2017, they still used 2012
Medicare data, while 2015 data are available above.
Expensive consultants also find
experienced doctors. Barrons says that PinnacleCare identifies top doctors, and
one of the most important pieces of information they give is "your exact
procedure and how many the doctor had actually performed in the past
year."
Other
Lists of Experienced Doctors
There are many groups which list
specialized doctors and centers, to help patients find doctors with
experience: National Cancer Institute Cancer and Aging Research Group Cystic Fibrosis, see counts at each center by registering National Lymphedema
Network National Multiple
Sclerosis Society Muscular Dystrophy Association Neurofibromatosis,
Children's Tumor Foundation Post-Polio
Health International Sickle Cell Disease, Centers for Disease Control Spina Bifida Association Tourette Syndrome Association Transplant Centers, Medicare ~ Analysis Transplants of Bone Marrow |
Checkup Sites for Specialists:
Specialists'
Experience+Cost 2014 (online inquiry, details above) Generalists
2013-14 Length+Cost of Appointments Reviews by doctors $, or editors: Castle $, Super Rates of death & complications Reviews by patients: Angies $, RateMDs,
Vitals Federal lawsuits State court
judges' decisions State license number, address, degree, age, some
malpractice (docboard) State of license, city, training, some malpractice (docinfo) NPI,
phone, address, hospitals, medical school, languages (Compare) State license number, NPI, phone, address, other state
identifiers (NPPES) NPI, phone,
address (docnpi) (national search: city+state optional) Docs who see same patients within X days (file is too
big for most people; 5 data items per pair of doctors, problems,)
(or here) Payments from drug+device companies 2013+ (CMS) Payments from drug
companies 2009+ (ProPublica) Drugs s/he prescribes
(ProPublica). Evaluation of drugs Compare billings
with state average Zip code average doctor costs, more or less technical Best treatment methods: UpToDate from Wolters Kluwer $ Search for over-used
procedures |
For primary care, the patient volume
doesn't show the best doctors, since all of them handle many office visits.
Another page helps you choose
primary care doctors by the length of appointments they offer, and
whether they can treat you in a hospital or nursing home when needed, as well
as in an office, to give you continuity of care.
Dr
Kussin's book (Dr, Your Patient Will See You Now) suggests almost
always getting a 2nd opinion, and getting it from another specialty (p.
184). He also recommends using foreign doctors, since it took brains to
cross all the hurdles to practice in the US (p.
135), and he suggests using doctors who trained at top hospitals, since it
took brains to get in (p.
131). A study of bypass operations showed no difference in death rates
between doctors trained at top hospitals and others (Hartz et al), but brains are also
important in deciding who needs an operation.
Another
page in this website on doctors discusses the many sites which show
Recommendations
from patients tell if a doctor speaks clearly and listens, as well as giving
early warning of problems. Dr Leana Wen, Baltimore's Commissioner of Health,
and Dr Joshua Kosowsky of Harvard say doctors need to communicate well with
patients to get information for a good diagnosis. "Choose someone who
makes time to listen to you and answer your questions... and who engages you in
a discussion of your diagnosis. By the same token, watch out for doctors who
display signs of impatience, intolerance, condescension, or inflexibility"
(p. 211). Wen's and Kosowsky's book goes on to describe in detail how patients need to
prepare before seeing a doctor.
Patients
can see how the doctor's overall Medicare practice compares to other doctors in the
same specialty and state (ProPublica's site). For example a knee specialist
does more knee repairs and orders more knee X-rays than an average orthopedic
surgeon. The same information on each doctor is in the Medicare file in STEP B above, without comparisons to
specialty+state averages.
Prescription
drugs which each doctor orders most often, can give patients another insight
into the doctor's practice ("Prescriber
Checkup"). Patients can get
independent information on those drugs.
Medicare
shows
affiliations to hospitals and medical groups, languages, phone numbers and
addresses of each location of a doctor. For that search you need to know the
doctor's zip code or city and state; another file allows a national search by name only.
Research papers by each doctor are usually
listed at pubmed.gov and
Google Scholar. A
more controversial source is Sci-Hub, which stores millions of papers and accesses
others as needed. It uses login codes from anonymous academics who have free
access. These searches work best for doctors with uncommon last names, since
pubmed often has only initials of first names. For common last names, a less
complete source is Doximity. You can put doctor
name site:doximity.com in your favorite search engine. Doximity also
shows multiple state licenses and certifications. To find the top researchers
and papers in a field, look at STEP D below.
Disciplinary
actions are few, but you can use DocFinder's free search of 17 states,
and links to the other state boards. Some states only divulge current
suspensions, not past suspensions. DocInfo
has a national search and another list of state
medical boards. There is a lag
before state data are posted in the central files. The same searches verify if
a doctor's license is up to date.
Legal
cases are discussed in another article with rich information from Pacer for federal courts, which is
often free at Recap,
and also a list of hospital suspensions and malpractice suits, which the public
may not yet see. Half of all doctors have been sued for malpractice; 96% of the cases gain money for the plaintiff.
Some
people want to know success rates of individual doctors, but success rates are
controversial, since they encourage doctors to avoid risky patients, have
unreliably small samples, and are hard to find anyway.
Most
commercial sites track
the web pages a visitor goes to. They provide the information to data brokers, revealing what diseases a person is
researching. Globe1234 does not (Privacy
Policy).
Data
on doctors' quality are still limited, but the data provided here on doctors'
volume are helpful in the absence of direct quality data. As quoted at the
beginning of the article, researchers in the field recommend choosing
high-volume doctors when possible.
Many operations are
risky, with over 1% chance of death, so they need careful thought whether the
risk is worth it. Here is a list created in 2015, based on operations from 2001-2006.
It does not show risks of each individual surgeon or hospital, just national
risk for each type of operation. Careful
research is crucial, because 60% of male doctors and 67% of female doctors do not necessarily tell patients when
another doctor is substandard (they fear retaliation). 9% of doctors do not tell patients about mistakes which
have harmed them.
Payments which doctors get from
major medical
companies (Medicare's site) and drug companies
(ProPublica's site) show which doctors have strong bonds with the companies. It
is not surprising when high-volume doctors receive payments from companies for
various purposes. Patients need to decide if these affect their care. Another
page discusses how drug companies give biased
information to doctors.
The sites do not reveal profits from
doctors' own businesses. Consumer Reports says that when a doctor orders X-rays or
other scans, "ask whether he is financially affiliated with" the
radiology clinic, since "studies have found that physicians who own
scanners or are part owners of radiology clinics use imaging substantially more
than others."
Dr Kussin's book (Dr, Your Patient Will See You Now) says that patients
as well as doctors need to subscribe to UpToDate
(UTD) from Wolters Kluwer when they face a major health issue. UTD costs $20
for a week or $53/month.
"That $20 UTD pass allows
you to learn about aneurysms, minimally invasive procedures, and a lot of
information that's important to know when facing a major decision... Those who
are chosen to write or edit these sections are doctors who are at the top of
their game... This search technique has given you a diagnosis that you can
research, in depth, and a doctor who wrote the book... Isn't it worth the trip
[to that doctor]?" (pp. 216-7)
UpToDate from Wolters Kluwer
summarizes (and addresses weaknesses
in) many published studies. If one of the studies is especially relevant,
an author may be available for an appointment. You may find free copies of
published studies through Google Scholar, or in the library of a university, hospital, or big city.
A more controversial source is Sci-Hub, which stores millions of papers and accesses others as
needed. It uses login codes from anonymous academics who have free access.
Besides UpToDate from Wolters
Kluwer, patients can read other respected, though less detailed, sites like NIH, Johns Hopkins and Mayo Clinic, and websites of high-volume doctors throughout
the country. For example the highest-volume knee replacement surgeon shows
exercises on his website which patients need before and after treatment. As
many say, exercises after surgery are a "race against scar tissue."
Reading many websites can be
overwhelming; UpToDate
from Wolters Kluwer usually has the best synthesis.
All these sources give patients
ideas for questions which they can type out and ask at a specialist
appointment. Questions to ask when making an appointment include whether the
doctor is a professor, working with interns and residents. Pros and cons are discussed
below in "Professors," and most patients have a preference one way or
the other. Another question is whether patients must sign any agreement
limiting their right to comment on internet sites; if so internet reviews are
not reliable for that doctor.
Patients may want the opinion of a
low-volume doctor as well as a high-volume doctor on whether they need a
procedure. If they decide to go ahead, patients may want a higher-volume doctor
to do the procedure. You can use the data to find doctors in your region who do
a procedure more or less than average. A patient who wants to avoid a
hysterectomy or prostate surgery will want names of surgeons who do a few of
them, rather than many, and go to those for advice.
The independence of the second
doctor is important, since hospitals and Accountable Care Organizations (ACOs) have been absorbing most practices, so that doctors refer within the group.
Lists of doctors who are independent of the major health systems are at: aid-us.org/directory, Idaho,
Georgia, New York City, Minneapolis-St. Paul, south Charlotte.
Some groups with "independent" in the name are ACOs with incentives
to refer to each other. Insurers also pay incentives to doctors to meet financial
goals.
Dr Kussin says to get a 2nd opinion
from another specialty. He gives the examples of asking a neurologist or
rheumatologist for a 2nd opinion on orthopedics, and a gastroenterologist for a
2nd opinion on "gallbladder, pancreatic, esophageal, and intestinal
surgery" (p.184). He also says to take your records with you, so you
know the 2nd doctor has a complete file. X-ray and MRI centers will give you a
CD while you wait, often free. Patients can ask their insurance if it will
cover a reasonable number of initial appointments with different doctors, so
they can explore all the options.
Some doctors gain high volume
without being good, by advertising heavily or by pushing extra procedures. A
companion article reviews some of those situations and how patients can
protect themselves. Patients need to keep their wits about them, but don't need
to fear all high-volume doctors.
The first protection is a 2nd
opinion. Another protection, mentioned above, is to get that opinion from a
doctor who does the proposed procedures less often. A 3rd protection is that
consumer reviews often give early
warnings.
Consumer Reports lists 10 overused procedures and 12
overused surgeries. 63
medical societies have released their own lists, with an overall search window.
Patients need to be careful before accepting one of these procedures.
Payments which doctors get from
major medical
companies (Medicare's site) and drug companies
(ProPublica's site) show which doctors have strong bonds with the companies. It
is not surprising when high-volume doctors receive payments from companies for
various purposes. Patients need to decide if these affect their care. Another
page discusses how drug companies give biased information to
doctors.
The sites do not reveal profits from
doctors' own businesses. Consumer Reports says that when a doctor orders X-rays or
other scans, "ask whether he is financially affiliated with" the
radiology clinic, since "studies have found that physicians who own
scanners or are part owners of radiology clinics use imaging substantially more
than others."
All these cautions show the need for
careful checking, whether one uses local or distant doctors. Primary care
doctors rarely have time for such checking, except in the specialties they
refer to most. Patient checking may give the best results and save substantial
time in treatment and recovery. Results are also better in the morning.
New doctors develop high volumes by
Professors often appear in the lists of
high-volume doctors, since all patient care they supervise counts as theirs,
even when treatment was done by interns and residents.
Many people want to be treated by medical school
professors, to get cutting edge researchers and freshly trained residents.
Other people worry about residents practicing on them, and surgical professors
who are out of practice since residents do most of their operations.
Two reports describe
residents doing most of the cutting and stitching when they are in the
operating room.
Dr Gawande when he was a resident wrote that "to say I
just assisted remains a kind of subterfuge... I hold the knife... I stand on
the operator's side of the table... raised to my six-feet-plus height... Given
the stakes, who in their right mind would agree to be practiced upon?" (pp. 22, 30). A doctor said about his own child's birth,
"We didn't even allow residents in the room" (p. 31) There is other research on the
dangers of undertrained doctors, both young and old, and the benefits of
learning on simulators instead of people.
A study of surgeries in Veterans Administration
hospitals reported "We believe in the majority of open repairs, that the
resident was on the side of the hernia, and presumably was the person making
the cut and putting the stitches in" (p.
352). The VA hernia study found more recurrences after open operations done
by interns and 2nd year residents (6.4% recurrence), than by 4th year
or older residents (1.1%). 3rd year residents were in the middle at 3.0%.
Recurrences in laparoscopic hernia repairs were about 11%, regardless of the
resident's year. "Only when the attending surgeon and the resident are
highly experienced in laparoscopic repair techniques, are recurrence rates for
laparoscopic repairs reduced" (p. 882).
A study of bypass
procedures found that patients of medical school professors had the worst
death rates, and explained it may have been "because more of their
operations are performed by residents or fellows" (p. 93).
Surgery at teaching hospitals usually involves residents. Patients who
value a teaching hospital appreciate the presence of the professor directing
the work, even if a resident does the cutting. Patients who doubt the residents
may need to go elsewhere, though they can ask if the professor will operate
without a resident, and cross out words allowing residents or substitute
surgeons from the consent form. When residents examine a patient in an
office or hospital, the patient can ask the main "attending" doctor
to do the exam, but the main doctor may prefer to depend on residents. For office
consultations, residents and fellows are often present, but patients can
focus on the main doctor's questions and decisions.
A test of 159 medical students from medical schools in 37
states, at a conference, found that only 1 did all 11 steps of a correct blood
pressure reading. The average was 4.1 out of 11. They comment we would never let a pilot or lab skip steps in
guidelines, so if blood pressure matters to us, we cannot let nurses skip steps
on blood pressure either. Incorrect arm placement raises blood pressure 10 or
more. The steps are on pages 28-29 of A Report of the American College of
Cardiology/American Heart Association Task Force on Clinical Practice
Guidelines. Guidelines include testing both arms, no exercise, caffeine, or
smoking for 30 minutes, empty bladder, sitting without talking for 5 minutes
and during both tests. Later tests can use the arm which had higher
pressure.
Regular eye exams miss a fraction of
early Age-Related Macular Degeneration (AMD). AMD is the leading cause of
irreversible vision impairment in older adults in the United States. It blocks
the central retina, so you can't see facial expressions or read. Vitamins and
other treatments are available to slow its progression when it is caught early.
A 2017 study in Alabama found that AMD was present (mostly
early stage) but not diagnosed in a quarter of people over 60 who got a regular
vision exam from an optometrist or ophthalmologist. 8% of the total undiagnosed
people over 60 had intermediate AMD, which is treatable
with vitamins. The researchers used digital fundus photography and
an expert reviewer to retest 644 patients. For comparison, nationally only 3.4% of
people over 60 have been diagnosed with AMD. If the Alabama results hold up
nationally with other researchers, then 27% of patients have AMD.
Therefore people over 60, where AMD
becomes more common, may want to get eye exams from optometrists and
ophthalmologists who are particularly familiar with AMD.
Aetna
and Medicare cover fundus photos (code 92250) after
diagnosis of certain eye problems, not just for screening Other insurers are
probably similar. Doctors who take fundus photos are familiar with reading
them, and may be able to take and interpret them without a diagnosis if the
patient pays the cost of $100 or so. 21,000 doctors did it in 2014 on 3 million
patients. They billed an average of $118, and Medicare paid $76. Patients can
find experienced doctors locally by clicking the filter button on the
Medicare file above to add filters for "HCPCS code"
92250, and for "Zip Code" "starts with" (can use
first 2 or 3 digits of a zip code to get areas near you).
It may still be valuable to ask
these doctors' offices what fraction of their older patients have been
diagnosed with AMD, since the important issue is diligent reading of the image,
which will result in higher than average diagnosis rates. However my experience
is office does not know what fraction of patients have AMD. Most people would
rather get a diagnosis and start vitamins, than miss the diagnosis and lose
vision sooner.
A parallel is that doctors who
provide colonoscopies track what fraction of their screening colonoscopies find adenomas
(tumors), and patients can ask doctors what their rates are. "Professional societies recommend adenoma detection rates of 15% or higher for
female patients and 25% or higher for male patients as indicators of adequate
colonoscopy quality..."
It is also possible to find doctors
who treat patients for advanced macular degeneration, but they may be
specialists who are not available for routine eye exams. A spreadsheet
identifies 107 doctors
in 32 states (20 in Florida, 17 in New York), who use the following treatments
for advanced macular degeneration. 17 of the 107 doctors fall in more than one
category below:
Treatments for advanced macular degeneration in 2014 on
Medicare patients with Part D drug coverage include:
Treatments for advanced macular degeneration in 2014 on
Medicare patients with Part B doctor coverage include:
Experts have written about Shouldice Hospital in Toronto, which
does more hernia surgeries than anywhere else. Hernias are one of the most
common operations by general surgeons.
Harvard's Dr Atul Gawande writes that for hernia operations done elsewhere,
"In anywhere from 10 to 15 percent of the cases, the operation eventually
fails, and the hernia returns... At Shouldice... Their recurrence rate is an
astonishing 1 percent... the dozen surgeons at Shouldice do hernia operations
and nothing else. Each surgeon repairs between six hundred and eight hundred
hernias a year - more than most general surgeons do in a lifetime... With
repetition, a lot of mental functioning becomes automatic and effortless... A
surgeon for whom most situations have automatic solutions has a distinct
advantage... Even the hospital building is specially designed for hernia
patients" (pp. 38-9).
On hernias, UpToDate from Wolters Kluwer ($20 for a
week) describes a range of options, including Shouldice and "watchful
waiting." UpToDate may be the best place to find the full range of options
on any disease.
Ralph Nader writes that "Shouldice's Director Daryl
J.B. Urquhart makes a strong case for small, specialized hospitals that can
deliver all-around superior outcomes."
A patient at Shouldice told me that his wife wants to specialize
in breast surgery, as the Shouldice doctors specialize in hernias. She has
enough patients, but other surgeons at her hospital resist, since they want her
to share on-call duties with the other general surgeons. She hasn't been able
to specialize, but elsewhere some surgeons do specialize in breast surgery and
perform 100 or so per year. Patients and referring doctors can find them in the
data files described at the top of this page.
Your correspondent has used both Shouldice and Wilmer, which is an
equally specialized eye clinic in Baltimore (the only place in Maryland with a
doctor on the AMD list described above). He can attest their quality as well as
the confidence gained by going where doctors have as much experience as
anywhere.
About, Comments & questions: mailto:primary@Globe1234.com COMPANION
ARTICLES ON: UNNECESSARY
WORK, KNEES,
LEGAL
CASES, REVIEWS
OF DOCTORS, PRIVACY,
RESEARCH ON DOCTOR VOLUME,
TRAINING,
and DRUGS