Two Doctors-A Morality Tale
Andrew Wilner, MD, Neurology
Recently, a close family member, let's call her "the patient," needed a complex elective surgery. Her medical doctor gave us a few surgical referrals. We picked the one at the top of the list.
Luxury of choice
The ability to choose one's medical doctor is a luxury. Often, an accident or sudden severe symptom such as syncope or chest pain results in emergency transport to the nearest health care facility, where one is greeted by the duly assigned healthcare provider of the day. The relationship is forged on the basis of urgency and need, and both patient and doctor accommodate accordingly.
How to Choose?
But sometimes, one has the luxury of choice. Before entering into the sacrosanct patient-physician relationship, a patient can do due diligence regarding the physician's training, experience, standing amongst his or her peers, as well as online reviews such as YELP, where doctors are rated "like restaurants." It's not clear how useful all this research is except to weed out the few bad apples who failed their boards and consistently receive one star online reviews. But bad reviews tend to be based on long waiting times and snarky staff, not the doctor's performance. A doctor's competence, except in the most flagrant cases, is exceedingly hard to judge. Even a surgeon's track record of successes and failures will be affected by the age, stage of illness and comorbidities of the patients. A surgeon who only operates on "easy" cases might have a great track record. A more proficient surgeon who takes all comers would have a much worse record. Most doctors are capable, competent, responsible, and get the job done. But even capable, competent and responsible doctors are not interchangeable.
Our trusted doctor's referral was sufficient endorsement, but I still did a background check that revealed an impressive website that included education materials, a patient portal, patient approbations, and boasted an affiliation with a nationally respected medical center. We made an appointment.
It was all uphill from there.
A few days later, the doctor's office called requesting that we change the appointment. The secretary explained that she was using new scheduling software and had made a mistake. Could we come the following day instead? We were able to change our busy schedules to accommodate. No harm, no foul.
We were told to register ahead of time on the patient portal. We tried, but the passwords didn't work. This was frustrating and took days to fix.
We faxed records several days ahead of time and even brought hard copies with us. I had already made several calls to the doctor's office to insure that we were "in network." We arrived early as instructed, completed registration paperwork, consents, record releases and more, then handed the records to the secretary. The doctor saw us on time, listened intently, and suggested further testing. These results would guide his final decision regarding which procedure to do. Upon review, his recommendations included many of the blood tests we already had. When I pointed this out, he seemed irritated and said that he didn't have access to these. This was incredulous, as I had faxed them days ago and handed hard copies to his secretary just minutes before. He just shrugged and indicated that the consultation was over.
Who's On First?
We went to another office where an LPN printed lab slips for the blood tests. I saw that there were new tests, as well as some we already had. Perhaps the doctor wanted the same ones repeated? Even though this surgery was outside my realm of expertise, I observed that an entire panel of blood tests had no bearing on the problem at hand. When I pointed this out, the LPN filling out the forms agreed, cheerfully admitting she had clicked the wrong box on the computer screen.
The blood tests had become a comedy of errors. The doctor had ordered additional tests that needed to be done, which were mixed with orders for blood tests that had already been done, combined with tests the LPN had mistakenly ordered. Sorting out this mess took more than an hour. That extra hour meant that we missed the 3 pm closing time of the blood lab and had to make another trip resulting in more time off from work, frustration, etc.
A few days later, when we checked the results on the now functioning portal (the office never called), I saw that despite my arduous efforts, the same blood tests had been repeated anyway. In this era of high insurance deductibles that can run into the thousands, and indeed, tens of thousands of dollars, these errors would result in hundreds of dollars of out of pocket costs. To make matters worse, one of the original routine tests that had been normal was inexplicably abnormal on the unnecessary repeat testing. A third "tie-breaker" would now be required, inflicting more discomfort on the patient and consuming more time and resources.
It's Up to You
When we returned for consultation, the doctor gave us the low down on the surgery. There were several options, all with varied degrees of success and risk, including death. He seemed loathe to make a recommendation. He insisted it was up to us. This position was infuriating. Of course it was up to us. But it was up to him to make a recommendation. After I insisted, he reluctantly chose one procedure and said that if it was his family member, that's what he would do. Based on the patient's age, history, comorbidities and testing, he estimated there was only a 75% chance of success. I asked what we could do to improve the odds. He said, "nothing, it's just luck." When I added that as a physician it was very difficult for me to be on this side of the desk, he just smiled and nodded. He offered no words of encouragement or advice.
No More Questions
Immediately after we left the consultation room, I remembered an important question and tried to stop the doctor as he strode down the hall. He glared at me as if I should know that the consultation was officially over. Now, it appeared, I was invading his personal space and time. Perhaps I was, but I didn't appreciate the glare.
Safety or Convenience?
The office assistant explained that the procedure would be done at the outpatient surgicenter at the nearby hospital, although often the doctor did the same procedure in his office. When I asked why we needed to go to the hospital, yet another foreign facility we would have to navigate, she explained that the doctor preferred operating there because they "turned over the room quickly." (The answer I was hoping for was that the hospital setting provided better facilities and proximity to emergency services should they be required, but that didn't seem to be the doctor's priority.)
Another Opinion? Really?
In the big picture, these were all small injustices; a change in appointment, a defective patient portal, some blood test errors, a receptionist's perhaps mistaken perception of the doctor's priorities, and my hassling perhaps an overhassled physician.
But I wasn't happy and told our family doctor. What if the surgery didn't go well? This doctor didn't seem to care one way or another. Our doctor recommended another surgeon for us to try. Faced with the possibility of having to repeat tests, fill out more forms, register on another patient portal, and check benefits with our insurance company, the patient, who had been pretty tolerant of all of the above, wasn't keen on getting another opinion. Wasn't one opinion enough? What if the opinion was different? Would we need a third? She had a point. Nonetheless, I insisted.
The second doctor had no opening in her schedule for months. However, out of professional courtesy, she would see us after normal office hours. I wasn't enthusiastic about getting a complex consultation at the end of a physician's busy day, but I appreciated the gesture. (A word of advice-if ever you need an appointment with me, first thing in the morning is best.)
The Doctor Did Her Homework
A few days before our appointment, the office called to say that the doctor couldn't read a few of the many fax pages we had sent. I was impressed. Not only had Doctor #2 reviewed the records, she wanted to insure they were complete.
A Clear Recommendation
The day of the appointment, we arrived early as usual and filled out paperwork. We were told the doctor was running behind. She didn't see us until almost 6 pm. We were happy to wait, but I was concerned that the late hour might mute her interest in our case. Not in the least. Our consultation lasted until 7 pm. She patiently listened and reviewed the now voluminous records and blood tests. Nothing needed to be repeated. She acknowledged that there were several options, but without hesitation, made a clear recommendation. She would do the procedure in her office where she had everything arranged as she wanted it, including an anesthesiologist on site. It was true there was risk of injury and death, but she had never seen these rare complications. She positively glowed as she advised that 3 out of 4 patients with this problem would do well.
The relationship between doctor and patient (and family) is intensely personal. Doctor #1's office was disorganized with poorly trained staff who made many small mistakes. This did not inspire confidence. Nor did the doctor. He was professional, but cold and dismissive. On the other hand, perhaps his technical skills, arguably a surgeon's most important attribute, were superior to Doctor #2. We had no way of knowing. When it came down to it, the recommended procedure, risk of complications, and chance of success were the same with either doctor. No doubt Doctor #1 was correct- it would all come down to luck. But if we didn't have luck, I knew which doctor I'd rather have at the bedside. Thank you, Doctor #2.