Clinical competence, and whether a doctor is good, or not

Is Dr. X a good doctor?

Being a doctor, I often hear this question being asked.  More often than not, the response that I hear is a rather clear cut one, “oh yes, Dr. X is a great doctor,” or “oh no, Dr. X is not a good doctor,” making me wonder what such a definite response is based upon.   Is it based on actual facts?  Is it based on subjective opinions?  Although most everyone has more access to facts about physicians today than they have ever had in the past, I think that when answering this question, most people still mainly use subjective opinions and not actual facts or research.

As I understand it, the average person will spend literally hours or days shopping for an automobile or a household appliance.  Although the majority of people if asked say that their health is the most valuable asset to them, how much time does the average person spend on researching or shopping for a doctor?  I can assure you, it’s not much in comparison to the time they spent on shopping for their last  refrigerator.  Part of the reason for this may be that good, valuable, trusted, accurate information on a doctor is not yet the easiest thing to find.  Although this appears to be improving, it is not quite here yet.

The subjective opinions used by people to conclude whether a doctor is good or bad seem to be based upon those aspects of a physician’s overall care that are most visible to the average person.  These include such things as the doctor’s bedside manner, their communication skills, and the attitude and helpfulness of their office staff.  Some responses may appear to a person to be reflective of objective fact(s), but are truly only further examples of subjective opinions, like many peoples’ common assumption that a great looking post surgical scar means the operation was obviously performed by a great surgeon.  Although peoples’ subjective opinions are definitely important , I believe that in order to get the best answer to the original question, one can’t ignore the value of truly objective facts as well, the most important of these having to do with a physician’s clinical competence.

I believe there was a time, not that long ago, when it seemed as though a physicians’ clinical competence was something that most people more or less took for granted.  For the various reasons, some of which are noted in my blog post and accompanying comments, Reasons Behind the Image Mutation of Physicians, on KevinMD.com, I believe that as a profession, or at least for many in our profession,  our clinical competence today, is more often being questioned than it is taken for granted.

Truly objective facts that directly correlate and are truly indicative of a physician’s clinical competence have been more difficult to arrive at and agree upon than one might have thought.  Some physician specific information available online today, although objective and factual, does not necessarily correlate well with clinical competency, take for instance, the number of times a physician has been sued.  Multiple studies have shown that physicians who by all other available indications are very competent, but have lousy bedside manners, are more likely to be sued than other physicians who are not as competent but have great bedside manners.  As another example, there are physicians who by all other indications are very competent, but as a result of having elected to care for the most difficult cases in their specialty, those that others most often elect not to see, may exhibit a higher percentage of lower clinical outcomes.

The development of evidence-based clinical guidelines for physicians, derived from the scientific method, with the intention of providing physicians with the best available evidence to use as part of their clinical decision making, would appear to be a huge benefit for everyone.  Although to a significant extent it has been, as written about by A Country Doctor, MD in a blog post and accompanying comments on KevinMD.com, Evidence Based Medicine at the expense of the art of medicine, simply having these evidence-based clinical guidelines being used by physicians does not directly correlate or assure clinical competence.  Clinical guidelines are meant to be used as guidelines only, necessitating the physician to individualize and personalize their content by taking the particular patient’s personal set of circumstances into account when deciding just how best to apply an evidence-based clinical guideline.

If these guidelines are not individualized e.g. used correctly, they can actually result in less than optimal outcomes.  Therefore just knowing how often a physician uses evidence based clinical guidelines’ to treat patients, may not paint the most accurate picture with regard to the physician’s clinical competence.  The challenge to date has been in figuring out how best to present this objective, factual information to the layperson in a manner that they can understand and most importantly properly interpret.

Unless and until we come up with a set of objective facts, accessible to laypeople, that don’t need interpretation in order to arrive at their true and accurate meaning for the purpose of verifying a doctor’s clinical competence, I think the way to get the best answer to this question to date is as follows:

  1. Gather as much information about the doctor, online and otherwise, as you possibly can.
  2. Ask friends, family and others who have gone to the doctor what they think.  Get their subjective opinions.  Ask them if the doctor ‘really listens’ to them.  Do they feel they can tell the doctor anything?
  3. Call the Emergency Department of the doctor’s primary admitting hospital, at a slow time, and ask to speak to the nurse in charge.  Ask her to honestly share what she thinks and knows about the doctor and what his/her patients that come to the ER say about them.
  4. Call the ward / floor that cares for the majority of the doctor’s patients (e.g. If you’re inquiring about a Pediatrician, call the hospital’s Pediatric Floor; inquiring about an Obstetrician, call Labor and Delivery), ask a nurse to honestly share what she thinks about the doctor and what his/her patients say about them.
  5. Hopefully you know another doctor who works with, in the same hospital as, or community within which the doctor in question works.  Ask that doctor whatever specific questions you have.  But, make sure before you are done, you ask the all important question, “would you have Dr. X see your wife, son, daughter, etc.”.  You get the point.

I believe it is part of every healthcare related providers’ moral obligation, e.g. doctors, nurses, etc., to help guide patients to the best quality, caring, trusted, competent healthcare information and providers we know.  Doctors should want nothing less for their patients than what  they are willing to accept for themselves or their loved ones.

Richard A. Foullon is a family physician.

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