Losing the Doctor Lottery

Donna Jackson Nakazawa's insightful Health Affairs article "How to Win the Doctor Lottery" is, in turn, sad, frightening, wise, and hopeful.  She recounts some of her personal travails in finding the right doctors, the ones who will truly listen and become "a partner on my path to healing," and offers several suggestions about what has to happen for us to have more chance to "win."  

The real question, though, is not how to win the doctor lottery we find ourselves in, but why we're playing it at all.

Getting the right doctor is hard.  Consider the following:

• It's easy enough to find out where a physician went to medical school and did their residency.  It's not as easy to know what the best medical schools or best teaching hospitals are, other than by reputations (that may or may not be deserved).  Maybe your doctor went to Harvard and did their residency at Johns Hopkins, but, otherwise, you may not be so sure about how good their training was.
• Even if you did know how good their place of training was, you still wouldn't know how your doctor did there.  They might have been last in their class.  Even if you did find this out, you don't know if it is better to have done worse at a "better" school or well at a lesser school.  
• In fact, it's not really clear that where one went to medical school or did their residency, or how well one did in those, has any measurable impact on actual competence as a physician.
• Being board certified as become an accepted measure of basic competence in a specialty, but there is fierce debate between physicians and the specialty boards as to whether the process -- particularly the ongoing maintenance of certification (MOC) -- does anything of the sort.  
• It would be good to know if a physician has had drug or alcohol impairment issues, has been charged with sexual improprieties with patients, or has a large number of malpractice suits, but don't expect to be able to find any of those out.  The medical licensing boards who should know aren't likely to tell you.   
• There are many measures for "quality" when it comes to physicians, but none that are considered definitive, many of which are not meaningful to consumers, and all-too-few of which focus on what we should care most about: patient outcomes.   
• Even for data that should be readily quantifiable -- e.g., how many of these procedures did Dr. X do?  How many patients die under Dr. X's care?  How many patients with my diagnosis does Dr. X treat? --  are rarely actually discoverable.  
• There are some physician satisfaction scores and patient ratings, but most of those are looked upon dubiously, due to low reporting volume and likelihood of being skewed by non-clinical factors (like wait time or how quick prescriptions were given).
• When your physician recommends a treatment or a drug, you don't know if the physician is doing so because the latest research solidly demonstrates their efficacy.  The physician may be being paid on the side by a drug/pharma company, may be influenced by the most recent drug rep visit, hasn't kept current on the research or simply doesn't accept it because it wasn't the way he/she was trained.  
• As skilled as you may be at researching doctors, you may still find yourself in an emergency or other rapidly developing situation, in which you end up being treated by doctors you haven't had time to research and have never heard of. 

It's a wonder any of us ever find the "right" doctor.

Calling choosing the right physician a "lottery" may be being unfair to lotteries.  At least lotteries disclose the odds of winning, low though they might be, and it is usually clear very quickly whether there is a winner and who it is.  

In health care, you may never really know if you've won or lost, or may only find out much too late to do anything about it.  You may have gone through unnecessary pain and suffering, you may have lost years of better health, or you actually die.  

And, of course, you'll get billed for everything all along the way.

The even sadder thing is that it's like this throughout health care.  It may be marginally better for hospitals, in least in terms of more available data, but the usefulness of even that is not entirely clear.  For other types of health care professionals or institutions, information is even less available than for physicians.

Similarly, data on efficacy of treatments, procedures, or drugs is highly variable, often not disclosed to or discussed with patients, and usually not easily understood by them.     

In the end, most of us select a doctor based on the recommendations of friends and family, or another doctor, all of which are likely to be subjective as well.  And if it is true that most of us have confidence in our current doctor, that may be because we've switched from doctors in whom we lacked it (a phenomenon that seems little tracked).

It's still a lottery.

Most people who play the lottery know their odds of winning are low, and aren't betting their financial future or their lives on it.  For most of us, most of the time, picking the right physician is not a life-or-death decision either.  But when it is, we'd all like the decision to be more than random luck.

It is like the scene in WarGames, where the computer concludes the only way to win is not to play:

We don't have a data-driven health care system.  We don't have a performance/outcomes-driven system.  We tolerate it because we usually don't realize it, because most of the time it doesn't impact most of us.  But those are poor excuses.  We can, and should, demand better.

Playing the lottery is not a sound financial strategy, and it shouldn't be our strategy for getting heath care either.