In the past, basic medical care of individuals and families was provided by family physicians. Typically they were general practitioners who did not limit themselves to one area of medicine. Many delivered babies, and some even performed major surgery. When a specialist was needed, the family physician remained as the primary contact and medical advisor, with the specialist serving as a consultant.
As medicine became more complex, the percentage of physicians becoming specialists increased. As our society became more mobile, the number of group practices and walk-in facilities increased, and more people consulted specialists without coordination and referral by a family physician. Lack of coordination raises the cost of care and may lower its quality. Managed care plans attempt to counter this problem by requiring authorization from a primary-care physician in order to consult a specialist.
The Good Physician
Because of the complexity of medical practice, it is difficult to construct yardsticks by which consumers can judge the quality of their medical care. In addition, what is good for one patient may not be what another needs or prefers. The qualities of a good physician include:
- Is intelligent and knowledgeable
- Is sympathetic and interested in the patient
- Advocates preventive measures
- Is sufficiently organized to maintain a reasonably smooth appointment schedule
- Takes a detailed history and gives the patient enough time to discuss problems
- After examination, gives the patient a clear explanation of the diagnosis and treatment
- May indicate that knowledge or diagnosis is lacking
- Knows his or her limitations and refers patients to specialists when needed
- Is conservative about recommending surgery
- Will not abandon a patient once treatment has begun
- Is available for appropriate telephone consultations
- Is available for emergencies or provides a competent backup physician
- Charges reasonable fees and is willing to discuss them
- Is on the staff of an accredited hospital
Locating Prospective Physicians
Medical authorities are unanimous in recommending affiliation with a primary care provider-a personal physician who becomes familiar with a patient’s medical needs and can coordinate care with other physicians should consultations become necessary. Ideally, primary care doctors generally offer “one-stop shopping” and lower cost and convenience. For many people, the choice of physician is limited by the nature and scope of their insurance coverage. Student health services, for example, offer relatively few options. The following guidelines apply to the extent that a choice is possible.
A board-certified family practitioner (for adults and children), internist (for adults only), geriatrician (for elderly adults), or pediatrician (for young children or adolescents) is likely to be a good choice, because all of them have taken advanced training in the diagnosis and treatment of general medical problems. Staff affiliation with a hospital connected with a medical school indicates that a physician is working with up-to-date colleagues and is therefore likely to keep abreast of current medical developments and techniques. A teaching appointment at a medical school and affiliation with a hospital that trains residents are favorable signs. Lack of hospital affiliation is suspect because it may mean that the physician is isolated from the community’s scientific mainstream. Even worse, it could mean that the physician’s standard of practice is not high enough to merit membership on a hospital staff.
McCall12 has pointed out that older doctors are more likely to fall behind, but those who make the effort to stay current combine their broad knowledge with a wealth of clinical experience. He also states that the best way to discover whether a doctor is up-to-date is to become well informed about subjects that concern you.
Because a personal physician can significantly affect a person’s health (and even life), considerable care should be exercised in looking for one. The best time to look is before becoming ill. Names can be obtained from many sources:
- The department of family practice or department of medicine at a nearby medical school
- A local accredited hospital
- A local health-care professional such as a dentist, nurse, or pharmacist
- The county medical society (names are usually given out on a rotating basis from a list of available members)
- Friends, neighbors, co-workers
- One’s physician from a previous community
- A list of physicians participating in a managed-care program provided through one’s employer or otherwise available; some managed-care organizations hold meetings to introduce primary care physicians to new or prospective members
Several years ago the Medical Association of Alabama asked people what counted most in choosing a family doctor. The following percentages indicate which characteristics the respondents thought were “important” or “very important”:
- Willingness to talk about your illness 100%
- Access to a hospital you want 89%
Length of time to get an appointment 88%
Personality or appearance 84%
Years of experience 73%
Office location 66%
Weekend and evening office hours 66%
Involvement in civic organizations 37%
Listing in Yellow Pages or other directories 30%
The Washington Consumers’ Checkbook has suggested asking friends the following questions:
· Does your physician seem to understand your symptoms when you describe them?
· Does your physician take time to explain your medical problems and their treatment?
· Is it easy to talk with your physician about concerns, however silly they may seem?
· How long do you usually have to wait for an appointment for a nonemergency medical problem?
· How long must you usually wait for an appointment for a full physical examination?
· How long do you usually wait in the physician’s office?
· Is it usually easy to reach the physician by phone?
· Will the physician advise you on the phone?
· Do the physician’s fees seem reasonable?
Another consideration that will become increasingly important is the use of electronic communication. Many medical offices will use the Internet to provide educational information and test results and to answer questions by e-mail.
Credentials may be ascertained by contacting the physician’s office and may be verified by consulting a medical society, hospital, or managed-care program with which the physician is affiliated. They are also listed in the Directory of Medical Specialists, the ABMS Compendium of Certified Medical Specialists, and the American Medical Directory, which are commonly available at hospitals and public libraries. Most physicians identified as specialists in the Yellow Pages have completed accredited specialty training. However, telephone directory publishers rarely attempt to verify credentials, so self-proclaimed specialists may be listed also. Board certification is easily checked on the American Board of Medical Specialties Web site at http://www.abms.org. The Board has also been placing lists of board-certified physicians in many telephone directories, but many board-certified physicians are not included because they do not wish to pay the required fee (over $200 per year). Additional information about credentials and disciplinary action is available on Web sites operated by the AMA, state medical boards, and several commercial sites.13
Meeting the Doctor
An excellent way to begin a relationship with a new physician is to have an evaluation that includes a thorough physical examination. Such an examination will provide a baseline against which future changes can be compared. Those who do not wish to have a complete physical examination might still wish to schedule a brief “get-acquainted” visit with the prospective physician. This will provide an opportunity to observe the physical characteristics of the office, to bring up troubling health questions, and to judge the physician’s personality. If satisfied, one can also sign a release form to enable the new physician to obtain past medical records.
Advance registration has another advantage. Some physicians will not accept new patients under emergency conditions, particularly outside of regular office hours. Once a patient is accepted, however, the doctor has a legal obligation either to treat the patient or to provide a substitute.
Having chosen a primary physician, it is a good idea to try to learn about the doctor’s routine. Most well-organized offices have printed information sheets for this purpose. If these are not available, ask questions. What are the office hours? Which are the days off? Who will cover in the doctor’s absence? Does the doctor make house calls? Which hospital does the doctor use? Knowing the hospital affiliation is important. In an emergency, unless instructed differently, ambulance drivers usually take patients to the nearest hospital. The doctor may not be able to take care of a person who goes to the wrong hospital.
In an emergency, try to phone the doctor immediately rather than just showing up at the hospital emergency room. Advance notice may enable one’s doctor to provide the necessary service. It also will enable the doctor to alert the emergency room personnel so that they may begin treatment or arrange for necessary tests.
Should an emergency arise before a doctor has been selected, the best bet is to go to the emergency room of the nearest accredited hospital. If a private practitioner is preferred, some emergency rooms and medical societies maintain a roster of doctors who are on call 24 hours a day. If an ambulance is needed, one can be obtained by dialing 911 (or other community emergency number), contacting the police, or calling a company listed in the Yellow Pages of the telephone directory.
Many cities have freestanding emergency centers, where fees are in between those of office practitioners and emergency rooms. These may offer rapid access, but do not usually provide the contintuity of care that enables a personal physician to thoroughly understand the patient’s health status and overall situation.
Finding a Doctor Abroad
Americans traveling in foreign countries can locate suitable treatment facilities through the International Association for Medical Assistance to Travelers (IAMAT). Established in 1960, IAMAT is a voluntary organization of hospitals, health-care centers, and physicians who pledge to provide travelers with physicians who speak their language, meet IAMAT standards, and adhere to a fixed fee schedule similar to that in the United States. When medical assistance is needed, the traveler can telephone the nearest center listed in the IAMAT directory to obtain a list of local physicians. The U.S. Centers for Disease Control and Prevention provides information on required vaccinations, prevention of foodborne diseases, and other tips for travelers.
Advice from Remote Sources
Advice is also available by telephone, by mail, and through the Internet. Many reliable agencies and groups operate toll-free hotlines and/or Web sites through which callers can obtain information or pose questions to knowledgeable parties. Some hospitals, organizations, and individual practitioners sponsor phone lines through which consumers can select tape recordings on various topics. Several managed-care companies offer phone-based counseling performed by nurses, access to prerecorded information, or self-help publications.
A few commercial services, accessible through the Internet or by phone, provide direct contact with physicians, pharmacists, or others who answer questions. The charges for such services are then billed through a credit card or on one’s phone bill. Critics of these services have warned that their advice has limited value because the person giving advice is unable to physically examine the caller. These services may provide useful information, but they are not suitable for personal diagnosis. Scientific studies concerning the quality and cost-effectiveness of commercially offered health advice have not been published.
Good dentists take a personal interest in patients and their health. They are prevention-oriented but not faddists. They use x-ray films and probably suggest a full-mouth study unless suitable films are available from the patient’s previous dentist.
- A thorough dental examination includes inspection of the teeth, gums, tongue, lips, inside of the cheek, palate, and the skin of the face and neck, plus feeling the neck for abnormal lymph nodes and enlargement of the thyroid gland. In adults a periodontal probe should be inserted between the gums and teeth to detect abnormally large crevices. Good dentists also chart their findings in detail. The frequency of maintenance care (including calculus removal and x-ray examinations) should be based on an assessment of the frequency of cavity formation, the rate of calculus formation, the condition of the gums, and any other special problem. Once current treatment has been completed, the patient should be placed on a recall schedule and notified when the next checkup is due.
High-quality dental work usually lasts a very long time, whereas low-quality work may fall out decays out in a few years. The price of dental work is not the best way to judge quality; rather, pay attention to the time the dentist takes to do the work. High-quality dentistry cannot be done assembly-line style; it takes time and meticulous attention to detail.
Avoid doctors who: