Doctor Networking...The Case for Peer Ratings

Facebook, Twitter, LinkedIn and more recently other sites like Instagram and Pinterest have emerged as complex social networks that “serve” the public in a variety of ways.  I put serve in quotations because it is thought that social media may be the single biggest detractor from corporate productivity (if you don’t count the glut of federal holidays) with fantasy sports leagues like Fantasy Football in a close second.

Facebook and Twitter have historically been more social and less professional.  LinkedIn specifically attempts to allows its users to develop a professional network in which you can interact with contemporaries and competitors alike.  Millennials seem to enjoy the “climbing-the-ladder” approach found on this site as they jockey for a better job while they sign the contract for their current one.  Medicine is different- isolated or at least insulated as a whole from the outside world similar to a caterpillar in its lazy cocoon.  Until recently, medical networking was a good ole boys network rather than a consolidated, organized effort.  Part of the reason for this has to do with the relative stability of jobs and lack of perceived backscratching that goes on in medicine compared to the real world.  Unfortunately, this lack of networking by doctors has meant that medical societies struggle to gain traction in politics and other arenas due to an unharmonized group of semi-precocious individuals- none of whom want to be told what organization in which to be involved.  This makes doctors appear to be a rag-tag group of highly intelligent, social phobic professionals who probably achieve un-“connected” time easier although not quite as often.   

Don't get me wrong…there are doctors on Facebook and Twitter who post professional content, but, for the most part, pictures of kids’ birthday parties and tweets from the latest hip celebrity seem to gain far more attention on these two particular sites.  LinkedIn has made an inroads to doctors and has gained a following in which doctors share their experiences, accomplishments, and also can grapple for the next best job in their field.  Admittedly though, I find very little useful about LinkedIn other than to keep up with friends and colleagues who are not on other social media sites.  

Doximity is a newer, doctor-only site that claims to have 2/3 of US doctors signed up and offers physicians a chance to integrate several needs into one site.  It asks new users to identify colleagues and friends but provides no easy way to interact with them.  It also allows doctors to sign up for a news feed based on professional preferences, but is clearly inferior to reading your favorite journals and medical websites.  Doximity also provides other free services like HIPPA compliant faxing and mail which are interesting but rarely used.  In the end, it just does not provide enough interactive media to take off.  

Since I have now detailed why US physicians are social media averse yet clearly need to be united by this area (think about the fight against Medicare cuts and the challenges of Meaningful Use), I want to point out how a doctor networking idea might work.  A good majority of US doctors are in private practice.  Private practice can be considered to be one of the best examples of supply and demand in America in that good doctors generally succeed while bad ones flounder.  The only real exceptions involve communities in which doctors (usually sub specialists) are in such short demand that patients will flock to a bad doctor because they have no other option.  Private practice doctors require word-of-mouth referrals from friends and family members as well as medical professional referrals from nurses, techs, as well as other doctors. Primary care physicians like internists, pediatricians, and family physicians rely less on other doctors for referrals and more on the friends and family discount. 

Although word-of-mouth referrals are a great way to build a practice, there seems to be something substantive and objective missing when it comes to the current process of doctor networking.  More and more, patients are turning to the internet for answers to the question:  “which doctor should I see?”  The problem is that search engines are the first stop and about 60% of first-page results on Google are from sites that offer patient satisfaction ratings.  You might ask why this is not objective, and the truth is that most of these sites have a scant few ratings mainly from dissatisfied patients.  To boot, there are now companies whose sole purpose is to charge physicians to make their ratings look better on these sites.   Thus, a physician’s online reputation is not only clouded by dissatisfied patients but also by greedy companies trying to help gain the system.  

Patient satisfaction scores from the internet and in paper form (after hospital discharge) are also poised to have a major impact on future physician reimbursement.  Press-Ganey already has a stronghold on Medicare, and by report, their executives are very aggressive with the company’s marketing strategy and it’s growth expectations.  Hospital-discharge patient satisfaction scores are not often a bell-weather for what is good or bad in physician care as the patients who are most unhappy about their care tend to be the ones most likely to take the time to fill out a satisfaction card and send it back.  An even more reprehensible part of this process has to do with how Press-Ganey and hospitals allocate these scores.  A consulting physician can give great care to a patient but then be placed on the hook for a bad outcome caused by either an unrelated medical illness or another doctor’s service.  For the record, none of this bodes well for physicians and their professional networks.  

Most physicians think that they cannot change the current process and feel helpless by their online ratings and post-hospital discharge scores.  One way for physicians to succeed in the Press-Ganey war is to educate patients at discharge about the need for them to return their satisfaction cards after discharge as part of the routine discharge instructions.  Press-Ganey scores will eventually be public knowledge.  Until physicians take an active role in this arena, our professional reputations will hang in the balance.  

For obvious reasons, doctors MUST take control of their online and professional reputations and form a professional doctor network.  In so doing, a doctor can build a network by rating his/her favored coworkers on DoctorRated.com (the only site on the web that allows physician peer ratings) and ask them to rate him/her back.  In addition, a simple DoctorRated card or poster in the exam room can ask patients to rate the doctor and thus provide a fighting chance against the chronically dissatisfied patients.  DoctorRated has a packet with printable posters and signs that is available by emailing DoctorRated@gmail.com.  The good old days of practicing medicine in a vacuum without outside interference are gone, go out and develop your DOCTOR NETWORK today.  

David Jones MD is the founder/owner/chief blogger at DoctorRated.com, the only physician peer ratings site on the web. 

DoctorRated Droid and iOS Apps are Now Available

Both of DoctorRated's apps (iOS and Droid) can be downloaded now from their respective stores by searching "DoctorRated" on your mobile device.

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The Aroma of Medicine- Wishing Doctors Something Different...Olfactory Agnosia?

As a physician, you are required to have keen senses.  Touch, smell, hearing, and sight are absolute necessities for most practicing physicians while we can only hope that taste is reserved for meals and non-professional situations.  I recently returned from a week of vacation in the great outdoors and found myself wishing that I had more olfactory agnosia.  Olfactory is a Latin adjective from olfacere which translates “of or relating to the sense of smell.”  Agnosia is of Greek origin from agnosia meaning “ignorance or inability to interpret sensations.”

I had spent the whole prior week on a dude ranch around cattle, horses, sheep, and the like.  The venue was quite relaxing and panoramic but the smells were expectedly unpleasant at times.  After we left, I certainly did not miss the constant sweating or the smell of the pigpen and the cow pasture.  The return to work after a week like this is often like a space shuttle’s reentry into the earth’s atmosphere- it requires a certain amount of inertia to get started, is dicey for a while as you adjust to the speed and heat, and then settles as you coast to the final destination. 

On my return to the real world, I woke up early that Monday morning and got into the hospital at a time when there was not much activity in the ICUs or on the floors.  I needed some rocket fuel to get out of the house but then settled back into my usual routine pretty quickly.  I often find this time fulfilling as I can get my hospital rounds knocked out prior to facing the day of procedures and clinic.  My first stop is almost always the medical Intensive Care Unit (ICU) at our hospital as it happens to be the farthest unit from the elevators so I go there and then make my way through the other ICUs before hitting the elevators for the medical floors.  

For a point of reference, a cardiologist will usually have a combination of:  ICU patients with sepsis (infections causing low blood pressure and organ failure), respiratory problems requiring ventilators, and other issues that can put stress on the heart; Coronary Care Unit (CCU) patients with heart attacks, congestive heart failure (CHF), and arrhythmias; Cardiovascular ICU (CVICU) patients who have had heart bypass and valve surgery; cardiac floor patients who are stable enough after their heart attack, stent, or CHF not to need a CCU; or medical/surgical floor patients who have had a non-heart problem that then triggers a heart problem.  

That particular morning, I had quite a few ICU/CCU and med-surg floor patients.  I remember walking into the ICU to see my first patient and smelling something so revolting that I nearly turned around.  My immediate thought was “oh God, I hope that smell isn’t coming from the room I’m about to go into” as something so intense is hard to handle in passing but will suffocate you if endured for several minutes at a time.  Of course, the smell was coming from my patient’s room who not only had a bowel obstruction and necrotic gut but also had a rapid heart beat called atrial fibrillation.  I looked around for some cotton balls to stuff up my nose, had no success, and so I dabbed my fingers with alcohol soap and lathered my nostrils with it prior to walking in the room.  The burn of alcohol in my nose temporarily diminished the rotten smell in the room.  Unfortunately, the patient’s wife had multiple questions which I suffered through as I tried not to pass out from the stench coming from the dead bowel three feet away.  

I managed to escape that room eventually and as I retreated 30 yards from the door, the smell dissipated enough that I could finally take a deep breath again.  I bounced in and out of several CCU patient rooms with various whiffs from unshowered, unshaven, non-toothbrushed patients.  Although not entirely pleasant, this was like smelling roses compared to the bowel obstruction patient.  Unfortunately several minutes later, I walked into the next cloud of mixed aromas emanating from another patient who thankfully did not belong to me.  She had the clear odor of Clostridium difficile colitis. Cdiff has a very recognizable scent which is both sweet and atrocious in the same sniff.  Had I known that my path was going to intersect with this odor, I clearly would have taken a more circuitous route to avoid it.  By this time, I became intensely aware that I was no longer on vacation and had forsaken the simple life for a more complex yet equally stinky return to daily life.  I also began to ponder an invisible, simple, disposable device that would allow a person not to smell anything around him/her.  I came up with nothing so I moved on…  

I breezed through the cardiac floor with its lot full of private rooms/bathrooms and well-bathed clients.  As I reached the med-surg floor that day and as is my ritual, I noticed the number of yellow bins full of yellow isolation gowns as I entered each hallway.  The number of bins (one for each patient with a particular kind of resistant infection that requires gown and gloves to enter the room) per hallway often will signal the overall smell of the walk down that corridor.  Today’s walk was particularly full of yellow bins.  I heard one patient vomiting behind a closed door (thankfully not one I had to enter) and accelerated through the perfume that was spilling out from under the door.  I slowed down to look at my list of room numbers and then was hit with an invisible wall of stench which made my nosehairs tingle.  I passed a nurse who exchanged a similar wrinkled-nose expression as she said “dressing change time”.  I rounded the corner into my next patient’s room to see a filet of flesh.  It was a diabetic patient’s foot being unwrapped from bandages exposing a necrotic ulcer.  The infection clearly was being treated by IV antibiotics as I saw no fewer than twelve bags of multicolored medication hanging from a pole in the room, but I would have bet big money that they weren’t actually achieving any sustainable results based on the malodor populating the room.  I talked to the patient briefly about his heart issue and quickly excused myself having only taken half a breath a minute for the duration.  

As I finished rounds in the hospital, I was thankful for a couple of things.  First, no bad smell in my clinic ever approaches the best breath/sniff in the hospital.  Second, I had several procedures that day and thankfully they involved wearing a mask which often will mitigate any foul odor.  Third, my hospital tour of duty for the day was over so I had twenty-four hours prior to re-enlistment.  Finally, as with all vacations my “smell” tolerance had waned and thus the first day back to work was overly intoxicating in a way similar to alcohol use after a time of abstinence.  The tolerance would rapidly improve with each day back.  

There are certain doctors and nurses who are exposed to a variety of smells on a regular basis which makes them smell tolerant.  General surgeons, ER doctors, GI doctors, and vascular surgeons come to mind as smell-aholics.  Tee totalers in the field of aromatic medicine are neurosurgeons, psychiatrists, and dermatologists.  

As you might know- doctors, nurses, and hospital workers are faced with difficult decisions and dilemmas all the time, but what is under appreciated is how sights/smells/touches can affect the care a patient is given.  This experience made me wonder how nice it would be to have olfactory agnosia- the inability to smell.  To be specific, I wouldn’t want to not have the ability to smell…I really just would want to be able to hit a switch that would turn off my olfactory bulb and prevent me from having to endure certain smells in certain locations.  Even cooler, a programmable switch that you would program to turn on in certain locations- hospital wards, public restrooms, towns with paper mills, et cetera.  

Obviously, what I have just suggested is not currently possible and likely won’t be for generations if at all.  Maybe I am just wishing all those smell averse people a little hope in the future.  Otherwise, I really need to work on my tolerance.  

David Jones is a practicing cardiologist and the owner/blogger at DoctorRated.com, a healthcare ratings website dedicated to physician peer ratings.  Check it out and start rating your peers!

My Doctor, The Juggler

The job of being a doctor can sometimes be like that of your favorite sidewalk juggler.  It used to be that a good ole family doctor would have to show up in the clinic for a couple of hours, make a few house calls, and be available if anyone needed him while he played a round of golf in the afternoon (really this is quite an exaggeration but it sets the tone).  In reality, most doctors today must compartmentalize their day, prioritize the patients from most sick to least sick, and then organize a plan of attack which then needs to be carried out with sniper-like precision (also a bit of an exaggeration for most doctors but if the shoe fits…).  Each day can be like a juggling act.  Despite perfect execution, a doctor still may have to call an audible when things don’t go as planned just like a juggler might have to do when a large wind gust arises or he/she mishandles a ball.  

I like the juggling analogy because the type of work each doctor does is different based on specialty, practice type, and patient population.  Some doctors juggle soft balls, others juggle crystal balls, and some tend to toss swords, chainsaws, or flaming torches.  Some juggle in padded rooms, others while walking a tightrope, and others in crowded areas full of women and children.  Real jugglers have to manage the crowds and other street performers like doctors have to deal with impatient patients and their competitors.  Both depend on being in the right place at the right time as much as their talent on some days.  

As a kid, I still remember seeing a juggler on the street managing six or eight flaming torches at a time.  He then caught them and changed them out to swords at which time he sent them hurling into the air and rotated them as if they were on a racetrack.  It seems to me that the job of juggling swords and flaming torches has some of the same perils as a neurosurgeon operating on a patient’s brain or a cardiac surgeon bypassing a person’s heart.  One slight mistake can lead to a waterfall of failure.  

Jesters and royal jugglers have been known to juggle their majesty’s crystal and glassware.  I would consider the medical equivalent to be an obstetrician catching babies or a pediatrician diagnosing an infant’s illness.  A plastic surgeon might also lay claim to this type of subject matter, although most doctors would agree that their craft is impressively delicate but the narcissism involved subtracts a point for style when compared to birthing and caring for the innocence of youth.  

The act of juggling can be as simple as tossing two balls in the air from hand to hand or as difficult as criss-crossing eight balls at a time.  Some doctors only work in a clinic, emergency room, or hospital and, therefore, have more of a two-ball juggle job.  That being said, different single venue situations can be as frenetic as some multi-site ones depending on patient acuity and volume.  Some doctors have an eight-ball rotation in which they bounce between a busy clinic, a procedural arena, and hospital/emergency department responsibilities.  Some primary care providers in small areas have the usual eight-ball motion but also have to deal with community expectations like neighbors knocking on the back door.  This would be the equivalent of the eight-ball rotation mixed with a bowling ball.  

Let me give you a real-life example of a multi-venue situation…I spend the first couple of hours of most days in the hospital rounding on inpatients, admitting ER patients, and following up on tests and procedures.  I can generally plan to get there early enough to see every patient and have a little bit of flex time without running late.  Not all doctors have this luxury as some are tethered to multiple hospitals and/or a high volume of patients admitted during each day.  The juggling occurs when you arrive and have several unexpected admissions and/or a really sick patient who needs twice or three times the amount of attention than you expected.  

Once finished in the hospital (around 7 or 8 am), I then usually spend the rest of my day evenly split between procedures and clinic, and then at the end of the day I go back to the hospital to take care of new patients and consults as well as discharges that need to happen prior to going home.  It sounds easy…four hours doing procedures (most of my procedures are scheduled as an hour each) and four hours in clinic.  Not so fast, my friend.

To break down each venue, realize that every clinic, procedural area, and hospital function differently.  No site is the same but there are some generalities that can be formed about each.  Clinic seems to be the most misunderstood portion of a doctor’s life when considered by the lay public.  Patients often become frustrated with clinic wait times as they expect their doctor to arrive on-time to clinic and to be seen in a straightaway manner as if there is no other priority.  What most do not realize is that the clinic schedule is only the first hurdle in the triathlon of a doctor’s day.  Assuming I get through with my hospital rounds on time and start my procedures on time with no interruptions, emergencies, or unexpected waylays, I usually arrive to clinic and am greeted by my nurses who inform me that one or more patients had called and needed to be seen urgently.  A good doctor’s clinic is usually pretty full in the first place and these add-ons are necessary for excellent patient care but devastating to a schedule.  I often will inhale lunch just before walking into the first room and then sink into my groove in clinic, bouncing from room to room, usually distracted and delayed by the various nursing calls from the hospital or the ten minutes on hold with the ER as they alert me to the arrival of my next admission.  

If I am lucky, I am able to keep up with the phone calls, electronic medical record, and patient load.  The biggest issue in clinic for me (which is so hard for the outsider patient to understand) occurs when a followup visit scheduled to take ten minutes takes forty-five minutes.  These “special” visits often involve true illness(es) like chest pain or congestive heart failure but can also be non-urgent delays.  One of the most common delays occurs due to a patient’s reaction to a piece of medical news that is exaggerated due to depression, anxiety, or current situation in life.  I usually have one patient cry all the way through their twenty-five minute visit per day and another patient per day will spend fifteen minutes telling me about his or her financial/marital/familial/religious woes that are not absolutely medically necessary but impossible to avoid.  There is no way to judge or plan for these delays, and thus a doctor is left to juggle the remaining patient’s anger and unhappiness while still trying to provide good care.  

Often times, clinic wait times are ridiculous due to emergencies related to non-clinic issues.  A partner will call occasionally to ask for advice or assistance with a difficult procedure…a patient will code or get into trouble in the hospital…a friend of a friend of a friend will become sick and need phone advice relayed via your spouse or mother (usually a twenty minute conversation)…an emergency will come into the ER which takes precedence over the more stable clinic patients (this is the equivalent of the juggler taking a sword to the chest as it usually blows up the clinic schedule)…a technology issue will arise in which the electronic medical record is slow or not working at all and will slow things down…a nurse will get sick during clinic and have to go home, leaving an understaffed clinic…and the excuses go on and on.  

This rant has covered most of the reasons why being a doctor is similar to being a juggler, but is by no means a comprehensive list.  We haven’t even considered the “business” side of medicine in which a doctor is forced to juggle insurance companies and their insane preauthorization requests, mounds of paperwork, hospital administrators, frivolous lawsuits, competition between other groups/doctors/etc, and a whole host of other issues.  We haven’t pondered the governmental regulations that are being enforced to make the practice of medicine about as messy as juggling ice cream cones in the dead of summer.  We don’t have time to mull over the quality metrics that all doctors are supposed to achieve yet seem to change on a daily basis.  I would be remiss if I didn’t mention that most doctors juggle the strains and stresses of their job with their responsibilities as a spouse or significant other, parent, sibling, and friend.  

In a way, all jobs have a juggling component and so I want to make it clear that this is not a plea for sympathy or respect.  My hope in this story was to give an insight into my profession’s challenges so that the lay public might understand the different scenarios which affect a doctor’s ability to meet their expectations.  Some days are flawless and others are littered with dropped swords.  

Written by David Jones, MD- owner/blogger at DoctorRated.com, a physician peer ratings website.  

Pulling My Hair Out…A Doctor’s Struggles with Patient Noncompliance and Managing Unrealistic Expectations

Several days a month, I come home from a long day at work feeling exasperated, frustrated, mentally dilapidated, and just plain tired.  Oftentimes, I feel like pulling my hair out…and for a middle-aged already balding physician, this presents a big problem.  The actual physical work varies by the day, but I have found that certain patient interactions can take a toll on me way more than the actual bodily stress does.  

Patient noncompliance seems to be one of my biggest stressors and it can take various forms.  It can be as simple as grandpa not caring to take his medications, grandma not being able to afford her meds, or crazy cousin Eddie not keeping his appointments.  I cannot tell you how many patients come into my office weekly and tell my nurses that he/she just ran out of meds and did not think to get them refilled.  Some patients truly think that one (or the last) bottle of meds “cured” their high blood pressure, others are just lazy and tell me that they never got around to going by the pharmacy again even though they clearly dropped in somewhere to pick up the pack of cigarettes in their front pocket.  Cost is a huge issue and with the exorbitant prices of some non-generic pharmaceuticals added to the fixed cost co-pays and outrageous deductibles, the price of healthcare can strangle some poor patients.  I have empathy for patients most times, however it is striking to see a poorly controlled diabetic walk into clinic with a McDonald’s bag and an iPhone (and iPad) then tell you that he/she cannot afford generic meds.  

The issue of noncompliance with medical appointments deserves special attention as there are days in which I have 1 out of 5 patients no-show.  This reckless and avoidable habit wreaks havoc on clinics nationwide.  Not only do no-shows mean lost revenue, but they also take away a spot that an otherwise sick person could have had.  Add to it, the patient who no-shows then has be rescheduled (assuming they want to be seen in the future) at their convenience which then bogs down the already tight schedule even more.  Some clinics and doctors have put in place policies to dissuade patients from no-showing like forcing the patient to pay a fixed cost if no cancellation within 24 or 48 hours of the appointment.  My office does not currently use this policy, however I suspect we will see more like-scenarios in the future to counteract this situation. 

The most glaring evidence of noncompliance seems to be rooted in local cultures.  My urban dwelling patients who are middle to upper class seem to have very little noncompliance.   Occasionally patients will return to my clinic earlier than scheduled to tell me that they have stopped a medication or therapy due to a misunderstanding or side effect.  My lower socioeconomic class patients, especially those who are illiterate, understandably seem to have the hardest time.  Most troublesome, however, are the rural patients who seem to march to a different drum beat.  When I go to an outreach clinic for a full day (and the patients know that I am in the clinic in their community all day), I often have late afternoon patients show up early in the morning and vice versa.   When asked by my nurses about their early or late arrival, they mostly say that they just thought that they could show up early (or late) and be seen.  I also have a tremendous amount of no-show/rescheduling, and I have patients who do not seem to be interested in their care/health/treatment/medications.  The Humpty Dumpty approach to medicine is strong in these locales.  

I have now grown accustomed to patient noncompliance and the ensuing disasters. Despite thorough education by multiple medical personnel, I have had multiple episodes in which a stent patient will stop his/her Plavix one month after a heart stent (and 11 months earlier than ordered).  This puts them at risk for clotting of the stent which can be life-threatening.  Cessation of blood pressure medications can also cause a similar emergency in which patients will develop chest pain, stroke symptoms, or have a heart attack due to lack of vital meds.  My patients with atrial fibrillation (a heart arrhythmia that can cause strokes unless treated with a blood thinner) often will stop their blood thinner due to a simple nosebleed, hemorrhoidal bleed, or trivial laceration/scratch on the arm or leg.  As expected, they then come into the ER with a large stroke from the AFib and wonder why.  

The other scenario that regularly causes me to want to pull my already scant hair out involves patient and family expectations.  As with the noncompliance section, I cannot give you a complete list of unrealistic patient expectations, rather I will just mention a couple of good examples.  Let me start by saying that all patients and families should have high expectations of doctors, nurses, staff, and their medical care.  The most common cause of trouble with these expectations in my experience has occurred AFTER a patient (and/or family) is educated about a disease process and told how to expect the course to go.

Cancer diagnoses and treatment plans often lead to incongruent patient-doctor expectations and thus can be frustrating for both sides.  Oncologists often have to balance the diagnosis/treatment of a metastatic cancer (which is almost always fatal and treatment plans are usually meant to prolong life while reducing pain and suffering) with the mental/psychological burden that has been placed on the patient.  Crushing the spirit of a patient too soon after diagnosis can  be extremely troublesome to the doctor-patient relationship.  

Emergency room patients and doctors often have a difference of expectations when it comes to being seen in a timely manner.  The patient often thinks solely about his/her presentation and symptoms, usually pain/trauma/etc.  The doctor must be tasked primarily with triaging patients from most sick to least sick and then endeavoring to see all patients as quickly as possible.  Most lay people do not understand the triage process and wonder why a patient who is having chest pain but appears comfortable is seen before the patient with a non-life threatening trauma.  ER doctors suffer quite a bit of stress from patient and family complaints due to the triage process which, for the most part, is out of their control.  

The above two examples are not everyday occurrences for me as a cardiologist.  My dealings with unrealistic expectations leading to frustration seem to be related to three situations:  post-heart attack or stroke apathy with repeat event, medication noncompliance leading to an unexpected event, and denial causing a false sense of well-being despite uncontrolled risk factors.  The second example has already been discussed above but is worth a repeat mention as a large percentage of patient events occurs due to medication noncompliance.  If insurers are ever able to capture this cause/effect in action, they are likely to try to unload the financial ramifications onto the patient.  

Certain patients take an apathetic approach to their life after an event like a heart attack or stroke.  They give up, or at least they stop caring about the healthy side of life.  They then set themselves up for a repeat event.  The family rather than the patient is usually the side who has unrealistic expectations when this event happens.  I often hear from them:  “how could you let Daddy have another heart attack when he just had one two years ago?  Don’t you think you should have treated him more aggressively?”  Unfortunately, this approach then pushes the physician to throw the patient under the bus by examining the reasons why Daddy had another event:  usually smoking, eating poorly, not taking meds, etc.  No matter the approach, the doctor-patient relationship is stressed.  

Finally, I bang my head against the wall and rip the hair from my scalp on a regular basis due to the patients who come into my clinic with diabetes, high blood pressure, high cholesterol, family history of heart disease, and tobacco abuse yet refuse to do anything about any of these disease processes.  These patients clearly expect not to have events despite overwhelming evidence to the contrary.  I have no answer for these unrealistic expectations nor do I hope to discover a cure for noncompliance.  

We can only hope that there is a culture shift and/or a new approach to educating patients and families which will alter compliance and expectations. 

David Jones, MD is the owner of www.DoctorRated.com, a healthcare ratings website dedicated to physician peer ratings, and a practicing adult cardiologist.  

Top 10 Reasons to Have an Established Primary Care Physician (PCP)

10.  Yearly physicals starting in your 30s or 40s can discover an asymptomatic serious medical condition, a cancer (remember the famous Seinfeld episode about a dermatologist saving a life due to skin cancer), or a lab abnormality indicative of a vital organ problem.  Knowledge is half the battle.  

9.  The Emergency Department (aka the ER) and an Urgent Care Clinic (aka a Doc in the Box) are your only other alternatives when you develop a symptom or illness that requires a visit to the doctor.  ER physicians are trained to take care of emergencies NOT your chronic migraine headaches.  

8.  Blood pressure, cholesterol, diabetes, and smoking are some of the biggest causes of heart disease and stroke in the US.  The first three generally do not cause symptoms and the fourth one is rooted in addiction and denial.  Let your PCP screen you for these so that you don’t leave this world too soon.  

7.  Whether you like it or not- starting at certain ages and at pre-specified intervals, all patients need colonoscopies, prostate cancer screening (men), and pap smears/mammograms (women).  All of these cancers can either be prevented or cured if found soon enough.  Those of you who keep putting off your screening clearly need to have a PCP set up a yearly schedule.  

6.  Some insurances require a PCP in order to be referred to a specialist.  Think about needing an urgent referral to a cardiologist for chest pain or to a surgeon for a bad gallbladder.  Having an established PCP allows you to have faith in this referral.  Otherwise you will be playing Russian roulette with the yellow pages. 

5.  Colds, coughs, and sore throats usually just go away without treatment, but they sometimes can turn into something more.  Let your doctor diagnose: a simple urinary tract infection before you are hospitalized with pyelonephritis/sepsis (a full blown kidney infection), strep throat before it turns into rheumatic heart disease, your cough and shortness of breath as a walking pneumonia before you end up on a ventilator for it.

4.  Although the author of this list disagrees, PCPs are a good place to start when you think you need an antibiotic or a pain killer.  

3.  Whether you believe in vaccines or not, you need a pediatrician or family practice physician to guide you through the important details of your child’s health.  The Internet is a very dangerous resource for this topic.  

2.  Think of your PCP as your health coach or teacher.  He/she should give you the best advice about all matters involving your health.  You can depend on him/her to treat you (or refer you) for things like back pain, chest pain, headaches, etc.

1.  Remember that your PCP is going to be your gateway into the medical world.  Think of him/her as a general contractor for your body who has a Rolodex of subcontractors if needed.  If you have a bad PCP, you are more likely to be treated less aggressively/appropriately and referred to poorer quality specialists.  Love your PCP!

David Jones is the owner/blogger at DoctorRated.com and a private practice cardiologist.  

The Problem with Healthcare Ratings Sites

The internet is such a fabulous medium with unlimited possibilities and the ability to seemingly find any piece of information on any topic in the universe.  American healthcare is one of the largest expenditures by GDP in this country, and thus is also one of the most discussed and debated sectors from a professional, personal, financial, and societal standpoint.  Physicians are at the epicenter of this debate and their professional reputations are in the crosshairs.  Patients (like consumers in other sectors) drive the discussions about doctors in social circles as well as water cooler diatribes.  A patient’s choice of physician can be as simple as a good recommendation from a colleague at the office coffee pot on Monday morning or on the 18th green on Saturday afternoon.   

We all know that gossip, opinion, and innuendo should not sway important life decisions which is why healthcare/physician ratings websites seem like SUCH a great idea.  Patients rate their doctors by quality, experience, knowledge, personality, availability, and bedside manner.  All is happy in the world as the sun sets onto a rainbow and the story ends…

Should a site like this have all of the qualities listed in the prior paragraph?  Absolutely.  Should patients have access to this data at the tip of their fingers?  Positively.  Is this type of site available now?  Negativo.  

Unfortunately, what should be a very popular way of rank ordering physicians by specialty on every mobile device, laptop, and desktop in the US so that consumers can make an informed decision IS a big mess of disordered ratings with bias, low numbers leading to unknown significance, and poor relevance to the general public.  Take it a step farther and one should be able to subdivide the good/great physicians by personality type, work ethic, peer esteem, etc. to sync up patients with preferred characteristics.  Undeniably, the availability of this type of site could change the way patients access their healthcare and ease tough decisions.  

The biggest issue with the current milieu of healthcare ratings is that the most popular ones out there are no different than your typical site that rates plumbers and electricians.  The bottomline is that the people who know doctors and hospitals best are not involved in the ratings process.  Other doctors, nurses, and healthcare workers should know the lay of the land better than even the most informed patients.  Someone recently commented to me that no one knows medicine doctors better than ICU nurses and no one knows surgeons better than operating room techs and nurses.  I believe it.  

Now we have to be careful not to make this a popularity contest, but the addition of peer ratings to patient ratings is a HUGE step in the right direction.  DoctorRated.com gives doctors, nurses, and patients the ability to rate anonymously or publicly. 

There are several challenges to this approach as doctors are historically as likely to participate in this type of process as a preacher is to be seen at a gentleman’s establishment.  Unfortunately, we cannot give physician’s incentives to rate each other for fear of bias.  However, physician satisfaction scores have now moved into a prominent role and are poised to determine a percentage of a doctor’s reimbursement in the future.  For this reason, DoctorRated thinks that physicians as a whole should embrace peer ratings and take control of the ratings sector.  The nice thing from a physician standpoint is that once you spend the time to rate your referring doctors, you should have minimal maintenance to do to keep your preferences accurate.  

Patients also do not seem to be interested in rating doctors as evidenced by the low number of ratings per doctor on the popular sites.  DoctorRated thinks the reason for this has to do with “the out of sight, out of mind” philosophy.  We need to attract patients to rate while in the doctor’s waiting room or on the way out of the office.  Otherwise, this may never gain traction.  Our hope is that you will start seeing DoctorRated signs in waiting rooms and given cards on your way out of the office.  

With some momentum, DoctorRated is poised to give the medical community and society a useful tool to help patients and doctors improve their healthcare decisions.  

David Jones is the owner of DoctorRated.com and a private practice cardiologist.  

How to Pick the Right Emergency Department

Regardless of age or gender, all patients will inevitably need emergency care at one point in their life or another.  I am often asked by friends and family members how to pick an Emergency Department (ED).  I usually give them my response and they sometimes will say:  “the wait time is too long”… “the ED physician did not give [a relative] enough attention last time”…  “the seats at [local hospital] are so uncomfortable”… “can you believe that [so and so] was sent home without pain medication?”… etc.  Although these explanations are certainly valid, this article is meant to point out that there is more strategy to an ED visit than a wait time, an uncomfortable chair, and sedative medications. 

Life's Second Childhood

Life can start as a whirlwind and end up a boomerang.  

You get your big break in life as an infant/toddler under the tutelage of your parent(s) who coddle you and raise you in their shadow.  All of your needs are filled and all of your decisions are quietly watched and judged.  You have little to worry about because they make most of the important decisions and allow you to drift happily through life while feeding and growing like the plant outside your bedroom window.  In the boomerang analogy, this is the initial flight just after leaving the hands of the thrower.  

Reading a Patient's Poker Face- the Complex Psychology Behind Every Patient-Doctor Interaction

Patient-doctor communication often has many facets, wrinkles, and twists.  Medical school prepares a doctor minimally for the ups and downs of these patient interactions.

  There is no mannequin who can train each medical student how to deal with every personality, response, or even outburst by each patient.  On the job training is sine qua non.  

During and after medical school, it took me several years of practice to hone my skills as a communicator.  I learned some lessons the hard way.

How to Pick a New Primary Care Provider (PCP)

I want you to think about your choice of Primary Care Physician (PCP) as one that is vital to your health and happiness- similar to your choice of church or school and just short of your choice of spouse.
Your choice of PCP can determine life or death because the PCP is your gateway to healthcare. Primary care physicians are on the front line and treat disorders varying from depression and anxiety to high blood pressure and cholesterol. They are usually the first to suspect stroke and heart disease and often will be the ones who discover cancer and other life-threatening diseases.

The Steady Domination/Destruction of Medicine

Doctors (and nurses for that matter) can be as tough as the nail that holds up the shingle hanging over the office door.  

Up all night with no sleep… “No problem”  

No help from partners or other doctors..“I’ll just have to work harder”  

No weekends off for [insert a number] months… “It builds character”

Haven’t seen my spouse or kids in a couple of days… “I’ll try to see them this weekend”

Let’s face it.  By most accounts, the healthcare lifestyle is not ideal for a social life nor for a family life.  Spouses and significant others tend to run in packs due to lack of maintenance and kids don’t always recognize the doctor parent for lack of attentiveness.  Although not all practice situations are the same, the average physician is overworked by the American standard.  Days and on-call nights are long, weeks and months can grind on in perpetuity, and it takes a toll on the body/mind/soul.  Yet medical and nursing schools are still seeing adequate applications and residency programs are still cranking out hard-working men and women after their apprenticeships.  

What Do Dr. McDreamy, The One-Eyed Guy Behind the Curtain, and George Clooney Have in Common?

What is a doctor rating and why are doctor ratings sites important for doctors and for patients?  Before Al Gore and the invention of the internet

(I know…I know…the two have nothing to do with each other except that one opened his mouth while the other was spawned), there were no doctor ratings. 

Humpty Dumpty Medicine

As a little kid, I used to love the bedtime poem about Humpty Dumpty and his fall from the wall. 
“Humpty Dumpty sat on a wall, Humpty Dumpty had a great fall.  All the king's horses and all the king's men Couldn't put Humpty together again.”  Until recently, I never thought about this story as a logical and sad analogy to the state of American healthcare. 

So you are wondering what this is all about…I practice adult cardiology in the salt, tobacoo, fried food, and obesity belt that is the US South. 

Going Out on a Limb...My Story about the Creation of DoctorRated

I see thousands of patients every year either in my clinic, in the hospital, or at the time of procedures. 
I try to take care of each one of them like they are part of my family.  Some of them want help, some don’t want help, and some can’t be helped.   Despite this, the margin for error is zero.