The Need for Doctor Performance Feedback, Not Patient Waivers

The May 1, 2009 edition of the AARP Bulletin spotlighted a waiver that increasing numbers of doctors are asking their patients to sign, whereby they promise not to "publish or air" any unfavorable information about their doctor's care, manner or office staff.  It is specifically targeted at combating the growing prevalence of online ratings of doctors such as HealthGrades.com, Angieslist.com, RateMDs.com, and most recently, Zagat.com.   The waiver's language was developed and is being marketed for a license fee by Medical Justice Services, a North Carolina-based enterprise.

Physicians have never liked being graded and compared.  Part of the unspoken, collegial oath of the profession is that they never speak badly of each other.  In fact, it is highly unusual for a doctor to lose his license and be barred from practice for having made mistakes in diagnosing and treating a patient.  Moreover, doctors are allowed great liberties without surveillance in prescribing drugs "off label," or outside of FDA-approved applications or dosages, and undertaking experimental surgery on patients. Much of this is necessary so that technology and knowledge will advance to eventually accumulate evidence-based protocols and practices.  Safeguarding the patient, however, depends on significant trust in the instincts and training of the professional.  

Zagat's approach is particularly interesting because the restaurant reviewer functions merely as the conduit for input from patients.  For instant credibility, the famous Zagat name is being licensed by insurer WellPoint, and the information gathered about doctors is for its Blue Cross plan members exclusively.  Specifically, the ratings are intended to help guide patients in their selection among specialists recommended by their primary care doctors.

In fact, the latest research on the use by consumers of online provider-rating systems indicates that patients are becoming less reliant on somewhat generic, online ranked sources, such as the U.S. News & World Report Top Hospitals in seeking their doctors and hospitals.  If seeking a new primary care doctor, they are most likely to ask the opinion of friends and neighbors, with the aim of finding a recommended one in proximity to one's home.  If seeking a specialist, consumers, especially younger adults, are willing to travel further distances from home than older adults.  They, however, are increasingly likely to depend on the recommendation of their primary care doctor, research shows.  But what do they do if only the name of an "in-house" colleague is given, as is more typical of a large, multidisciplinary system?

Patient goals and preferences and corresponding satisfaction with care and outcomes are essential elements in determining the providers most likely to deliver the best care.  We need to find an objective and cost efficient means of obtaining this input in order to direct others to the best possible providers. Zagat delivers this to a portion of the population.  There are at least five other elements not to be ignored; namely:  1) the training, experience, and capabilities of the clinicians and the technology of the tools and systems they have available, 2) the resources and availability of the entire support team or facility and the quality of their interrelationships with each other, 3) quality metrics and an efficient means of discretely capturing, analyzing, and publicizing the data while maintaining patient privacy, 4) benchmarks to which clinicians aspire for improvement, and 5) evidence of a process by which quality can continuously improve with integrity.