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Irwig L, Irwig J, Trevena L, et al. Smart Health Choices: Making Sense of Health Advice. London: Hammersmith Press; 2008.

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Smart Health Choices: Making Sense of Health Advice.

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Chapter 6Choosing a practitioner or a hospital

A few weeks after starting treatment for depression, Claire noticed a marked reduction in her libido. She was puzzled because the medication had helped improve her mood and enjoyment of life generally. She mentioned it at her next appointment and was surprised to hear that the antidepressant might be to blame. The psychiatrist explained that this particular drug affected libido in some people whereas other drugs appeared to be less likely to cause this side effect. On the basis of this information, Claire decided to try one of the other antidepressants. She wished her doctor had spent more time initially explaining the pros and cons of the various antidepressants, and resolved to ask more questions next time that she was in such a situation.

In this chapter we outline some of the aspects that you might consider in choosing from whom and where you will seek healthcare treatment and advice. We recognise that different health systems will not always provide you with the type of practitioner or hospital that you would most want. This may be a result of differences in access for private fee-paying, as opposed to government-subsidised, places.

However, most health services are becoming more patient-focused and aim to give you a greater degree of choice. Although the National Health Service (NHS) requires British residents to register with a local GP, patients have the right to change doctors without giving a reason and many GPs operate within a group practice setting. Similarly, the NHS now has a policy that, when a GP refers a patient to a specialist or hospital for treatment, he or she can choose from several hospitals in the local area. In Australia, patients are free to seek medical advice including a second opinion without restriction, although choice of practitioner in some hospital settings is restricted if you are a non-insured patient. People usually choose their own pharmacist, dentist, homeopath and other health providers, but what is the basis on which we make these important choices in seeking health advice and treatment?

Many consumers are taking more active roles in their health care. The role of many practitioners is also changing, moving from one of professional paternalism to being a partner in their patients’ decisions.

A survey of 652 Australian women in 2001 showed that 95 per cent of women wanted an active or shared role in treatment decisions about their healthcare.1 Slightly lower figures were reported in a European survey, but still a majority of 74 per cent people preferred some active involvement in healthcare treatment decisions.2

In 2004, The UK Department of Health launched a program called Better information, better choices, better health: putting information at the centre of health.3

It is a three-year program underpinned by four principles. People should:

  1. have access to accurate, high quality, comprehensive information delivered in the way they want
  2. have their personal information needs considered and discussed at every contact with health professionals
  3. receive as much support as they want to access and understand information
  4. be empowered to ask questions and be involved as far as they want in making decision about, for example, the benefits and risks of action and how any risks can be mitigated.

The patient–practitioner partnership encourages and depends on a level of trust that demands mutual respect, clear concise communication and shared responsibility. Finding a practitioner with whom you can establish this partnership may take some time and effort, but ultimately it is in your best interests to make this choice carefully. You may have already found one, but may not have been taking full advantage of your role in the relationship. One of the aims of this book is to help you do that confidently. In other words, choosing a practitioner may include looking beyond technical expertise and also include considering decision-making expertise.

It is also important to consider your role in the broader community. When communicating one to one with your health professional about the best treatment options for your situation, it can be easy to forget that your decisions can have an impact on others. These may include your family and those who are close to you, as well as people in your workplace, school or wider community. There is often a conflict or tension between what may be your own personal preference and what may be best at a societal level – and there are no easy answers to this one.

For example, some parents choose to exercise their right not to immunise their children but this potentially puts very young babies and children with immune deficiencies at risk of disease. Similarly it is understandable that a patient with cancer might want the government to fund a new, expensive and not yet proven treatment in order to give them a chance of increased survival. However, when health budgets are limited this may divert funding from other health problems. This may lead to other people being indirectly penalised. These are difficult issues and not ones that can necessarily be resolved by individual patients but it is worth bearing them in mind. You may feel daunted by the idea of ‘examining your doctor’ in the way that we suggest in the following pages, but just ask whatever you are comfortable with. As time goes by and you ask about more issues, it will become easier.

Judging a practitioner’s decision-making expertise

Competent decision-making expertise involves good clinical judgement to make a diagnosis and the proper use of evidence combined with patient preferences to choose the best course of action. However, not all practitioners approach decision-making this way. Although it is probably true to say that most practitioners can diagnose common illnesses fairly accurately, they vary in their ability to use evidence appropriately to decide what intervention – if any – is best and in their willingness to take account of patients’ preferences.

Consider an elderly man who is considering whether to have surgery for an enlarged prostate. There is good evidence that an enlarged prostate is not life threatening, although it can be a nuisance. The potential side effects of surgery include impotence. A practitioner should be able to present information about the benefits and harms of surgery, but only you can decide which harm is the most acceptable – increased frequency and urgency of urination from an enlarged prostate or possible sexual dysfunction and incontinence from the surgery.

To help you judge whether your practitioner has good decision-making skills consider whether he or she:

  • uses the best evidence available
  • readily shares information with you
  • takes adequate account of your preferences.

Does your practitioner use the best evidence available?

If your practitioner is using the best evidence available, he or she should be regularly updating his or her practice using the results of randomised controlled trials. Many practitioners say that they already practise evidence-based medicine, but, unless they make a conscious effort to keep abreast of the latest results from randomised controlled trials, you cannot be sure that their advice is really based on the best evidence.

There is no easy way of testing your practitioner’s approach to evidence-based care without discussing it openly. You might start by asking their opinion on some treatment that you have found on the internet or been told about by friends. See if the practitioner evaluates it taking account of whether the effect of interventions has been tested in randomised controlled trials, and whether he or she talks about outcomes that matter, such as survival and quality of life.

If practitioners do not update their practice from randomised controlled trials, those who try to keep up to date through continuing medical education or by being involved in professional college activities are more likely to be using better evidence than those who do neither of these. Be cautious about practitioners who rely only on their early university medical education or information from the pharmaceutical industry.

Does your practitioner share information with you?

Another important issue is whether your practitioner’s decision-making process is based on sharing information with you – whether it be about the diagnosis, prognosis or intervention options.

A few years ago, one of us (Judy) developed a very severe pain and restricted movement in one shoulder, and was diagnosed with a tear in one of the ligaments in the rotator cuff and some tendon impingement. (This means the tendon had been ‘pinched’ or compressed slightly by the swelling.) When the pain persisted after some analgesic treatment and a steroid injection, she saw a surgeon who had an exemplary decision-making process. He explained the possible causes and implications of Judy’s condition, and then told her the options and their risks and benefits. He also gave her some written information to take home to read.

Her options, as he explained them, were:

  • Watchful waiting: he said that, according to published studies, the pain was likely to ease within a year or so, if nothing was done.
  • Arthroscopic repair: he said that studies show most people report considerable relief after surgical repair by arthroscopy, a relatively simple procedure to remove the impingement. But Judy remained cautious because these were case studies based on personal testimony and therefore it was not clear whether the improvement was a result of the intervention or would have occurred anyway. It is also possible that those in whom the operation was unsuccessful were not included in these reports.
  • A more complicated surgical procedure: this option, he explained, would repair the ligament and increase the rotator cuff mobility. It would require a few days in hospital and intensive, prolonged physiotherapy.

Does your practitioner take account of your preferences?

On the basis of Judy’s discussion with the surgeon and the written information that he provided, she decided that the potential harms of surgery, although small in her case, were sufficient to outweigh the potential benefits – which seemed unclear anyway. In addition, as she is not an athlete and not heavily reliant on the use of her shoulder, Judy could afford the time to wait and watch.

For some time afterwards, the pain woke Judy at night, making her question the wisdom of her choice. But within several months, she was almost completely pain free and after a few more months, she regained the mobility in her shoulder. If the problem had continued, she might have reconsidered other options.

In fact the problem did recur several years later. For some months Judy tried to ignore the pain, hoping that it might resolve, but when it continued to get worse she went to see her practitioner. As she is averse to surgery, she asked about other options and he suggested physiotherapy with someone who has special expertise in shoulder problems. Judy decided to try that option on the grounds that it might help and was unlikely to do any harm – aside from the time and financial cost that she felt were reasonable ‘harms’. The physiotherapist gave her a regimen of stretching and strengthening exercises that he monitored regularly and adapted as Judy’s mobility increased. Within a week or two she noticed a dramatic improvement, suggesting that the physiotherapy was working. Judy continues with a maintenance programme of exercise every other day, which she tries to adhere to, but, when she lapses for a week or two, some stiffness and discomfort return. It seems to her that the physiotherapy is doing the trick, as judged by criteria outlined in Chapter 8.

In contrast to Judy’s experience, a friend, Sarah, who had a similar problem with her shoulder, had an unpleasant experience with her practitioner. He had diagnosed inflammation in the rotator cuff, but had not dealt with her concerns in the same caring way that Judy’s had done. He had dismissed her questions saying ‘Anything I haven’t already told you is not important.’

After speaking with Judy, she decided to go back to her practitioner and ask for more information. She was nervous about doing this, and was worried that he might be upset or resentful at her questioning – after all, it is not always easy for a patient to question their doctor, and doctors are not always used to being closely questioned.

But it was much easier than Sarah expected. Once she’d clearly and calmly explained her concerns and her wish for more information, her doctor provided the information and she decided that the potential benefits of surgery outweighed the small risks. Her lifestyle – having a small child and a job that involved using her arms a great deal – was not conducive to waiting it out as Judy had done. Her choice to undergo surgery was driven by personal preferences relating to her lifestyle.

Judging a practitioner’s technical expertise

After you and your practitioner have decided either to treat or to investigate your illness further, the procedure should be done by someone with the appropriate technical ability.

The degree of expertise of any surgeon is extremely difficult for either a GP or a patient to assess. Surgeons who enjoy a high media profile may, in fact, be more competent at issuing press releases than at performing surgery.

Guy Maddern4

To assist you in judging whether your practitioner has the necessary technical expertise, you might want to know whether he or she:

  • is qualified to perform the procedure
  • performs the procedure often enough
  • is part of a quality assurance scheme or some similar programme.

If you are seeing a practitioner in a large outpatient’s department or clinic, ask who will be performing the procedure. If it is not the practitioner whom you are consulting, ask the same questions about the person who will be doing the procedure. In some settings it may be a trainee, in which case you also need to know who will be supervising the trainee and something about the supervisor’s experience.

Is your practitioner qualified to perform the procedure?

Among the issues that you should consider are the practitioner’s special qualifications or certification to undertake this particular procedure. Even for a relatively minor operation such as an arthroscopic repair for a shoulder injury, you are likely to be better off choosing a surgeon specialising in shoulders. An unsupervised surgeon who is inexperienced in the procedure will not be a wise choice.

Report cards on doctors or health services have been discussed as an option but there is debate about how reliable they are. Some professional colleges have membership databases that will help you find a surgeon in a particular location who operates within a particular specialty area such as breast surgery (www.surgeons.org). Other directories are available, such as mydr.com.au, but none of these provides sufficient detail about the credentials of the doctor concerned. Websites based in the USA will provide you with a report card on a particular doctor for a fee. In the USA, patients tend not to use the report cards but rather follow the advice of their referring doctor. Even the former US President, Bill Clinton, went to one of the lowest-rated hospitals for heart surgery despite the publicly available rating. In addition to this, it has been shown that some hospitals tend to ‘fudge’ the reports by selecting ‘safe’ patients for their reporting framework. Doctor and hospital report cards appear to need more work if they are to become useful tools for patients and other interested parties.

How often does your practitioner perform the procedure?

It is useful to know how many of the particular procedures your practitioner does in a week, month or year – depending on how common the procedure is. There is evidence that patients are more likely to have better outcomes after a procedure if their doctors perform many such procedures.5, 6 Centres that specialise in a particular condition are also more likely to offer comprehensive, multidisciplinary care. But there is a paradox: although experience may increase with age, physical and mental agility decline. Professor Guy Maddern,4 an eminent Australian surgeon, notes that many hospitals now recommend that surgeons should not operate after the age of 70:

While clearly some surgeons could go on longer than this and others should have stopped much earlier, choosing a surgeon over 70 to perform your operation is perhaps ill-advised.

Is your practitioner part of a quality assurance scheme?

The third important criterion for assessing technical competence is whether your practitioner belongs to a quality assurance or credentialing scheme to assess technical proficiency. This will be relevant only to major interventions, such as surgery. Quality assurance schemes monitor patient care by examining patient records at random to make sure that care adheres to established practice, by monitoring adverse outcomes and by evaluating satisfaction through patient surveys. Many hospitals also have a credentialing process, to ensure that practitioners are appropriately qualified and skilled to undertake certain procedures. To ensure that a practitioner is covered by such a programme, you could ask the practitioner directly, your referring practitioner or the hospital.

All doctors are required to participate in continuing education programmes with their respective professional college and this is now a mandatory condition of registration. For most other health professions this is optional.

Many people ask whether litigation is a measure of a practitioner’s technical competence, assuming that those who have been sued are best avoided. However, we do not believe that this is a reliable indicator of technical competence because studies have shown that litigation often reflects poor communication between practitioner and patient rather than technical failings

Finding a practice or hospital that suits your needs

Apart from looking for an evidence-based practitioner with good clinical expertise, there may be practical issues that you want to consider. These might include the location of the practice or hospital near your home or work, the gender of the doctors at the practice, the hours of opening and after-hours arrangements, the fee structure and any special expertise among the practitioners such as an interest in skin cancers or young families or women’s health.

Choosing not to choose

You might feel unable to participate actively in decision-making if you are overwhelmed by serious illness or have other problems. In this case, you also have the right to delegate decision-making.

But think hard about this. The more serious your health problem, the more valuable your participation is likely to be. So, if you do find yourself wanting to delegate decision-making to your practitioner, and if the problem does not require immediate attention, take some time out. Arrange to see your practitioner again after you have had a chance to reflect.

If you decide to delegate decision-making, your practitioner will be better able to make informed decisions if he or she knows something about your preferences, your general attitude and your lifestyle. It may also be a good idea to ensure that a friend or relative is aware of your health preferences in case the need arises.

Summary

Everyone who offers you health advice should not only respect your right to be involved, but also encourage your participation. If you feel it necessary, ask for written information to take home with you.

  • In most situations, you should expect your practitioner to explain to you:

    what your problem is thought to be

    what you can reasonably expect if your illness or condition is not treated

    the benefits and harms of the various treatment and diagnostic test options.

  • When choosing a practitioner, you should consider whether they:

    are abreast of the latest evidence from randomised controlled trials

    share information with you

    respect your involvement in decision-making.

  • If you are considering having a procedure, you should also assess the practitioner’s technical competence by asking about:

    their qualifications

    how often they do the procedure

    whether they are part of a quality assurance programme.

References

1.
Davey H, Barratt A, Davey E, et al. Medical tests: women’s reported and preferred decision-making roles and preferences for information on benefits, side-effects and false results. Health Expect. 2002;5:330–40. [PubMed: 12460222]
2.
Coulter A, Jenkinson C. European patients’ views of the responsiveness of health systems and healthcare providers. Eur J Public Hlth. 2005;15:355–60. [PubMed: 15975955]
3.
UK Department of Health. Better information, better choices, better health: putting information at the centre of health. 2004. http://www​.dh.gov.uk​/en/Publicationsandstatistics​/Publications​/PublicationsPolicyAndGuidance​/DH_4098576.
4.
Maddern G. Questions You Should Ask Your Surgeon. Sydney: Bay Books; 1994.
5.
Begg C, Cramer L, Hoskins W, Brennan M. Impact of hospital volume on operative mortality for major cancer surgery. JAMA. 1998;280:1747–51. [PubMed: 9842949]
6.
Hannan E, Racz M, Ryan T. Coronary angioplasty volume–outcome relationships for hospitals and cardiologists. JAMA. 1995;277:892–8. [PubMed: 9062327]
Copyright © 2008, Professor Les Irwig, Judy Irwig, Dr Lyndal Trevena, Melissa Sweet.

All rights reserved. No part of this publication may be reproduced, stored in any retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publishers and copyright holder or in the case of reprographic reproduction in accordance with the terms of licences issued by the appropriate Reprographic Rights Organisation.

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