From an e-mail I received:
As a proponent of SBM, and a someone who places a high value on reason, logic and evidence, I would like to find a physician who shares this mindset.
He went on to ask how he could go about finding one.
Another correspondent was referred to a surgeon by her primary physician, and the surgeon inspired confidence until she started talking about using homeopathic arnica pills to improve healing post-op. How she could determine the technical competence of this surgeon? Was acceptance of homeopathy a reason to shed doubt on her judgment in other areas? Should she seek a second opinion?
I get a lot of inquiries about how to find a good doctor. I don't have a good answer. I thought it might be useful to throw out some ideas that have occurred to me and hope that readers will have better ideas and will share their experiences about what has or hasn't worked.
What Do We Want in a Physician?
- We want a doctor who is knowledgeable and technically competent.
- We want one who exercises good judgment.
- We want one we can trust not to use quack diagnostic tests or quack remedies.
There are a lot of other considerations. Do you like him? Does he act like he cares about you as a person? How's his bedside manner? Does he explain things well? Does he encourage questions? Is he authoritarian or does he treat the patient as a partner in making decisions? Is his office conveniently located? Is he booked up months in advance? Is he on your insurance plan? Is he available in an emergency? Is he reachable by phone or e-mail?
If it's a straightforward technical matter like setting a broken bone, personalities may not matter; but in other cases (a difficult diagnostic puzzle, a chronic disease, or a psychological issue) they may matter a great deal. Sometimes through no fault of their own, a patient and doctor are simply not a good fit for each other for developing a good doctor/patient relationship. Perhaps the doctor reminds the patient of an uncle who abused her; perhaps the patient reminds the doctor of his wimpy, hypochondriacal cousin. Perhaps they have different political opinions, different religions, or different cultural backgrounds with different world views. I know an atheist who walked out of a doctor's office when she found out he was a Christian.
What kind of doctor?
As a family physician, I'm partial to a board certified family practice doctor (FP) as primary physician; as a general rule, the FP mindset tends to be more comprehensive and practical than that of internists or specialists. A urologist sees a lot of prostate cancer and is more likely to insist on PSA screening; an FP is more likely to weigh all the pros and cons and involve the patient in deciding whether to screen. (Of course there are exceptions.)
Consider other options besides MDs. In the US, DOs pass the same licensing exams and are trained in the same residency programs as MDs and can be considered equivalent. Physician assistants and nurse practitioners tend to be more interested in routine patients; many of them work in group settings with ready access to doctors when needed.
How To Find One
I have no experience in choosing a doctor. I've always been arbitrarily assigned to one in the military health care system. But let's say you've just moved to a new city and want to find a primary physician. How could you go about it? I don't know, because I've never had to do this, but here are some ideas that have occurred to me:
- Word of mouth. Ask friends, relatives, neighbors, and co-workers about their doctors.
- Ask your previous doctor. If he doesn't know anyone in your new area, he might know someone who does.
- Use the Internet. Social networking sites, forums, sites that rate doctors, lists of licensing board disciplinary actions and malpractice lawsuits, the websites of doctors and the groups they work for, etc.
- Nurses know things. If you can find a nurse who works in a local hospital or medical center, who has had experience working with lots of different doctors, she may have a good sense of which ones are better than others, and she might have heard some pertinent grapevine gossip.
- Call the doctor's office and ask if the receptionist or nurse knows if the doctor ever recommends CAM or refers to CAM providers.
- Check to see if the doctor's group includes CAM providers or advertises integrative medicine.
- Ask about credentials: training, board certification, hospital privileges, etc. If you are contemplating surgery, ask about the doctor's and the hospital's volume and complication rates for that operation.
- Interview the doctor. Make a new patient appointment and tell the doctor you want to ask some questions to see if you and he are a good fit. Ask how he goes about deciding when to adopt a new drug and whether he gets his information from drug reps. Ask what he thinks about CAM. If you have a medical problem, ask what experience he has had with that problem. Watch to see if he washes his hands.
- If for any reason you don't feel comfortable with a doctor, don't hesitate to look for one you feel more comfortable with.
- If you have any doubts about a recommended treatment, it can never hurt to get a second opinion.
- Ask if the doctor reads SBM. If he answers yes, that's a good sign! If he answers no, maybe you can get him to start reading it.
Maybe I've been unusually lucky. In the military health care system, I've been treated by MDs, DOs, PAs, NPs, and even a clinical pharmacologist; some of them were military officers, others were civilians employed by the military. I've seen multiple specialists in the military system and when appointments were not available in the system I've been referred out to civilian doctors, both primary care and specialist. None of them ever mentioned homeopathy, acupuncture, chiropractic, or energy medicine. When they talked about questionable areas, they always acknowledged that the evidence was inconclusive. The surgeon explained the biology and the statistics and then asked me to choose between breast biopsy and watchful waiting. The retinal specialist gave me a brochure about a new vitamin mixture that I 'might' want to consider as a possible preventive measure for macular degeneration, but she wasn't selling it herself or even recommending it, and she said so far there was no real evidence for prevention but only for slowing progression of established disease.
I know the medical profession includes a significant number of charlatans, of individuals who don't really understand science, and of gullible, misguided swallowers of the Kool-Aid. But in my own anecdotal sampling of the medical profession, I haven't come across a single health care provider who would not be acceptable to patients who are proponents of SBM, and who place a high value on reason, logic and evidence. I'm guessing a doctor picked at random would be more likely to agree with SBM than with Mercola. I'm hoping our readers will comment and offer practical suggestions about how best to avoid the minority of duds.
This post originally appeared on the Science-Based Medicine blog.