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A+ Doctors
There's still no scientific way to find the best doctor, but our survey of local physicians reveals 250 medical specialists they'd recommend.
by Mario Quadracci With additional assistance from Andrea Albrecht and Sarah Brzezinski | July 2004
Kevin Svoboda didn't know it, but his insistence on driving 90 miles to have Wauwatosa psychiatrist Dr. James Winston treat his anxiety was a life-or-death decision. During his normal appointment, Svoboda mentioned a slight tingling in his head and left arm. A licensed physical therapist, the 29-year-old Svoboda had dismissed it as something that would "go away on its own."
Winston, who has treated Svoboda for five years, suspected otherwise. Without waiting for Svoboda's health plan's approval, he ordered an immediate MRI.
The scan revealed a brain tumor. Winston, who accompanied Svoboda to the test, broke the news. "He told me in such a comforting and reassuring way," says Svoboda.
The tumor was successfully removed at the University of Chicago's nationally recognized neurosurgery center, and Svoboda has received a clean bill of a health and a prognosis for a healthy life. "Throughout my treatment, all of the doctors involved were amazed that Dr. Winston had the intuition he did," says Svoboda. In fact, University of Chicago specialists said that considering Svoboda's symptoms, only one in 100 physicians would have ordered the MRI. And even now, nearly a year later, Svoboda "still calls me every month to thank me for saving his life," says Winston, selected in a Milwaukee Magazine survey as one of the area's Top Doctors.
While stories like Svoboda's are testament to the excellence found in the area's medical community, at the other extreme, there are other doctors in Wisconsin "who, would they be practicing in many other states, doing exactly what they are doing, would have lost their license," says Dr. Sydney Wolfe, an internist who co-founded Public Citizen, a Washington, D.C.-based nonprofit public interest organization.
Those bad docs are the minority, but they illustrate one end of the range of quality among physicians. Most doctors fall somewhere in between.
So how can you tell how good your physician really is? Unfortunately, you can't - at least not decisively. At least not yet, and objective quality measures for individual practitioners may never exist due to cost, complexity, privacy concerns and the fact that many physicians are "resistant to it," says Dr. Michael Dunn, dean of the Medical College of Wisconsin (MCW).
But because Wisconsin ranks 49th among the states in ridding the medical profession of bad doctors, according to Public Citizen, Wisconsinites have reason to be a little more anxious about choosing their physician (more on that later).
Meanwhile, the frontier in measuring medical quality lies with provider systems (hospitals, clinics, health plans, et cetera) and in developing a nationally standardized method for comparing them. It's a logical first step. After all, even great doctors can be limited by the systems in which they operate.
Ironically, even those who are developing healthcare quality measures feel that defining quality of care is like proving or disproving the existence of God; at best, certain benchmarks can be identified and measured. Others are more optimistic. One thing is certain - a standardized definition of quality and a universal set of measures to determine quality in the healthcare delivery process don't yet exist. But that hasn't stopped some pioneers from attempting to shine a light on quality.
Most current quality measurements look at specific outcomes, such as mistakes, complications and deaths for particular treatments within a hospital or clinic. They also commonly correlate the number of specific procedures (angioplasty, high-risk births, et cetera) a facility performs with higher quality - the more the better. But at some point, although no one knows where that point is, hospitals can cross a line and actually perform too many of a particular procedure for its infrastructure to support at the same level of quality. Such inconsistencies confound the whole issue of quality measurement.
Using standard business models to evaluate healthcare quality is problematic, too. In most sectors of the free market, competition ultimately drives a product's - or service's - cost down and its quality up. But in healthcare, competition frequently has the opposite effect. One reason for this, especially in the Milwaukee area, is the aggressive expansion and consolidation of hospitals. Many say this causes duplication of services (too many hospitals offering the same treatments), which translates into higher costs and shortages of quality doctors and nurses.
A customized science is really needed to evaluate healthcare quality, but the measures now used to grade performance in healthcare are "primitive," says Cheryl DeMars, director of quality for The Alliance, a Madison-based employer cooperative that collects and publishes healthcare quality data on hospitals in southern Wisconsin. MCW's Dunn concurs: "We are making efforts to provide measures to help consumers assess quality, but it is really entry-level stuff... You can be given all of the things we measure and still not be given good care."
"If healthcare were to focus on quality and stand behind procedures with something like a warranty, it would profit more - even if it can't get as many patients through the system," says Greg Bass, chief financial officer for Healthcare System Consultants. But there are no "warranties" in healthcare. Consumers and their insurers, and hence, employers, end up taking the hit financially when healthcare quality is poor. When a procedure or diagnosis fails, the purchaser pays the added expense of subsequent procedures, which means that healthcare providers are rewarded financially when care is substandard. That begs the question: Where is the incentive for provider systems to deliver quality care?
A study published in the June 2003 New England Journal of Medicine found that patients in 12 U.S. metropolitan areas were given the standard recommended medications, screening, testing, surgery and interventions only 54.9 percent of the time. What's more, 98,000 people die each year as a result of preventable medical mistakes, according to the National Academy of Science's Institute for Medicine. If incentive, aside from the ethics of practitioners, has existed, it has either been slight or ineffective.
But the tide may be turning.
While quality measures are still in their developmental phase, making those that do exist available to the public has caused unprecedented reform in hospitals that have undergone quality evaluation. "Will hospitals invest in quality when quality data are published? Unequivocally, yes," says Dunn.
A 2003 University of Oregon study that looked at quality data for 24 Wisconsin hospitals found that when a hospital or clinic's poor track record is exposed, it will move to improve deficiencies. The research also found that when the same data were presented only to the hospitals and not to the public, quality was far less likely to improve.
While most quality-measurement groups focus on a few aspects of care, the Wisconsin Collaborative for Healthcare Quality (WCHQ) studies data in a more holistic manner. WCHQ is a voluntary consortium of healthcare organizations whose aim is improving medical care. Working with employers and individual healthcare purchasers, the organization has designed 42 quality measures in six broad categories identified by the Institute for Medicine as "aims for improvement." The categories: safety, effectiveness, patient-centeredness, timeliness, efficiency and equity. For example, as one measure of efficiency, WCHQ charted the percentage of hospitalized heart attack patients prescribed aspirin at discharge, a standard measure for reducing the chances of another attack.
While such efforts are sophisticated in scope, even WCHQ officials admit their reports don't yet tell "the whole story" on quality, and they plan to expand their measurements. In its inaugural effort in 2003, WCHQ applied its 42 measures to 18 volunteer healthcare plans, clinics and hospitals, including Froedtert Memorial Lutheran Hospital. The consortium hopes to attract more provider participants. Says Dr. John Toussaint, collaborative chair and co-founder: "As long as we continue to try to be the best, most comprehensive quality measurement effort around, providers who are interested in doing the right thing will come aboard."
Some have resisted. Earlier this year, Covenant Healthcare, Aurora Health Care and ProHealth Care chose not to participate, citing the $17,000 cost as a primary reason. But, says Alliance Chief Executive Officer Chris Queram, "The cost argument is just not defensible" when Milwaukee-area hospitals spent $7.4 million in advertising last year. Aurora alone spent $1.9 million, according to the Milwaukee Journal Sentinel.
Covenant, Aurora and ProHealth will instead participate in CheckPoint, the Wisconsin Hospital Association's own quality measurement program. CheckPoint publishes quality data online but measures fewer than half as many quality indicators. To many involved in the issue, Checkpoint looks like an effort to control the process and avoid quality measures that may prove embarrassing. Checkpoint's credibility is already questionable; at the end of April, only eight out of 121 member hospitals had submitted data.
"Until we start comparing apples to apples publicly, we are not going to get the level of improvement needed. A lot of these systems are broken," says WCHQ's Toussaint.
While healthcare quality measurement continues to evolve, another, more controversial, problem remains: bad doctors - physicians who are guilty of poor performance, criminal activity or abuses of their position.
Patients put their lives in the hands of their physicians, trusting that they are competent, current and acting in their best interest. Without an established uniform system to measure the quality of individual practitioners, that trust is based on faith in the profession and the entities that oversee and govern it. In Wisconsin, that trust may be ill-placed.
The courts (which mete out malpractice awards) and hospitals (which can deny a doctor the privilege of practicing at their facility) do act against bad physicians, but it's state medical examining boards that determine whether or not a suspect physician is fit to practice and under what limitations. Wisconsin's regulatory effort is lethargic at best.
According to the Federation of State Medical Boards, Wisconsin issued 20 serious disciplinary actions (license revocations, surrenders, suspensions and restrictions) against doctors in 2002 - 1.4 serious actions per 1,000 physicians (14,241 total state doctors), a record that places Wisconsin 49th in the country in issuing serious discipline.
Public Citizen examined state disciplinary actions relating to misprescribing or overprescribing drugs, criminal convictions, substance abuse, substandard care, incompetence or negligence and sexual abuse or misconduct. It found that Wisconsin - with 518 disciplinary actions taken against 384 state physicians between 1992 and 2001 - was up to eight times less likely to issue license revocations, surrenders and suspensions; restrict practices; or take action against controlled substance licenses than were other states.
During that time period, only 43 percent of Wisconsin doctors found guilty of sexual abuse or sexual misconduct with a patient were issued a license revocation or voluntarily surrendered their license. And only 15 percent of Wisconsin physicians disciplined for "substandard care, incompetence or negligence" suffered license revocation, surrender or suspension. Just 44 percent of physicians who pleaded guilty or no contest to a crime had their license revoked, surrendered or suspended.
The executive director of the Wisconsin Medical Examining Board refused to comment on the board's anemic record, and the group's chair failed to return our calls.
So what's a patient to do? In the absence of scientific measures of doctor quality, the best we have are reputational surveys like this one. Since 1987, Milwaukee Magazine has conducted five such surveys of area medical personnel, asking them to help us identify specialists they'd go to themselves. For this one, we surveyed 3,078 area physicians.
With a 13 percent response rate, we identified 250 physicians in 25 medical specialties. Inevitably, some good doctors get missed in such a survey, but those A+ physicians who do emerge inspire our confidence.
Mario Quadracci is an assistant editor of Milwaukee Magazine.
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