How Patients Can Assess the Quality of Their Outpatient Care

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Even before I launched my geriatric consultation practice, I found myself often poring over another doctor’s outpatient notes, trying to explain to a patient what the other doctor was doing.

Not every patient had questions and concerns about what their other healthcare providers were saying, and doing, but a fair number of them did. And family caregivers, in particular, were often concerned that perhaps their older loved one hadn’t been getting the “right” medical care.

These are, in truth, legitimate concerns. Busy doctors often don’t have the time to explain the assessment and plan to a patient and family. And in many cases, the care that clinicians provide may not correspond to best practice guidelines – if applicable to the situation – or to the patient’s preferences and values.

So if you are a concerned patient or family member, and you’re not entirely sure about the medical care you’re getting, what to do?

Should you:

  1. Look up the provider’s quality ratings online, through a government, non-profit, or other website?
  2. Figure that the ACO or payer is on top of it, now that we are moving to pay-for-quality and fee-for-value?
  3. See what other patients have said about the provider’s care?
  4. See how many doctors are referring to the provider in question, and assume that if many doctors refer to this clinician, the clinician must be good?
  5. Look up your medical problems online, and try to determine for yourself whether you’d been getting the right medical care?
  6. Get a second opinion from another doctor?

I’ve come to believe that facilitating second opinions is integral to empowering patients, and to improving the quality of outpatient care. To begin with, when I consider my own experience trying to solve a problem like home renovation or web design in which I lacked adequate expertise, I see that I’ve often turned to an expert, only to find myself later checking in with another expert.

Some may say I have expertitis, but how else am I supposed to determine whether expert #1 is providing me with suitable expertise, especially if after seeing expert #1 I’m left with a nagging feeling that maybe this isn’t quite the help I wanted. In my case, the stakes have been my time, money, and satisfaction with the end product. But if it were a question of health and wellbeing, I’d probably be even more diligent about getting a second opinion.

This is how many patients and families now find me. They have been getting care, but they are either dissatisfied, or they’re worried that perhaps not all the right things are being done.

Today, I’m mainly a consultant to elders and families. And just as I did when I was a PCP, I find myself spending a lot of time explaining to families what other doctors are doing.

This, I think, is good work to be doing. By looking over records and discussing a family’s medical concerns, here are the specific things I’ve found myself doing:

  • Reassuring families that the current medical treatment plan is reasonable. Often, in looking over the care, I find that the medical care so far corresponds to guidelines and common standards of practice. However, in many cases clinicians have not had time to explain their approach in depth to the patient and family. Families are often relieved to hear this, and appreciate developing a better understanding of their usual clinician’s plan.
  • Pointing out which aspects of the care plan are worrisome. Worrisome, as in really not concordant with guidelines or best practice. These include benzodiazepines for sleep in the elderly (with no discussion of the risks, or plan to avoid indefinite use), or failure to initiate workup for alarming symptoms such as significant weight loss.
  • Pointing out medications, procedures, or other medical interventions that are likely to be of marginal benefit. This comes up quite a lot in frail elderly patients, because many common approaches in general medicine – such as statins for high cholesterol – require time to benefit. In other cases, clinicians have developed the habit of referring patients for tests that research has shown to not be very helpful, such as screening for asymptomatic carotid stenosis.
  • Pointing out which aspects of the care plan could be considered choice and preference sensitive. There are some things in medicine that definitely should be done. If an older person has a loud murmur and shortness of breath on exertion, he or she should almost certainly be sent for an echocardiogram, to evaluate for symptomatic valve disease. But for many other things, especially when it comes to elderly patients, there are many reasonable ways to proceed. Back pain without alarm symptoms? One could refer for physical therapy, or prescribe analgesics. Or do both. Ideally this would depend on the patient’s preferences and particular circumstances. But in common practice it seems to depend more on the style of the clinician.

The main reason we should make it easier for patients to get second opinions is because often there is no single right way to proceed medically, and so how to proceed is essentially a judgment call.

Now, in an ideal world, this wouldn’t be an issue because clinicians would be able to consistently let patients know which aspects of the treatment plan consist of judgment calls, and would always offer patients the option of shared decision-making for these situations.

But the real world is different. Most clinicians are not used to presenting patients with options, and then tailoring the care plan to meet the patients’ preferences rather than the clinician’s habits. If nothing else, doing so takes time, and no clinician has much time these days. So judgment calls proceed according to the clinician’s preferences, in accordance with our time-honored belief that “doctor knows best.”

Except, we often really don’t know what’s best, or even better. Among other issues, in many cases we have not had the time or inclination to develop a good understanding of the patient’s experience. As a result, patients may not be aware of trade-offs, risks, and alternative options. For that, they need more information, and although some of it can be found through diligent searching online, they should also be able to access an expert who can synthesize information and tailor it to the situation at hand.

In this way, patients and families can be empowered to check on the quality of their care, and can identify other courses of medical treatment may be a better fit for them.

Barriers to second opinions and how to overcome them

There are, of course, significant barriers to making high-quality second opinions more easily available to patients. They include:

  • Difficulty accessing patient data and bringing it to another clinician. My own work is often held up by the effort of obtaining records and information from other clinicians. Patients should be able to access and collect their own healthcare data, as this will facilitate care coordination and empower them to participate more in their own healthcare. But until this is widespread, the challenges of health information exchange make it hard to have another clinician weigh in on one’s care.
  • Inadequate clinical documentation. Even when one manages to get information from another clinician, it’s usually quite hard to tell what the clinician was really thinking or planning to do. Before templated electronic health record notes, the problem was that notes were very short and uninformative. Now that EHRs provide templates, I receive notes with lots of text and still have no idea what is going on. Plus some of the information is quite frankly wrong, presumably because the clinician has checked too many boxes in a hurry.
  • Difficulty accessing and identifying a suitable expert. Even when patients have gathered the right medical information, they may often find it difficult to access someone for a second opinion. Academic clinics often have long waits for an appointment. Clinicians who are not subsidized by a larger institution may not offer appointments that are long enough to allow for review of a complicated medical situation.
  • Cost. If the patient’s insurance does not cover the cost of a second opinion, many who would like to go that route cannot afford it.

Second opinions can help patients and families check on the quality of their care, in real-time. This can reduce a family’s anxiety about ongoing medical care, and can help patients better understand the care they’ve been receiving.

Although occasionally real gaps in care are uncovered, in my own experience I’ve found that second opinions mainly help patients and families identify other management approaches which their previous clinician may not have discussed with them. For older patients in particular, care should be individualized and tailored to the patient’s – and caregivers’ — needs and preferences. Historically physicians have tended to dictate care according to their own habits and preferences, in part because shared decision-making takes more time. Second opinions can help educate patients, and empower them to better individualize their care.

Barriers to facilitating second opinions include difficulty accessing clinical information in the possession of other providers, as well as inadequate information within the progress notes. Last but not least, patients may currently find it difficult to find a provider willing and qualified to provide a second opinion.

 Leslie Kernisan, M.D. M.P.H., 36, is a practicing outpatient geriatrician in San Francisco. She blogs about geriatrics and technology at GeriTech. This post was initially published on The Health Care Blog.

One Response to “How Patients Can Assess the Quality of Their Outpatient Care”

  1. Carol Eblen

    I have read this article twice now and I think Dr. Kernisan has identified fairly and truthfully the problems that lead to “over treatment” of the elderly/disabled on Medicare that start in the outpatient setting of specialists’ incorporated offices and clinics where they can legally “self-refer” patients within their own clinics and practices — which are “for profit” organizations. .

    So often in outpatient care wherein the patient is getting outpatient radiation and chemo therapy treatments as recommended from the specialist, there is no thought by the patient to reject the recommendation of the specialist and to get a “second opinion” about the treatment from a geriatric specialist like the author of this article, Leslie Kernisan. This is unfortunate, indeed!

    It is not so much that the second opinion won’t be paid for, it is that the elderly patients have no idea that they might need a second opinion in which they might discover other options, such as the option of doing “nothing” at all and then accepting palliative care and transition to Hospice in the last six months of life –which is legal under the provisions of the 1991 Patient Self Determination Act and which may contribute to an easier and less painful and stressful death for elderly patients.

    I see that the author defends the clinicians who don’t have the time (or the inclination) to talk about the other legal option, palliative care/hospice with their elderly Medicare patients,

    I, of course, can’t defend them and don’t understand how oncologists have been getting truly informed consent for the treatment of their elderly patients with chemo and radiation in the outpatient setting UNLESS they inform their patients in keeping with their “educated” prognosis that there is another legal standard of care created and paid for by Medicare, i.e. palliative care/transition to Hospice.

    Of course, two thirds of patients in the outpatient setting believe that the treatments are curative and have NO IDEA that they are getting merely palliative care and NOT Curative Care and that the cancer/disease is going to kill them sooner or later.

    Why should these experts think that they should be paid for end-of-life conversations with elderly Medicare patients with life-threatening diseases if and when the “educated” prognosis indicates that it is highly unlikely that the patient is going to be cured.

    The Science of Prognostics has advanced in the past twenty years, especially in cancer, and is it really true that the oncologists don’t know?

    The original vision of “self determination” in the 1991 PSDA was that the states would implement laws to support the vision of the 1991 PSDA whose goals were to prevent cruel and grievous over treatment of the elderly on Medicare —–and thus save money on end-of-life costs for the elderly for Medicare and its private partners, Big Insurance, when these elderly “educated” patients would CHOOSE/ELECT to refuse life-extending/life-saving treatments to shorten their suffering into certain death.

    Elderly patients with late-stage cancers would no longer die “futilely” in expensive ICU and CCU in Acute Care hospitals and instead would die less expensively in their own homes or nursing home residences on palliative care/Hospice.

    The problem is that the experts in the outpatient setting think they have no legal duty to SEEK informed consent for palliative care/Hospice as opposed to Curative Care, both of which are reimbursed out of the people’s Medicare purse.

    This, of course, is changing as more States, like New York, California, and others pass new laws that do somewhat compel physicians to SEEK informed consent for one or the other of the two legal standards of care reimbursed by Medicare, or face fines and private law suits for over treatment and lack of informed consent, etc…for the treatment given the patient>

    The excellent Medical Futility Blog of Thaddeus M. Pope points out that the CALIFORNIA CASE HARGETT v VITAS may result in an “expanded duty” if Hargett wins his case.