How NOT to choose a doctor: Part 2 – Referral patterns and bedside manner

People choose their doctor for a host of reasons, some logical, some not. In this second of a series of blog posts, I’ll review several more points to consider as you make your choice of care provider. Once again, we’ll look at a few ways NOT to choose a doctor.

Don’t take one doctor’s referral to another doctor until you understand how that referral chain works and agree to it. If the doctor you see is still one of the shrinking minority of physicians working independently (that is, not as an employee of a hospital) and needs to refer you to someone else for evaluation, she is still free to send you to the specialist she believes would be best for you to see.

If your doctor is employed by a large group or hospital, however, she or he will most likely send you to someone within the same group or hospital, regardless of whether that’s the best person for you to see.  Doctors (and PAs and NPs) who are employees of a hospital or clinic, especially those who are now part of accountable care organizations, are under pressure to refer to other doctors in the same group in order to keep the patient’s business (and money) rolling in. So even though another doctor in town might be better for you, you aren’t likely to be sent there, especially if “there” is the competition.

The administrators of hospitals — which are buying up small, independent clinics at an alarming rate and creating gargantuan healthcare systems — have their eyes on their own bottom line and make decisions based primarily on business, not necessarily what’s best for the patient. They have been known to reprimand and penalize doctors who refer patients outside the group, and this is true regardless of whether the hospital is non-profit. Too many times, I have heard doctors and nurses employed by such hospitals say that, for the administrators, “It’s all about the money” when it comes to patient care. (Despite the label, non-profit hospitals do in fact make a hefty profit and the mandate for them to reinvest that profit in expanding services means they are quickly becoming monopolies in many parts of the country.)

From the patient’s perspective, this practice of referrals might not be apparent on the surface. For example, if you go to the emergency department at the non-profit hospital in my town, you will be asked if you’ve ever been a patient at that facility before. Although that sounds like an innocuous question, the underlying motivation for it is to keep your business in house. If you’ve been a patient there before, they consider you one of “their” patients and will call in one of their own employed physicians to see you, even though the doctor currently on call — but not one of their employees — is more available. The hospital is trying to ensure that it gets your business as a patient, and you aren’t seen by someone they consider a rival.

The increasing pressure on healthcare facilities from insurance companies and the Affordable Care Act makes this focus on money even greater. Accountable care organizations are given bonuses by the government and insurance companies if they can keep their costs down. The best way for a hospital to accomplish this and still remain profitable is to ensure their income stream by controlling which doctors you are able to see. The well known caveat – “follow the money” – now applies to patient referrals just as it does in other corporate and political networks. This is one of the more disheartening outcomes of the interference in health care by government agencies and powerful insurance companies: more money for the business, less choice for you.

Don’t pick a doctor based solely on bedside manner. Once upon a time in the medical world, we chose our doctors based on their skills and knowledge. Now, too often we choose them according to their bedside manner – the term we use to measure how well we like the doctor.

In his book Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care, Dr. Marty Makary, a surgeon at Johns Hopkins University deeply involved in improving the quality of medical care, describes the misconceptions many of us have about the value of bedside manner. In the first chapter, Makary describes two types of physicians – Dr. Hodad and the Raptor.

“Hodad” stands for “hands of death and destruction,” the phrase used among nurses and other care providers to describe doctors who are dangerous. This is the doctor who has excellent bedside manner but is woefully lacking in judgment and ability.  Makary tells the story of a patient who crowed about how kind his doctor was after surgery when the patient’s hospital stay was prolonged because of a series of complications. What that patient didn’t know was that the complications were the direct result of the physician’s lack of judgment and skill. If the physician had sound judgment and better skill, the complications never would have occurred. No amount of kindness or good bedside manner makes up for such a lack and the damage it causes, and kindness and an agreeable personality do not guarantee expert care.

The Raptor, on the other hand, is the physician who exercises good judgment and employs exceptional skill.  Raptors may not have a good bedside manner, are even blunt or abrupt in communicating, but they have the patient’s best interests (not their own ego) at heart. Raptors do what’s necessary for the patient, regardless of the impression others have of them. These are the physicians you want on your team, even if they’re not the nicest people in the room.

In short, when choosing a physician, skip Dr. Hodad and go for the Raptor.

And if you want more information about what goes on behind the scenes in your average American hospital, pick up a copy of Dr. Makary’s book.


Next time: How NOT to pick a doctor: Part 3 – The office, the accent, and the parking lot


About Julie Yamamoto

Firmly anchored in mid-life, I look back to places I've been, and forward to places -- both interior and exterior -- I've yet to go. With a penchant for crossing cultures -- geographic, demographic, medical, mental and many others -- I seek humor and beauty along the way. I have an M.A. in English, a freelance business in writing and editing, and a talent for teaching. I hope you'll enjoy what you find here.
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4 Responses to How NOT to choose a doctor: Part 2 – Referral patterns and bedside manner

  1. Pingback: How NOT to pick a doctor: Part 3 – The office, the accent, and the parking lot | The Educated Patient

  2. A regular reader of this blog pointed out to me that there are in fact good doctors who also have good bedside manner, as well as poor doctors who have poor manners, and this is entirely true. As with people in any profession, there is a wide range of abilities and behaviors, and to imply there are only two types of doctors is inaccurate. That’s why I suggested not picking a doctor based *solely* on bedside manner. Bedside manner is important, and patients should be able to feel comfortable with their doctors, but bedside manner should not be the only, and certainly not the primary, reason for choosing a particular doctor.


  3. Cathi says:

    How do you recommend inquiring about whether the referring MD is free to refer out of the group?


    • First off, if the type of specialist you might need to be referred to isn’t included in the doctor’s practice group, the doctor should be free to refer you wherever she or he chooses without incurring the wrath of administrators. The trick here, however, is to know the extent of the hospital’s facilities. For example, out here in Seattle, the Providence system has merged with the Swedish system, but each facility retains its original name. So, if, for example, you were to see a doctor at Swedish and that doctor’s group didn’t have the specialist you needed to be referred to, you might very likely be sent over to Providence, which, despite the different name, is part of the same system.

      If you want to inquire about the doctor’s referral patterns, there are a couple of ways to go about it. The first is simply to ask the doctor straight out. There’s no harm or offense in asking, and we hope the doctor would answer honestly and directly. If you feel uncomfortable asking the doctor, you could ask the front office staff when you check in if the doctor is an employee of the hospital or the physician group appended to the hospital. (The physicians group may be listed as a separate entity even though the docs in the group are in fact employees of the hospital.) If the answer is yes, you can assume the doctor is under pressure to refer in house. But, if you have a particular doctor that you’d like to be referred to, by all means let the doctor know. You should then get the referral you want and the doctor shouldn’t be under fire for making the referral. Even in an accountable care organization, which tries hard to keep patients in house, patients do not have to agree to the doctor’s referral and can ask to go elsewhere. But most patients don’t know that.


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