Pick Your Doctor Very Carefully, Says Lawrence Horowitz, M.D.—it's a Matter of Life and Death
A graduate of Yale Medical School, Horowitz served from 1977 to 1981 as staff director of the U.S. Senate Subcommittee on Health, which was chaired by Sen. Edward Kennedy, and as Kennedy's chief of staff from 1981 to 1986. "When I worked for Senator Kennedy, I traveled to Indian reservations, migrant labor camps, inner cities and prosperous suburbs, comparing American medical care at its best with the average," says Horowitz. "There was an astonishing variation. I wanted to write a book that would help people navigate through the medical system." With senior writer Kristin McMurran, Horowitz, 43, dispensed some advice.
Why is it so important to take charge of your treatment?
You can't get the best in American medicine by chance. There is too great a difference in the quality of doctors' diagnostic and surgical skills, medical treatment, laboratory tests and hospital care. Fortunately, many ailments cure themselves, but when you are seriously ill, the difference between going to the right doctor and going to just any doctor can cost you your life.
What's wrong with the way American medicine is practiced?
For one thing, there are no performance standards. Doctors don't have their competence reexamined regularly in any meaningful way. You wouldn't get into an airplane if the pilot had been licensed in 1960 and hadn't been reevaluated since then. The quality of hospital care, surgical and nursing teams and the equipment used varies so much that your chances of dying during surgery can be five times greater in one hospital than another. Yet most people go wherever their doctor sends them. Lab tests are so uneven that you can take one blood sample, divide it into three parts, send it to three labs and get back three completely different results.
Are lab tests always necessary?
Our system encourages too many tests, and the results contain too many errors, which can lead to inappropriate treatment. Tests should not be done to give you reassurance but to give your physician scientific information. Ask your doctor whether a test is necessary and what he will do with the information. If that question can't be answered, the test shouldn't be done.
Are some doctors too quick to recommend certain surgical procedures?
Absolutely. When a procedure is new, it is widely embraced before its implications are understood. When coronary bypass surgery came on the scene, its use increased 400 percent within a decade. It was done to prolong life and eliminate pain. Today we know it's a terrific procedure for eliminating pain, but a number of studies have questioned whether it prolongs life. There has also been an enormous increase in cesarean sections in the past 20 years because of advances in medical technology. However, many experts now feel that too many ejections are being done in cases where there is no offsetting gain.
Are some procedures underutilized?
Yes. Mammography is one. It is the best way to detect breast cancer early, but many insurers won't pay for it as a screening test and doctors won't push you to be screened, so you must push them. The risk from radiation is negligible. If your doctor disagrees about the need for mammography, find out what he or she knows that the leading experts—who are unanimous in their support of mammography—don't know. If you can't get a convincing answer, get a new doctor.
Are regular checkups a waste of time?
No. It is far better to detect cancer or rising blood pressure or diabetes during a regular checkup, before they cause symptoms. Serious illnesses can be silent for a long time, gathering strength. Often whether you get better depends on whether you start treatment early enough.
What should you question about specific treatments?
Never swallow a pill, perform an exercise, adhere to a strict diet or take an injection without knowing why the doctor has suggested it and how it will help you. Ask your doctor to compare the risks of any given treatment to the benefits, and make sure you know how to recognize an adverse reaction.
What should you do if you are diagnosed with a life-threatening disease?
Ask your primary-care physician who the experts are in the field. Insist that he or she consult with a university specialist. If your doctor doesn't know one, call the nearest university medical center and ask for the department chairman in the specialty you need. You will almost always be better off in a university medical center where there are a lot of consultants trained to treat complicated problems.
How do you find the right treatment center?
Ask your doctor where he would go if he had your illness. You can also call the National Institutes of Health in Bethesda, Md., and ask where research is being done and where the most difficult cases are treated. Most important, just because you live in, say, Cleveland doesn't mean you have to be treated in Cleveland, because if you pick the wrong doctor in the wrong institution you may die in Cleveland.
If you have cancer, what should you know about getting the best care?
The National Cancer Institute has developed a nationwide, computer-based information system called Physician Data Query [PDQ]. With any IBM-compatible computer, your doctor can get the latest information on every form of cancer: all the treatment options, the closest specialists and every ongoing experimental treatment program for your particular cancer. You should not be treated for cancer without tapping into this system.
How would you advise patients who are afraid to confront their doctors?
While physicians are not trained to treat patients as partners, the best ones don't mind informed discussion with the patient. Simply explain that for your peace of mind you want to know the treatments he is considering and what your options are. If you are not capable of taking charge or can't handle knowing the details of your condition, you need an advocate such as a spouse to speak on your behalf.
What should you keep in mind if you need surgery?
For complicated procedures, for example, open-heart surgery, a hospital needs a high volume of cases to keep the surgical team's skills finely honed. To be blunt, if they do too few, too many of their patients may die. Until recently, hospital mortality rates were confidential. Now consumer groups are winning a long battle for disclosure. Ask your surgeon about his track record, as well as that of the hospital. The government keeps a record of mortality rates for Medicare patients that you can get by calling the Federal Health Care Financing Administration.
To sum up, what would you do to improve medical care in this country?
I would insist that doctors have their competence recertified on a strict and regular basis. Hospitals' records should be made public. I would develop PDQ computerized systems for every serious illness and insist that doctors use them. I would require postmarketing surveillance of prescription drugs. And I would have an education-oriented peer review system.
I believe that at its best the American medical-care system is without equal in the world, but there is a big gap between the system at its best and what is done routinely across this country. The most important thing is to convince the patient that closing that gap depends on his or her own efforts.