纽约时报载文：寻找好医生

作者，华裔医生 By PAULINE W. CHEN, M.D.

In Search of a Good Doctor

By PAULINE W. CHEN, M.D.
Published: January 8, 2009

In response to my recent column on patients trusting doctors too much, several readers wrote in about the difficulty of finding or sifting through information on doctors and diseases. Many asked for suggestions, so a couple of weeks ago I contacted several nationally respected leaders in family medicine, pediatrics, internal medicine, oncology, surgery and anesthesia and asked them to share their advice on researching doctors and diseases.

Go to Well »Many of the doctors I spoke to or exchanged e-mail with made commonsense suggestions that were not unexpected. They urged patients to find out which doctors their closest friends really like, to ask a prospective doctor questions like how much experience he or she has with a specific condition or operation, and to make sure that as a patient you feel part of a shared decision-making process and comfortable saying how you feel, or that you don’t understand or that you respectfully disagree.

But many of the physicians also shared links to valuable Web sites, several of which I was unfamiliar with. All the sites are free to the public and accessible to anyone with an Internet connection. When I looked at these sites while writing this column, I became really excited as a patient about the amount of information available. For example, one site from the Department of Health and Human Services called Hospital Compare (www.hospitalcompare.hhs.gov) allows you to select three hospitals within a 25-mile radius of your home. It also lets you compare a wide variety of quality indicators, like the percentage of heart failure patients who were given discharge instructions, the percentage of surgery patients given prophylactic antibiotics at the right time, or the percentage of hospitalized patients who felt that doctors or nurses “always” communicated well (the differences among hospitals surprised me).

And according to several of the doctors I spoke with, the amount of information available to patients will only increase in the future.

Throughout our conversations and e-mail exchanges, every one of the doctors stressed the importance of patients doing research and becoming an active part of the medical team. “This is a shared responsibility between the physician and the patient for the patient’s health,” said Dr. Ted Epperly, president of the American Academy of Family Physicians.

Dr. Lisa V. Rubinstein, president of the Society of General Internal Medicine, said that sharing in decision-making “will help raise the quality of care given by any clinician, because it will sharpen the focus on the key decision points and help the clinician put a plan in place that the patient understands and agrees with.”

Here is a summary of these experts’ advice and the Web sites they use themselves and recommend to patients, friends and family.

Choosing a Doctor

All the doctors I contacted stressed the invaluable contribution of a good primary care doctor in helping patients identify specialists or other physicians. “I cannot emphasize enough how important it is for every patient to have a trustworthy primary care physician who can help them navigate our challenging, but potentially excellent, health care system,” said Dr. David T. Tayloe Jr., president of the American Academy of Pediatrics.

Primary care doctors can identify qualified subspecialists through local and national networks or professional organizations. “Even for a patient in a distant city,” Dr. Rubinstein said, “I can usually find a local respected colleague who knows someone in the general area.”

When a primary care doctor does not have a recommendation or when the patient does not have a primary care physician to turn to, Dr. Rubinstein advised identifying high quality medical groups or hospitals that “carefully monitor the quality of the clinicians affiliated with them” and that provide “decision support, continuous quality improvement and continuing education to keep their clinicians functioning well.”

Data on hospital and medical group quality is more readily available to the public than information on individual physicians, and Dr. Rubinstein offered several Web sites (see below) that patients can use.

One way to help assess the quality of individual physicians is to establish that a doctor is board certified, Dr. Epperly said. To become board certified, doctors must complete a full residency at an accredited training program, pass written and, depending on the specialty, oral examinations, and provide proof that she or he has experience with a defined set of clinical problems and technical procedures. However, cautioned Dr. Roger A. Moore, president of the American Society of Anesthesiologists, “board certification is one indication, but it’s certainly no guarantee.”

Another way to get a sense of physician quality is to contact the national professional society for that doctor’s specialty.

“There is lots of good information at professional societies compared to years past,” said Dr. Thomas R. Russell, executive director of the American College of Surgeons. “On our Web site, for example, you can go look at a surgeon’s profile and see what they do.”

A breast cancer patient can, for example, find out if a recommended surgeon has a practice devoted exclusively to breast disease versus a more general practice. Or a patient with a colon mass can choose a surgeon who is not only board certified in colorectal surgery but also has a special interest in laparoscopy, or minimally invasive surgery. Generally, membership in the national professional society of a specialty — often referred to as being a “fellow” in the organization, as in Fellow of the American College of Surgeons, or F.A.C.S. — requires board certification and a certain degree of clinical experience. Many physicians will denote their specific society affiliation after the M.D. in their name; for example, if the doctor is a fellow of the American College of Physicians, the national professional society of doctors specializing in internal medicine, his name might appear as “Joseph Smith, M.D., F.A.C.P.”

Go to Well »The advice of close friends and colleagues can further help to distinguish among doctors. “I suggest that people first identify the hospital where they wish to be admitted,” said Dr. Jeffrey P. Harris, president of the American College of Physicians. “Ask the hospital for a list of board-certified internists with admitting privileges. Then ask trusted friends, neighbors and colleagues whom they see and feel comfortable with.”

The last — and most critical — part of deciding on any physician is the first appointment. Most of the doctors I contacted unequivocally stated that patients should know what to expect and arm themselves with the right questions. And, as Dr. Rubinstein said, bedside manner is only one of many concerns. “While excellent quality health care integrates caring with doing the right thing medically,” she said, “a caring attitude can mask poor quality medicine.”

Dr. Richard R. Schilsky, president of the American Society for Clinical Oncology, recommends that cancer patients meeting an oncologist for the first time ask about board certification in the specialty needed, length of time in practice, experience with the patient’s specific problem, membership in professional organizations and participation in clinical trials.

If the patient is meeting a surgical oncologist for the first time, Dr. Schilsky recommends also asking the surgeon about the number of times annually she or he performs the specific operation needed, as well as the hospitals in which those operations are performed. While it is difficult to specify a standard number patients can keep in mind, research has shown that hospital mortality rates are lower when those operations are performed frequently.

Some individuals may feel uncomfortable questioning their prospective doctors, but becoming more active and knowledgeable can only improve your care. There is even a nonprofit group, the Foundation for Informed Medical Decision Making, devoted to educating patients to become more involved in their health care decisions (see below).

Researching Your Condition

All the doctors I spoke with urged patients to exercise caution when going through information from commercial or industry Web sites.

“The Web can be a good place but also a dangerous place,” Dr. Epperly said. “It’s important to find sites that aren’t biased and that provide evidence-based information.”

Many of the doctors suggested going to sites supported by patient advocacy groups or nonprofit groups that are focused on certain diseases. Such sites often offer not only information but also active online communities.

Almost all of the national professional societies now have part of their official Web sites devoted to patients. These sites and links are excellent sources of information on the illnesses treated by that specialty and, in the case of surgical or anesthesia professional organizations, the procedures performed.

“Our specialty site, familydoctor.org,” Dr. Epperly said, “aims to help meet patient needs on common afflictions in this country. The content is written by experts and presented in a way that people without medical training can understand.”

Finally, several of the physicians also recommended several federally sponsored Web sites as excellent resources.

In Search of a Good Doctor
寻找好医生
By PAULINE W. CHEN, M.D.
Published: January 8, 2009
2009年1月8日

In response to my recent column on patients trusting doctors too much, several readers wrote in about the difficulty of finding or sifting through information on doctors and diseases. Many asked for suggestions, so a couple of weeks ago I contacted several nationally respected leaders in family medicine, pediatrics, internal medicine, oncology, surgery and anesthesia and asked them to share their advice on researching doctors and diseases.
在最近的专栏文章中我曾写到，患者过于信任医生，对此几位读者来 信讲述了寻找好医生以及了解疾病信息过程中存在的困难。很多人寻求这方面的建议，因此两周前我联系了国内数位家庭医学、儿科、内科、肿瘤学、外科和麻醉方 面的专家，并就如何获取医生和疾病信息请他们提供一些建议。

Go to Well »Many of the doctors I spoke to or exchanged e-mail with made commonsense suggestions that were not unexpected. They urged patients to find out which doctors their closest friends really like, to ask a prospective doctor questions like how much experience he or she has with a specific condition or operation, and to make sure that as a patient you feel part of a shared decision-making process and comfortable saying how you feel, or that you don’t understand or that you respectfully disagree.

我 采访或通过电子邮件交流的很多医生都给予了一些常规建议。他们建议患者找那些好朋友喜欢就诊的医生，对于准备就诊的医生，询问一些比如处理过多少特殊情况 或手术等问题，而且做为患者，要保证你能参与治疗方案决策过程，以及自然的表达你的想法或你不明白的地方以及不赞同的地方。

But many of the physicians also shared links to valuable Web sites, several of which I was unfamiliar with. All the sites are free to the public and accessible to anyone with an Internet connection. When I looked at these sites while writing this column, I became really excited as a patient about the amount of information available. For example, one site from the Department of Health and Human Services called Hospital Compare (www.hospitalcompare.hhs.gov) allows you to select three hospitals within a 25-mile radius of your home. It also lets you compare a wide variety of quality indicators, like the percentage of heart failure patients who were given discharge instructions, the percentage of surgery patients given prophylactic antibiotics at the right time, or the percentage of hospitalized patients who felt that doctors or nurses “always” communicated well (the differences among hospitals surprised me).
不过很多医生也提供了一些有用的网站链接，其中几位与我并不很熟识。所有这些网站都是免费 向公众开放的，通过互联网，任何人都可登陆。当我为了写该专栏而浏览这些网站的时候，看到了大量可用信息，以患者的立场我感到特别激动。比如说，美国健康 服务部的一个名叫医院比较的网站（www.hospitalcompare.hhs.gov）会提供你居住地附近25公里范围内的三家医院供你选择。也会 帮你比较不同水平的数家医院，比如，心脏衰竭患者出院比率、给手术患者恰当应用预防性抗生素的比率、以及住院病人对医生、护士服务的满意度（各个医院间的 差别让我震惊）。

And according to several of the doctors I spoke with, the amount of information available to patients will only increase in the future.
而且从接受采访的数位医生获悉，将来向患者提供的这类信息只会越来越多。

Throughout our conversations and e-mail exchanges, every one of the doctors stressed the importance of patients doing research and becoming an active part of the medical team. “This is a shared responsibility between the physician and the patient for the patient’s health,” said Dr. Ted Epperly, president of the American Academy of Family Physicians.
在我们的整个采访及电子邮件交流中，每位医生都强调了患者参与临床试验并与医疗小组积极沟通的重要性。美国家庭医生学会主席泰德.艾伯利（Ted Epperly）博士称，“对于患者的健康，医生和患者两者都负有责任”。

Dr. Lisa V. Rubinstein, president of the Society of General Internal Medicine, said that sharing in decision-making “will help raise the quality of care given by any clinician, because it will sharpen the focus on the key decision points and help the clinician put a plan in place that the patient understands and agrees with.”
美国内科学会主席丽莎V.鲁宾斯坦（ Lisa V. Rubinstein）博士称，加强治疗决策沟通“将有助于提高临床医生的护理质量，因为这样会集中在关键的决策点，并有助于临床医生实施获得患者理解及同意的治疗计划。”

Here is a summary of these experts’ advice and the Web sites they use themselves and recommend to patients, friends and family.
以下是一个摘要，包括这些专家的建议以及他们经常访问并向患者、朋友、家人推荐的网站地址。

Choosing a Doctor
选择医生

All the doctors I contacted stressed the invaluable contribution of a good primary care doctor in helping patients identify specialists or other physicians. “I cannot emphasize enough how important it is for every patient to have a trustworthy primary care physician who can help them navigate our challenging, but potentially excellent, health care system,” said Dr. David T. Tayloe Jr., president of the American Academy of Pediatrics.
我联系的所有医生都强调，在帮助患者寻找专家医生或其他医生方面，一位好主治医师所起的作用无法估 量。美国儿科学会主席大卫.泰勒（David T. Tayloe Jr.）博士说，“主治医师可以帮助患者在复杂、但先进的医疗体系中寻找合适的医生，因此对于患者而言，拥有一位值得信赖的主治医师将十分重要”。

Primary care doctors can identify qualified subspecialists through local and national networks or professional organizations. “Even for a patient in a distant city,” Dr. Rubinstein said, “I can usually find a local respected colleague who knows someone in the general area.”
主治医师可以通过地方和国家网络系统或专业组织来判断一位专科医生是否合适。鲁宾斯坦博士说，“即使是偏远城市的一位患者，我通常也可以为他找到一位备受尊敬的当地同行，而这位同行一般会清楚当地整个地区的医生。”

When a primary care doctor does not have a recommendation or when the patient does not have a primary care physician to turn to, Dr. Rubinstein advised identifying high quality medical groups or hospitals that “carefully monitor the quality of the clinicians affiliated with them” and that provide “decision support, continuous quality improvement and continuing education to keep their clinicians functioning well.”
当一位主治医师无法给出参考意见或者当患者并没有一位主治医师进行咨询的时候，鲁宾斯坦博士建议要选择那些“严格监测内部临床医生医疗服务质量”并提供“决策支持，不断的改进医疗服务质量及继续教育来保证临床医生医疗水平”的高水平医疗机构或医院。

Data on hospital and medical group quality is more readily available to the public than information on individual physicians, and Dr. Rubinstein offered several Web sites (see below) that patients can use.
相对于医生的个人资料，公众更容易获得关于医院和医疗机构医疗水平的资料，而且鲁宾斯坦博士提供了以下几个网站可供患者使用。

One way to help assess the quality of individual physicians is to establish that a doctor is board certified, Dr. Epperly said. To become board certified, doctors must complete a full residency at an accredited training program, pass written and, depending on the specialty, oral examinations, and provide proof that she or he has experience with a defined set of clinical problems and technical procedures. However, cautioned Dr. Roger A. Moore, president of the American Society of Anesthesiologists, “board certification is one indication, but it’s certainly no guarantee.”
艾伯利博士说，对医生的业务水平进行评价，其中一个方法就是证实该医生是否获得美国专业委员会 认证。要获得专业委员会的认证，住院医师必须在整个实习期接受公认的培训课程，通过笔试，并根据专业情况，进行口试，并提供证据证明她或他经历了指定的一 系列临床问题和专业操作。不过美国麻醉医师学会主席罗杰A.穆尔（Roger A. Moore）博士警告说，“专业委员会认证只是一个证明，但不是保证书。”

Another way to get a sense of physician quality is to contact the national professional society for that doctor’s specialty.
了解医生业务水平的另一条途径就是联系该医生所属的国家专业医师学会。

“There is lots of good information at professional societies compared to years past,” said Dr. Thomas R. Russell, executive director of the American College of Surgeons. “On our Web site, for example, you can go look at a surgeon’s profile and see what they do.”
美国外科医师学会执行董事托马斯R.罗素（Thomas R. Russell）博士说，“跟过去几年相比，已经有大量关于专业医师学会的信息”。“比如在我们的网站上，你可以搜索到一位外科医师的资料，并了解他们做了什么。”

A breast cancer patient can, for example, find out if a recommended surgeon has a practice devoted exclusively to breast disease versus a more general practice. Or a patient with a colon mass can choose a surgeon who is not only board certified in colorectal surgery but also has a special interest in laparoscopy, or minimally invasive surgery. Generally, membership in the national professional society of a specialty — often referred to as being a “fellow” in the organization, as in Fellow of the American College of Surgeons, or F.A.C.S. — requires board certification and a certain degree of clinical experience. Many physicians will denote their specific society affiliation after the M.D. in their name; for example, if the doctor is a fellow of the American College of Physicians, the national professional society of doctors specializing in internal medicine, his name might appear as “Joseph Smith, M.D., F.A.C.P.”
比如说，一位乳腺癌患者就可以 （通过该网站）查明别人推荐的那位外科医师是否主要研究乳腺疾病，还是也研究其他方面。或者一位结肠癌患者可能选择一位不仅在结肠直肠手术方面获得专业委 员会认证，而且在腹腔镜检查或微创手术方面也有研究的医生。一般来讲，某个专业医师学会成员（通常被称为某个组织的会员，如美国外科医师学会会员 （F.A.C.S.））需要获得专业委员会的认证，并且要具有一定的临床实践经验。很多医生都会在名字及医学博士头衔后，再标明属于某个学会会员；例如， 如果一位医师是美国内科学会会员（美国内科医生组成的一个专业医师学会），他的名字会表示成“约瑟夫.史密斯（Joseph Smith）博士，美国内科学会会员（F.A.C.P.）”。

Go to Well »The advice of close friends and colleagues can further help to distinguish among doctors. “I suggest that people first identify the hospital where they wish to be admitted,” said Dr. Jeffrey P. Harris, president of the American College of Physicians. “Ask the hospital for a list of board-certified internists with admitting privileges. Then ask trusted friends, neighbors and colleagues whom they see and feel comfortable with.”
朋友 和同事的意见可以进一步帮助你选择医生。美国医师协会主席杰弗里P.哈里斯（Jeffrey P. Harris）博士说，“我建议，人们首先要选定乐意入住的医院”。“做为入院条件，向医院索要一份经专业委员会认证的内科医师名单。然后咨询值得信赖的 朋友、邻居及同事，询问他们都找谁治疗，觉得哪个医生好。”

The last — and most critical — part of deciding on any physician is the first appointment. Most of the doctors I contacted unequivocally stated that patients should know what to expect and arm themselves with the right questions. And, as Dr. Rubinstein said, bedside manner is only one of many concerns. “While excellent quality health care integrates caring with doing the right thing medically,” she said, “a caring attitude can mask poor quality medicine.”
选择一位医生的最后一步，也是最关键的一步就是首次会面。我联系的大部分医生都明确地表示，患者应该知道作何预期并准备好恰 当的问题。而且，如鲁宾斯坦博士所说，医生对病人的举止态度仅仅是很多需要考虑的因素之一。她说，“虽然对于高水准的医疗护理，正确的医疗方案和护理应是 一体的，但护理态度可能会掩盖低劣的治疗水平。”

Dr. Richard R. Schilsky, president of the American Society for Clinical Oncology, recommends that cancer patients meeting an oncologist for the first time ask about board certification in the specialty needed, length of time in practice, experience with the patient’s specific problem, membership in professional organizations and participation in clinical trials.
美国临床肿瘤学会主席理查德R.斯勒斯基（Richard R. Schilsky）博士建议，癌症患者首次约见一位肿瘤医师时，要询问其该专业委员会的认证情况，医生的临床实践时间，处理特殊病例的经验，是否是专业医师组织成员及是否参加临床试验等。

If the patient is meeting a surgical oncologist for the first time, Dr. Schilsky recommends also asking the surgeon about the number of times annually she or he performs the specific operation needed, as well as the hospitals in which those operations are performed. While it is difficult to specify a standard number patients can keep in mind, research has shown that hospital mortality rates are lower when those operations are performed frequently.
如果患者首次约见一位外科肿瘤医师，斯勒斯基博士建议同样也要询问她或他每年实施特殊手术的例数，以及该医院实施该类手术的例数。虽然很难为患者明确指定一个标准数字，但研究显示实施手术频率越高的医院，死亡率也越低。

Some individuals may feel uncomfortable questioning their prospective doctors, but becoming more active and knowledgeable can only improve your care. There is even a nonprofit group, the Foundation for Informed Medical Decision Making, devoted to educating patients to become more involved in their health care decisions (see below).
有些人可能不好意思向医生询问这些问题，但是了解的越多、主动性越强只会改善你的护理情况，不会有坏处。甚至存在一个非盈利组织（医疗选择咨询基金会）专门教患者要了解自身的医疗选择。

Researching Your Condition
研究您的健康状况

All the doctors I spoke with urged patients to exercise caution when going through information from commercial or industry Web sites.
我与之交谈的所有医生都建议患者在浏览商业或企业网站信息时要保持谨慎。

“The Web can be a good place but also a dangerous place,” Dr. Epperly said. “It’s important to find sites that aren’t biased and that provide evidence-based information.”
艾伯利博士说，“这类网站可能为你提供帮助，但同样也会带来一些误导”。“找那些不存在偏见、提供循证医学信息的网站很重要。”

Many of the doctors suggested going to sites supported by patient advocacy groups or nonprofit groups that are focused on certain diseases. Such sites often offer not only information but also active online communities.
很多医生建议去那些集中讨论某种特定疾病，由患者建立或由非盈利组织支持的网站。这类网站通常不仅提供信息，而且也会有积极的在线交流。

Almost all of the national professional societies now have part of their official Web sites devoted to patients. These sites and links are excellent sources of information on the illnesses treated by that specialty and, in the case of surgical or anesthesia professional organizations, the procedures performed.
几乎所有的专业医师协会目前都将其官方网站向患者部分开放。这些网站及链接是提供该专业疾病信息的最佳来源，而且以外科或麻醉学会为例，还会提供具体的实施步骤。

“Our specialty site, familydoctor.org,” Dr. Epperly said, “aims to help meet patient needs on common afflictions in this country. The content is written by experts and presented in a way that people without medical training can understand.”
艾伯利博士说，“我们的专业网站---familydoctor.org 目的就是解决患者的一般问题。这些内容由专家撰写，然后以让没有医学基础的人可以明白的形式表述出来。”

Finally, several of the physicians also recommended several federally sponsored Web sites as excellent resources.
最后，几位医生也推荐了几个联邦政府网站。