How do you choose the specialist you’ll see?

When we asked this question, most people respond that they go where their family doctor or nurse practitioner sent them. There is an intrinsic trust that the referring physician knows the community and will make a referral that is a good fit. What determines a ‘good fit’? The referring doctor uses their knowledge of you, as their patient, and many other criteria such as what services are available locally, the wait-time, perhaps professional relationships, the quality of reporting, diagnosis and patient follow-up, and of course considers feedback from patients who already went there. While all of these factors are important, few are objective measures. Granted, medicine is as much an art as a science and people can experience the same event in vastly different ways. Objective measures are hard to get. Nevertheless, Cancer Care Ontario, an agency of the Ontario government, has done its best to try.

Colonoscopy is a significantly standardized and repetitive procedure. One colonoscopy is much like any other. This means that standardized quality measures can be applied to the doctors who do colonoscopy.

For interest, here are the Cancer Care Ontario quality reports for Dr. Mark Reimer:

As you can see, Dr. Reimer achieved “Top Tier” status in every category measured. That’s the green thumb’s up icon. He achieved “Top Tier” status not only in the most recent year, but also in every year and in every category since these reports were first issued.

These quality measurements were chosen by Cancer Care Ontario to be in their opinion the best available metrics to give an objective view of the quality of the general surgeon or the gastroenterologist who does the colonoscopy. Each doctor has their own report. Doctors can access their personal report through a secure web portal that uses several layers of security so that their quality reports remain confidential. Nevertheless, Dr. Reimer’s reports have been good and he’s chosen to share them publicly.

The measurement criteria are not infallible nor are they immune to being gamed. Some categories such as “inadequate bowel preparation” may be hard for doctors to control. Many work at hospitals or clinics where there is one set of instructions for everyone. The “cecal intubation” rates could be improved by perhaps taking more risk of raising the “outpatient perforation” metric. Doctors whose "total colonoscopy volume" is low could put greater emphasis on speed to get more procedures done in their limited time allocation in the endoscopy suite. (As an aside, for doctors who work in fee-for-service medicine and who pay their own expenses, their staff expenses are calculated by the minute and their revenue is calculated by the procedure or by the number of patients seen. The difference determines the physicians' pay. Our present system is set up to encourage great speed by using one of the most effective motivating forces known: money.) The rate of “post-polypectomy bleeding” could be reduced by selecting healthier patients or by sending patients with larger polyps to sub-specialist physicians called interventional endoscopists. These usually work in complex hospital environments and I would expect them to have higher perforation and post-polypectomy bleeding rates than average, more than likely because they self-select the more difficult cases, rather than that their skills are at issue.

Hence, the measurements are not perfect, but they’re what our government agency has chosen to use both as a way to determine quality and as a way to prioritize certain practices as being praiseworthy. Readers are free to draw their own conclusions.

Author: Mark Reimer, MD MBA BSc FRCSC
Medical Director of The Reimer Clinic and director in Freiheit Care Inc., premium home care services.