There is no one simple answer on how to pick a good nephrologist (or any physician for that matter). Selecting a physician who meets your needs is a multi-step process, the key being the ability to network. I will try to provide a stepwise method on how to select a physician. All parts of the following algorithm can be tried. Let us start with a "ground zero" assumption that the patient desires a knowledgeable physician but is unfamiliar with how to proceed.
Word of Mouth
Colleagues, acquaintances (close, distant, "second-hand") in your geographic area with a similar problem may be the best place to start. There are several components that must be considered:
- Is the physician knowledgeable about polycystic kidney disease (PKD)? This knowledge must include an understanding of current modalities of care, based on some degree of familiarity with current, proven science and ongoing research.
- Besides having the requisite expert fund of knowledge, one of the most critical issues is the ability of the physician to listen. In order to be an effective physician, he/she must be a good listener. If the physician does not listen, he/she will not learn about the patient and his/her needs. Without this necessary learning from listening, the physician (no matter how scientifically knowledgeable) cannot truly help the patient afflicted with PKD. Therefore, when quizzing a member of the community about a nephrologist, a critical question is the physician’s ability to listen carefully to the patient. President Theodore Roosevelt once stated to a group of physicians, "the patient does not care how much you know until they know how much you care".
- Be wary of the "iPhysician" – one who looks and communicates with the computer screen during an office visit and does not interact with the patient by direct eye contact. Such physicians tend to focus on the technologic aspects of medicine and decrease the direct contact with the patient.
Primary Care Physician (PCP)
Asking your PCP for a referral can in actuality be a "hit or miss" proposition. Physicians are generally limited in the referral network to their colleagues who work in the same hospital(s). They are often unfamiliar with physicians outside their immediate framework of practice. In addition, I have seen physicians refer to individuals with whom they play golf or with whom they enjoy other social relationships. Sometimes these referrals can be good, but often they are not the best resource for the patient.
If there is no physician known to the patient by reputation, then the patient should try calling the closest major academic medical center/university hospital/medical school. Ask for the renal/nephrology division (different terms are used at different institutions). Start with the division chief; either he/she directly or this individual’s assistant may be able to provide the name of the clinician within their department who is interested in PKD. As a general rule of thumb, the more defined the problem (such as PKD), the more the likelihood that the nephrologist has a major academic affiliation. The referral source must make sense from a physical-proximity standpoint. Interaction with a subspecialist on an episodic basis must be reasonably convenient. Many times the subspecialist can work with the local primary care physician (PCP).
Issues of Insurance
In modern-day medicine, insurance is frequently the driving factor which dictates physician referral. If one belongs to a health maintenance organization (HMO), there are generally two arrangements. The HMO/insurer could have a closed panel of physicians. This means that only physicians who are employed full time by the HMO are available to you. Other HMOs have an open physician panel. This means that many physicians have contracts with this particular HMO. If you belong to an HMO, it is best that you check with them first to see their panel of available nephrologists. Insurance may greatly limit your choice, and it is important to know your restrictions up front to avoid frustration. In fact, limitation of choice is becoming ever-more prevalent in deciding which physician a patient can see. Every HMO will readily provide to the member a list of nephrologists in their panel.
Details of Referral
No matter how good the physician, a major stumbling block can be management of the practice. If the physician does not have a user-friendly front office, "getting through the system" can be onerous. There must be reasonable access to the physician and/or his/her representatives (nurse practitioners, physician extenders). If phone calls are not returned, then question seriously whether the frustration of not getting your questions answered is worth the effort.
In order to effectively use our current health care system, one must learn how to be his/her own advocate. Do not be afraid to "push." If you serve as your own vociferous advocate, you are most likely to effectively navigate our healthcare system. Inquire when calling an office if the physician will accept specific questions via email. When using email, limit the questions you need answered. When posing questions via telephone, be respectful of the physician’s time. Therefore, your questions should be written out ahead of time for your telephone interaction. Be specific so as to limit the amount of time both of you spend on the phone. On your own, utilize the Internet. You will be amazed how much information is readily available on the Internet. Many patients told me they have "Googled" me before a referral visit. With background information, you can most effectively utilize your physician. Remember that most physicians are committed to quality of care and want to assist the patient to find the best resource. It will take an effort on your part, but always be your own best advocate.
Theodore Steinman, MD, is Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center in Boston, MA. He is a past member of the PKD Foundation Board of Trustees and former Chairman, Scientific Advisory Committee.