Choosing the "right" treatment setting and “right” provider(s)

As a patient your major choice is between an academic center (i.e. Johns Hopkins) vs a private practice setting (i.e. a solo doctor or group of doctors working at an office).  While there is no “right” answer for you as a patient, each setting has advantages and disadvantages as listed below. I don’t recommend that patients take “Top Hospital” type guides too seriously since the experience at any center is variable- I have had a number of patients be unhappy with “top” medical centers!

Academics

Advantages

  • May be better at treating rare tumors due to higher volume of rare tumors
  • Expertise in certain treatments that you sometimes cannot find in the private practice setting (i.e. surgery for esophageal tumors)
  • May offer more “comprehensive multidisciplinary care” – for example are all your doctors talking to each other? Note that in good private practices doctors should be talking to each other about any major treatment decisions. Also note that “comprehensive multidisciplinary care” is sometimes used as a marketing ploy – make sure it has some substance behind it!
  • May get treatment by nationally or internationally renowned attending physicians

Disadvantages

  • Speed, or lack thereof. Academic institutions tend to move slowly when it comes to making appointments for patients. You may have to wait over a month sometimes for an appointment, which can be nerve racking and sometimes simply not safe from a medical perspective!
  • Distance. When a patient is getting daily or weekly treatment and/or checkups a one hour commute will get old quickly.
  • Treatment by physicians in training and the lack of continuity between physicians in training. On one hand you are contributing to the future of our field by using your case to train physicians in training (who will often be your primary point of contact while the more famous attending physician will take a back seat), on the other hand some patients just aren’t comfortable with this. Are you OK with someone in training operating on you while supervised by an attending physician? Additionally, physicians in training tend to rotate in and out of clinics every few months, which can bring up continuity issues.

Issues to think about with academics

  • Research. This is an essential role for academics and without it our field could not move forward, but research relies on patient participation. However, at some academic institutions your attending physician may not be that interested in your case if you don’t sign up for a research protocol.
  • Subspecialists. In academics it is easier to find subspecialists, i.e. docs who only see breast cancer patients. Your doc will be able to talk about breast cancer till it makes your head spin, but for example if you develop a complication such as myelodysplastic syndrome (a hematologic problem) from your breast cancer treatment you will need to be sent to a hematologist, while in most private practice setting your doc should be comfortable at dealing with both disorders (and a bit of primary care as well, which tends to erode out in the subspecialist setting)

Private Practice

Advantages

  • Consistency of provider. When you’re in a private practice setting, you generally will be seeing the same doctor for all your appointments, unless your physician leaves the practice or is on vacation.
  • Speed. Private practices by their nature are much more able to accommodate patient appointments on a last-minute or urgent basis.
  • Versatility. Many private practitioners in hematology-oncology will do hematology, oncology, and a little bit of primary care.
  • Smaller and more personal.
  • Easier to find within a shorter driving or public transportation distance.

Disadvantages

  • Lack of expertise in rare tumors. Private practitioners will see tumors that are relatively common, and a good private practice doctor will tell a patient when a particular case is “out of their league” and should be referred to an academic subspecialist.
  • Lack of research protocols. Note that some private practices will have research protocols if that is what you are interested in.

An issue to ponder with BOTH private practice and academics:

  • Nurse practioners or physician assistants. The usage of these individuals will vary by practice. Note, that they are also being used in the academic setting. As a patient, you must decide if you are comfortable being treated by someone “who is not a doctor”. A good nurse practitioner or physician assistant can be a fantastic complement to a good physician, but the consistency of that model is quite variable. For example, if you are being seen 80% of the time by a nurse practioner or physician assistant, you may start to ask yourself why the doctor never has time for you.

How do you choose the “right” doctor?
Ultimately this choice boils down to you as a patient feeling comfortable with your doctor. All the awards in the world, publications, and degrees from prestigious schools and training programs may not matter if there is too large of a style and personality difference between a patient and physician.  Also note you can always blend private practice and academic physicians in any combination you desire – for example, if the academic institution you want to go to is just too far away, you can go visit them and use a local doctor as well to implement any treatment protocols they recommend.

 






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