Section 1. Patient Choice

The concept of patient choice includes every aspect of an individual’s health from the decision of when to go to a physician, to what procedure to undergo. This chapter explores one aspect of patient choice; how individuals choose their physician.

a. Ability to Choose

Access to health care is an enormous problem in the United States that some estimates predict prevents upwards of 41 million Americans from receiving regular health care benefits (IOM 2003). This cohort of individuals is completely ignored in most analyses of health care choice and the literature that focuses on how patients choose their physician. Uninsured or inadequately insured individuals do not have adequate access to basic health care provisions and in turn do not have much (if any) choice of who provides them care. In a competitive market, such as the one that exists for health care in the United States, without choice between providers, it is easy to see how one could be forced into receiving poorer care by having access only to those physicians who were not chosen by others. It is possible that, due to open-door policies for physician practices, the high standards upheld by all physicians, and the choice of some high quality physicians to make special efforts to care for those who otherwise would be left without care that decreased access does not lead to impaired quality of care. However, one of the most complete reference books on this topic, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care” by the Institute of Medicine, suggests that patients without adequate access to health care are left without the ability to choose higher quality providers, and they in turn receive lower quality care defined by increased morbidity and mortality. This finding highlights the importance of expanding the investigation of the physician choice process to include populations not included in the summary presented in this chapter, and it provides incentive for future research to focus on how competing on quality may result in certain populations receiving lower quality care.

Throughout this chapter, the choice process referred to is primarily upheld by those in employer-based health insurance plans or Medicare. This focus leaves out other individuals in addition to those individuals without access to health insurance. There are several circumstances, for example, in which the process of choosing a physician occurs in conjunction with an individual’s choice of a hospital, health plan or a clinic. Many of these individuals are not directly choosing a physician, and individual physician information may not factor into their decision process. This phenomenon may be becoming increasingly true as the health care system moves towards a team-based care environment. Other circumstances, such as emergency care or health plans that force individuals into choosing in-network physicians, may also put limits on the weight individuals place on physician-level information. Lastly, certain acute care episodes do not allow the individual the luxury of choosing their physician, and therefore these individuals fall outside of the realm of this chapter.

b. Time and Effort

For individuals who do undergo the process of choosing a physician, the amount of time and effort they spend searching is a critical in the evaluation of how patients choose a physician. Some researchers have investigated consumer activism, and they have consistently found that the level of activism is correlated to health status and socioeconomic status (Harris KM 2003; Wolinsky 1982; Kasteler et al. 1976). Individuals with greater severity of disease and individuals with lower socioeconomic status use fewer formal sources that would provide the patient with information about the cost and quality of their decision to choose a particular physician. Harris hypothesizes that individuals who spend more time with their physician may derive less value from external quality data, because they are more comfortable with their choice of physician. The alternative is that physician-level quality data is more valuable to these patients, because the quality of care with regard to more severe treatments may be more important to outcomes (Harris KM 2003).

Additionally, studies that have investigated the number of different sources used when choosing a physician have found that only a minimal amount of the available resources are utilized by most patients (Harris KM, 2003; King & Haefner 1988). In King and Haefner’s survey, they found that 62.6% of their population used only one source of information to choose their current physician and only 5% of their population used more than four sources of information.

c. Information Used

Several studies have investigated the patient choice process with the intent of trying to identify the most commonly used types of data. Crane and Lynch found that personal referral, followed by a physician’s demeanor and aspects of the physical facility were most important to patients when choosing a physician (Crane FG & Lynch JE 1988). Several other studies have also found that word-of-mouth is the most commonly utilized information source of patients choosing a new provider (Hanna N et al. 1994; McGlone TA et al. 2002; Trandel-Korenchuk DM 1998). The most common sources of information used by King and Haefner’s survey participants were referrals from a physician, followed by advice from a friend, advice from a relative, advice from a nurse and then advice from another health care professional (King & Haefner 1988).

There are many reasons to hypothesize that the physician search process is different from what was observed in previous studies. For example, the changing health care landscape in the United States has seen increasing attention on quality of care (IOM 2001), a shift from a paternalistic to a patient-centered model of care (van Amerongen D 2002) and increased access to information on health plans, hospitals and physicians (Kowalczyk L 2004) all which could change the physician search process. More recently, studies have shown an increasing reliance on the Internet for health care information, but to date, no studies have tried to draw a connection to the actual choice processes used when finding a physician (Calabretta N 2002). Therefore, although there may be reason to believe that the actual search process undertaken by patients is changing, there is no current evidence to support this hypothesis.

d. Ideal vs. Reality

It is important to investigate not only what information patients use to choose their physician, but also what information they would like to use in choosing their physician. If patients hypothetically were to have access to any information about all physicians, what information would be most important to them?

Several studies have addressed the topic of patient choice from this angle, and the majority of them have concluded that physician-level quality information is at the top of consumers’ lists (Isaacs SL 1996, Harris KM 2003). In a 1995 survey that asked individuals about the types of information they would like to know when choosing a health plan, the most important consideration noted was the quality of physicians. Quality of the physician was followed by courtesy and manner of the physician and staff and the ability to choose one’s own doctor (Isaacs SL 1996). Additionally, an article by Cheng and Song found that 73% of individuals surveyed said that they would consult a physician-level performance report if such a report was available, and 77% of those individuals said that they were prepared to switch providers if their doctor preformed poorly on the report (Cheng SH and Song HY 2004).

Articles probing consumers on the types of quality information they would like to see have consistently found that consumers perceive board certification, patient satisfaction survey results and the doctor’s reputation among other physicians to be the most important types of quality information (King KW and Haefner JE 1988, Bornstein BH et al. 2000, Engstrom S and Madlon-Kay DJ 1998). These findings highlight consumers’ interest in a physician’s professional skills over aspects such as personal characteristics (physician’s race, gender, etc.) or office management criteria such as proximity to the office or the size of the practice.

Section 2. “Good” Doctors

a. Defining Quality

Several organizations are dedicated completely to defining and measuring quality in health care. Organizations such as the Agency for Healthcare Research and Quality (AHRQ) (http://www.ahrq.gov), the Institute for Healthcare Improvement (IHI) (http://www.ihi.org/ and http://www.qualityhealthcare.org), the National Quality Forum (NQF) (http://www.qualityforum.org) and the Institute of Medicine (http://www.iom.edu) can provide additional information on this topic above what is presented here. A widely accepted definition of quality is presented by the Institute of Medicine in their Health Care Quality Initiative:

Quality is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

While this definition is widely used by academic institutions throughout the U.S., it is not necessarily the definition promoted through the quality reports that appear on websites. Many quality reports reviewed use proxies for quality such as the physician’s educational background, professional activities such as publications and academic appointments, scores on patient satisfaction surveys or simply the praise of their peers. While many of these measures may be loosely correlated with health services that increase the likelihood of the desired health outcome, the strength of their association is not definitively known.

b. Patients’ Perception of Quality

It is important to consider the patient’s perception of quality, because it may be different from the definition of quality used by healthcare agencies or even by physicians (Fitzsimmons D 1999, Dinkevich EI 1998). Most of the current literature measures patients’ perception of quality by way of patient satisfaction surveys which tend to measure only the qualitative aspects of care. In addition to patient satisfaction surveys, however, some researchers have surveyed patients on their perceived value of different quantitative quality measures. Although findings confirmed that interpersonal aspects of care are central to a patients’ perception of quality, quantitative aspects of their care were also found to be important to patients (Merkouris A et al. 2004). Specifically, one study identified three main areas to help describe most patients’ definition of quality; professional skill, office management and personal characteristics. This study found that professional skill was rated highest by patients surveyed, followed by office management characteristics and then personal characteristics (Bornstein BH et al. 2000). These studies highlight that in considering the patients’ perspective of quality it is important to concentrate on the interpersonal aspects of care, but one cannot ignore the office management characteristics and outcome measures that can also significantly influence the patients’ experience.

c. Physician’s Perception of Quality

The American Medical Association and many state licensing boards quote the IOM definition of quality on their website suggesting that physicians’ perception of quality is in line with the IOM’s definition of quality and is therefore based heavily on outcome performance measures. In addition, the American Medical Association convened expert panels to develop physician performance reports. These reports were developed by physicians for physicians, and they are meant to be used within clinical practice to enable a physician to constantly measure and improve their own quality of care. These performance measure reports boast evidence-based clinical performance measures which include data collection flowsheets (http://www.ama-assn.org/ama/pub/category/4837.html). The performance improvement suggestions in these reports make no mention of the interpersonal aspects of care and in stead focus on quality improvement from the perspective of evidence-based clinical guidelines.

There is evidence, however, to suggest that the physicians’ heavy focus on outcome measures to define quality is perhaps starting to grow to include a greater focus on professionalism and communication. This shift is evident in the efforts of the American Association of Medical Colleges (AAMC) and the American Medical Student Association (AMSA) which are focusing on integrating professionalism training into medical schools. They report on their website (www.amsa.org) that over 90% of medical students receive formal training in professionalism and that this number reflects the addition of professionalism training to many medical programs over the past few years.

d. Currently Used Methods of Measuring Quality

Quality is usually measured by researchers in three key areas:

· Structure - Are the right elements in place to be able to provide quality service?

· Process - Are the right things done to the right people at the right time?

· Outcome - Is the result as good as it should have been, given current knowledge?

In addition to these key areas used by researchers, physician quality is reported through other indicators such as:

Board certification
Malpractice claims
Medical society appointments
Years in practice
Place of residency
Place of medical school
Patient satisfaction ratings
Hospital, health plan or physician group affiliations

This list of methods and measures of quality is a brief snapshot of the current literature. For more information on the methods currently used for measuring quality refer to “Crossing the Quality Chasm: A new health system for the 21^st Century” by the Institute of Medicine.

Section 3. Patient Advice

a. Internet “Help” Sites

There is information available via the Internet to help guide patients in choosing a physician without actually providing information about individual physicians. These websites tend to portray themselves as guides in a sea of information, but depending on which organizations are producing these patient guides, they could have very different messages. In addition, some formats are much easier to navigate and understand than others, and this discrepancy will make some sights accessible only to more computer savvy individuals. Some examples of these methods for guiding consumer choice are:

· Lists of hyperlinks to other information

v These sites tend to not be user friendly, but they can be gateways to an incredible amount of information. An excellent example of this type of website is the physician.info and about.com series of websites, one of which is highlighted below.

· User guides meant to be printed and read throughout the care process

v These are generally produced by public health advocacy groups, state health departments or other public service groups. A good example can be found at http://www.health.state.ny.us/nysdoh/opmc/howto.htm

· Theoretically based definitions of helpful topics

v These are generally produced by research agencies who are advising patients based on the research that they are performing. A good example is the Agency for Health Care Research and Quality’s website (www.ahrq.gov).

http://arthritis.about.com/cs/docpad/a/rightdoctor.htm

Within the arthritis section of the about.com network of websites, this web page is written in the style of a news article with links to other sites that allow you to search for a physician. Although it is sectioned under the arthritis category, the website offers general information about choosing a doctor based on the physicians personal and academic attributes. The website suggests checking a doctor's academic history, board certification, continuing medical education, and hospital affiliations before making a choice. In addition, they give links to the AMA’s doctor finder (reviewed in future sections) and more articles with more information on how to choose the right physician.

b. Non-Internet Sources

In addition to the information above, there are several other methods by which different organizations advise patients on how to choose a physician. Some examples include hospitals giving out information by means of pamphlets, posting flyers or discussing alternative referral options with patients. Health plans often send physician lists in hard copy to patients when they sign up. Government offices, advocacy groups, and others produce suggestions for selecting a physician on occasion, and there are also some nonprofit organizations who are working to produce physician quality reports. News Papers and magazines also occasionally address the topic of finding the right physician.

Section 4. Currently Available on the Internet

a. International Sites

Many areas outside of the United States have extensive and relatively free or inexpensive sites that incorporate information about all physicians in the country, often managed by the government. The United Kingdom, for example, has an extensive website that allows consumers to search for a physician throughout the U.K., find information about their specific disease, learn more about the British health care system in general and connect to numerous other sites that provide more information on specific topics beyond the scope of their national website. The service is relatively inexpensive, and provides the ability for patients to provide feedback about physician practices and hospitals directly on the website. For a more complete list of international physician search engines refer to (http://www.physician.info). The Physician.info websites collect an enormous amount of links that serve as gateways to many other services on the Internet.

http://www.drfoster.co.uk/

Dr Foster claims to be the definitive source of information on British healthcare services. Dr Foster is an independent organization that collects and analyzes information on the availability and quality of health services in the U.K.. The website can be used to learn more about the healthcare system in the U.K. or choose a physician, physician group or hospital. Using guides, the website links consumers to both disease-specific health information and information about their local care centers such as care methodology and practice standards. The information about quality comparisons between groups is for the most part contained within their members’ section, which requires a monthly fee to access.

http://www.physician.info/MD_CD.HTM

This site is an educational service provided by the Physician.info network, similar to the about.com network referenced above. It is free for both consumers and providers. It is intended to provide educational links to help find a physician in Canada. The website contains specific information about physician practice locations and credentials, and how to find out which physicians are on the medical staff at which hospitals in Canada.

b. National Sites

i. Disease Specific

Many national websites are run by professional societies or nonprofit organizations with disease-specific interests. These websites can be very helpful not only for finding a physician who specializes in one’s particular disease, but also for providing an enormous amount of disease-specific information. These national organizations serve as gateways to information on the Internet that can help the interested consumer learn more about their disease and find a physician who specializes in their disease.

http://www.ncqa.org/dprp/

The diabetes physician recognition program (DPRP) referenced at the link above offers a list of recognized physicians, which is produced through a collaboration between the National Center for Quality Assurance (NCQA) and the American Diabetes Association (ADA). The website encourages physicians to pay for an evaluation of their practice that could possibly result in recognition through the DPRP. The evaluation is concentrated on outcome measures for diabetics in the physician’s patient population, and recognition is awarded to providers who have managed to keep the majority of their diabetes patients in control of their diabetes. Successful completion of the recognition program allows a physician to post their information on the recognition program’s website, post signs around their office demonstrating that they are a recognized diabetes physician and a logo can be placed on the physician’s personal website. In addition, many other websites that provide information about finding a diabetes physician refer patients to the American Diabetes Association’s search engine, and therefore recognition could prove to be a substantial marketing tool.

ii. Non-Disease Specific

The United States health care system expects market forces to drive health care in the appropriate direction. These market forces could work positively by driving up patient expectations and creating overall higher quality care, but they could also work negatively and create an unjust selection process that favors those who have access to better choices. The websites listed below are reviewed in light of the competitive market system and should be used with the understanding that many of these companies have profit driven interests and therefore incentives to highlight certain aspects over others. Non-disease specific websites that provide physician information for providers across the country are primarily maintained by for-profit companies selling physician information. Some of the largest and most popular websites are listed below.

U.S. Physician Search www.dr-411.com

This search engine provides information on physicians in all specialties and boasts that they provide contact info for over 681,000 physicians. Although the website allows you to do basic searches, it limits the results you see and tries to get you to buy complete lists by purchasing their physician database on CD. The website and the purchased database do not provide quality data beyond board certification and medical education, and the website appears to be targeted at businesses selling or marketing to physicians.

Healthgrades www.healthgrades.com

This website allows you to access background and performance information on doctors. Healthgrades supplies reports to health care consumers that are personalized to a specific physician or to compare multiple physicians. Both reports are only produced for a fee. The only information available without a fee is name, address and specialty information. Within the reports, Healthgrades offers background data on disciplinary actions if any exist, such as malpractice claims or institutional actions against the physician. The complete report also includes the physician’s educational history and additional office information if it was provided by the physician.

America's Top Doctors www.AmericasTopDoctors.com

This website provides its members with physicians from every specialty who have been nominated by their peers to be “America’s top doctors.” Membership requires a fee, and access allows one to search a list of providers who were recommended by their peers by geographic area or specialty. Additionally, the website allows patients to fill out an online questionnaire about their satisfaction with their own physician. The idea of a list of preferred physicians is an attractive option for many patients, and the company has been around for many years and also produces their list in the form of a book. The book can be purchased on the website as well as many bookstores.

c. Statewide Sites

National sites may not be attractive without aspects that narrow the search down to reasonable geographic limits, and the same is true with statewide sites. Most individuals may not be willing to travel several hours for a preventive care check-up, and therefore the majority of the sites’ benefits come in listing all physicians within a feasible travel limits. Similar to National sites statewide sites still have the appeal of comparing data for a very large region, which may be especially useful for specialty services. It may be quite feasible that an individual will travel several hours to receive the best possible cancer care or heart surgeon. For this reason, statewide sites could be a very attractive option for patients.

Statewide sites are often managed by the state licensing board and simply list the location of licensed physicians. Other statewide sites, however, are run through government funds such as the New York site featured below or nonprofit organizations providing a statewide service. There are also a few websites that appear to be run by for-profit organizations that provide basic physician information such as licensing, malpractice claims and state misconduct findings, and the information is provided for a fee.

http://www.nydoctorprofile.com/welcome.jsp

In 2000, Governor George Pataki signed the New York Patient Health Information and Quality Improvement Act making it possible for all citizens of New York to access information on physicians in New York State. After this act, the Center for Consumer Health Care Information in the New York State Department of Health created this website. It is easy to navigate, and it provides the basic tools for finding a physician. The site does not offer any comparison charts, and it does not provide recommendations of one physician over another. The search engine starts by allowing the user to search for a physician by name, location, specialty or hospital affiliation. Once a physician is selected, some additional information is available. Some categories are provided on every doctor selected while other categories are optional and are provided only if the physician writes in to update their profile. The website gives information on the following:

Educational information including

Medical School

Graduate Medical Education

Board Certification (optional)

Professional Membership (optional)

Practice Information including

Field of Practice

Offices

Translation Service

Government Insurance Programs (optional)

Health Plans (optional)

Hospital Privileges (optional)

Professional Activities including

Professional and Community Service Activities (optional)

Publications (optional)

Academic Appointments (optional)

All Legal Actions against the physician including

Malpractice

Out of State Actions

Current Limitations

Hospital Restrictions

Criminal Convictions

Statement by Physician (optional)

State law in New York allows every physician the option of making a statement that explains or simply comments on their profile.

d. Local Sites (City and Community)

In general, one advantage to a local community or city developing and managing a website that provides its residents with information on local physicians is that there is a better chance that the marketing efforts of the website are in-line with the local interests. Individuals living within a community most likely have a good sense of the cultural, religious and other themes present in the community that would influence the way in which individuals perceive the quality of their provider. Some local sites create chat rooms, and forums for posting comments, and other community sites actually ask their users to rate the physicians in their area. One of the most extensive community sites is the University of Buffalo’s site for the Community of Western New York and the city of Buffalo.

http://www.smbs.buffalo.edu/find-a-physician/fad_about.htm

The main website is actually the Buffalo University’s School of Medicine and Biomedical Sciences website. It offers educational information for patients, more in-depth information for physicians and scientists, and an entire section that allows consumers to search for a physician by specialty, location or insurance provider. The information listed on physicians includes their educational background, a photo if provided, location of offices and insurance types accepted by the physician.

e. Hospital Sites (Hospital Networks)

Hospitals have a vested interest in promoting their physicians, and many hospitals offer information that compares physicians on their websites. The value of this service naturally should be considered in light of the bias of the hospital to promote all of their physicians. Therefore, a lot of the information gained from such sites could be valuable in what they add to an interested consumer’s portfolio on different physicians, but should probably not be used as the sole source of information in one’s search for a physician. Information about disciplinary action, malpractice claims and other potentially harmful information is not found on a hospital’s physician information page. In addition, if the consumer is choosing the hospital or health system first and then pursuing physicians within the hospital system, the hospital’s website could be the most complete source of information on possible physicians, because the information on a hospital website tends to be up-to-date and accurate. The hospital has a vested interest in keeping their list of practicing providers as reflective of reality as possible to make the most of this marketing tool. A good example of physician profiling on a hospital site is the University Hospital Health System website highlighted below.

http://www.uhhs.com/physiciansearch.aspx?pageid=88&MID=1

University Hospital Health Systems is a network of hospitals located in and around Cleveland, Ohio. The physician search engine above allows the patient to search the entire hospital network by physician name, specialty or location. After generating a list of applicable physicians, the user can gain more information about each individual physician. The physician’s educational background, practice information and picture are provided for the patient. Additionally, patients can request an appointment with a physician of their choice directly through the website. The website also provides disease specific information, links to health information and information about University Hospital Health System’s accolades.

f. Health Plan Sites

Many health plans are leading the charge in physician profiling and physician-level report cards. These terms refer to information that allows consumers to compare and choose a physician based on several different criteria such as board certification, location, etc. In addition, many health plans are moving to add patient satisfaction reports to their physician profiles, which would allow health plan members to browse for and review evaluations of physicians based on the insight of that physician’s patients (Kowalczyk 2004). One downside to these types of sites is that access is usually granted only to health plan members. This feature allows the health plans to release what may be more confidential or personal information about certain providers, but it also limits a consumers ability to use the resource prior to committing to a given health plan. The extensiveness of a health plan’s provider selection is becoming a marketing tool for health plans. This trend could potentially drive improvements in quality.

http://provdirectory.tufts-health.com/main?req=public&fn=ProvSearch&redirect=5

Tufts Health Plan in Massachusetts has an extensive site, which they allow the public to browse. Their physician search engine offers several different search methods including specialty, location and hospital affiliation. In addition, Tufts Health Plan has a physician group quality report that compares physician groups throughout their network on both patient satisfaction scores and process measures. The report is provided free on the website, and members have access to information about which physicians are in each physician group. In addition, physicians’ group ratings are listed along with their educational backgrounds, location and specialty.

g. Physician Network Sites

In many areas of the country, the medical market place has developed large integrated physician networks. In Massachusetts, for example, Harvard Vanguard Medical Associates, Partners Community Healthcare, Inc., and Provider Services Network account for a very large proportion of the marketplace. These large integrated physician networks are sometimes referred to as IDN’s (Integrated Delivery Networks) or IDS’s (Integrated Delivery Systems). These large physician networks provide another source of information about individual physicians, and many of these networks use the Internet as a marketing tool.

http://www.lahey.org/PhysDir/

Lahey Clinic is one of the nation’s oldest multispecialty physician group practices located in Massachusetts, and it provides an extensive website for its patients. The website offers a “physician finder” that allows a consumer to search for a provider within their network, make an appointment, send them an e-mail or request more information. The search engine automatically provides information about a provider’s education, recent accolades and board certification. The website will also tell the consumer whether the physician is accepting new patients.

h. Physicians’ Private Sites

Many physicians also have their own websites. These websites serve as marketing tools and usually provide consumers with the most accurate and up-to-date information on the Internet. The exception to this rule would be if the provider does not directly control the website or does not have the capacity to continual update the website.

Because physician owned websites are primarily marketing tools, the information contained on the site will most likely only be positive. These websites do provide, however, a unique opportunity to find out more information on a physician that may be hard to find otherwise such as recently published articles, special interests and information about the practice environment and the staff. An excellent example of a physician website is highlighted below:

http://www.ccjronline.com/index.php

The website features general information about the surgeons at the Cleveland Center for Joint Reconstruction, a small private practice office. The office environment and the specialty services offered such as minimally invasive surgery are highlighted for prospective and current patients. In addition, the site lists the practice’s mission statement, office information and links for patients to find out more information on their disease.

i. Other Sites

There are other sites on the internet that do not fall easily into one of the other categories listed above. These websites tend to be for-profit multi-state sites. These sites do not necessarily provide more information than national sites, and they do not promise a more intimate look at the culture of a physician’s practice. Most-likely developed on a multi-state level for financial reasons, these sites appear to provide information similar to that found on a for-profit state-wide site. One multi-state site is listed below.

http://www.healthspannetwork.com/providers.htm

HealthSpan is a multi-state provider-owned PPO that is owned by the Mercy Health Partners. Their website offers educational and professional information about providers within their network. Users can search for a physician by specialty, name or location. Once a physician is selected, users can find information about office location, educational background, medical board licenses and any specialties listed. The website also offers direct links to driving directions and maps.

Conclusion

While there is a significant amount of physician-level information currently on the Internet, the majority of information available to the public is contextual. Websites primarily offer contact information and board registration information. While some sights also offer educational background and misconduct information, few sights are offering information that allows the user to compare physicians based on quality as defined by either improved interpersonal relationship building or improved outcomes. With the exception of peer-acclaim and provider recognition programs, quality reports on the internet fall well short of the IOM’s definition of quality.

The information available on the internet is constantly growing, and this chapter provides a snapshot of the current state of physician-information on the internet as well as some insight into the current beliefs on the patient search process. This chapter is not meant to be an exhaustive list of the resources available via the Internet nor is it meant to be a complete reference for the patient choice process as it relates to choosing a physician. For more information on these topics, please refer to the following sources:

For information on the psychology of patient choice –

William Glasser. Choice Theory: A new psychology of personal freedom. Perennial. 1999
Karen Glanz, Barbara K. Rimer, Frances Marcus Lewis. Health Behavior and Health Education (3^rd Edition). Jossey Bass. 2002

For information on the influence of choice on free-markets –

Milton Freidman. Capitalism and Freedom. University Chicago Press. 2002 (Reprint)
Milton Friedman and Rose Friedman. Free to Choose: A Personal Statement. Harvest Books. 1990 (Reprint)

For information on the resources available on the Internet –

http://www.physician.info/ - an extensive listing of available internet resources that is truly astounding and consistently updated.
The Journal of Medical Internet Research http://www.jmir.org/index.htm
International Medical Informatics Association http://www.imia.org/
The Society for Medical Decision Making http://www.smdm.org/