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In Quality Measures and the Individual Physician, Danielle Ofri, MD, PhD, questions the usefulness of feedback report cards for individual providers. She states, “Only 33% of my patients with diabetes have glycated hemoglobin levels that are at goal. Only 44% have cholesterol levels at goal. A measly 26% have blood pressure at goal. All my grades are well below my institution’s targets.” (http://danielleofri.com/?p=1169)

It would be better for Dr. Ofri’s patients if these numbers were higher. I think even Dr. Ofri would agree with that assessment. And yet Dr. Ofri’s response to these low scores is that “the overwhelming majority of health care workers are in the profession to help patients and doing a decent job.” And more upsetting is Dr. Ofri’s conclusion where “I don’t even bother checking the results anymore. I just quietly push the reports under my pile of unread journals, phone messages, insurance forms, and prior authorizations.” (http://danielleofri.com/?p=1169)

Dr. Ofri’s defense that doctors are smart and good people who are trying hard to help others does not reassure me as a patient or physician executive. Everything we know about cognitive neuropsychology tells us that humans are not good at judging our own competence in any field of endeavor. One hundred percent of high school students rank themselves as having a higher than average ability to get along with others (a mathematical impossibility), and 93% of college professors rank themselves as above average at their work. (http://ow.ly/2sCLw)

Literature teaches us the same lesson. Martha Nussbaum discusses how Proust has Marcel confident that he does not love Albertine any longer. And then Marcel finds out that she has left; he now knows for certain, without the least room for doubt, that he loves her. (http://ow.ly/2sCOI) Humans are masters at self-deception, and Michael S. Gazzaniga even hints that this quality separates humans from other animals. (http://ow.ly/2sCLw)

Richard Russo makes a similar point in Straight Man about the need for humans to have feedback from others, about our inability to know ourselves without it. “Which is why we have spouses and children and parents and colleagues and friends, because someone has to know us better than we know ourselves. We need them to tell us. We need them to say, ‘I know you, Al. You are not the kind of man who.’” (http://ow.ly/2sCzk) Physicians need report cards to tell us how well we are taking care of our patients, even when we sincerely think we are doing a fine job.

As Chief Medical Officer for a large health system, I never met a clinician who did not think that they did a good job at taking care of diabetic patients. And yet when I did an audit of their care, I found that many had suboptimal results. They were genuinely surprised that patients fall through the cracks and did not receive their required retina exams.

Physicians are always telling me that they have to be the leaders of the health care team. Well, then they need to accept that feedback is necessary for learning and improvement and leadership. Good leaders in my experience only do four things: they examine the environment and decide on a vision that can excite themselves and others. They translate the vision into strategies and tactics; they assign the strategies and tactics to someone to carry out; they then hold the responsible party or parties accountable for the results. In my experience health care does not do a good job at the accountability step.

Who is accountable for the quality of care in Dr. Ofri’s clinic? Do we have examples in medicine where someone has stepped up to the plate and become accountable so that the quality results improve instead of never budging from the results two years ago?

Dr. Kim A. Adcock, the radiology chief at Kaiser Permanente Colorado, created a system that misses one-third fewer cancers on mammograms and “has achieved what experts say is nearly as high a level of accuracy as mammography can offer.” At the heart of the program was his willingness to keep score and confront his doctors with their results. He had to fire three radiologists who missed too many cancers, and he had to reassign 8 doctors who were not reading enough films to stay sharp. (http://ow.ly/2sCGD)

The Kaiser experience mirrors the literature on how to be a best performing organization in a chaotic, rapidly changing environment: one has to focus on sources of error and failure and learn from them to improve the results. The Kaiser leaders worried about negative publicity, malpractice claims, women neglecting the test due to skepticism, but in the end they did what was right for their patients. They tracked down the women who were at risk for having cancer even though the less skilled radiologist had read their films as normal. (http://ow.ly/2sCGD)

I agree with Dr. Ofri that “we need good evidence that the data measure true quality and that providing data is actually helpful.” However we will never get to that point by not “checking the results anymore.” (http://danielleofri.com/?p=1169) We have to emulate Dr. Adcock and wade into the messy reality of why Americans receive only 55% of indicated care. We can learn how to do better if we embrace feedback and learn from it; we cannot improve by ignoring reality. Trust me I am a doctor just doesn’t cut it. We all deserve better than that.

Kent Bottles, MD, is the President of The Institute for Clinical Systems Improvement in Minnesota. He is past-Vice President and Chief Medical Officer of Iowa Health System (a $2 billion health care organization with 23 hospitals). He was responsible for the day-to-day operations of a large education and research organization in Michigan prior to his work with in Iowa with IHS.

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40 Responses for “Trust Me I’m a Doctor vs. Physician Quality Report Cards”

  1. I am a physician. The days of ‘old school’ thinking about how we justify successful care delivery needs to change. Frequently at our institution’s conferences we hear “That’s how I have always done it”, “Well that’s what the patient (or referring doctor) wants, who am I to refute that”, “Well that’s what I would want done”. Using simple available data to guide some of the ‘easier’ decisions is a necessary start, with consequences that should be met at the institutional level.
    Tools such as societal guidelines, Cochrane’s, etc. are readily available. Not reviewing, correcting and evolving one’s care paradigm is a sure way to promulgate the mediocre care we have been blamed for in the US.

  2. pcp says:

    ‘Dr. Kim A. Adcock, the radiology chief at Kaiser Permanente Colorado, created a system that misses one-third fewer cancers on mammograms and “has achieved what experts say is nearly as high a level of accuracy as mammography can offer.” ‘
    Meaningless endpoint, like most quality measures. How did this affect survival rates in KP patients? How many KP patients underwent mastectomies and chemotherapy for cancers that would not have shortened their lives?

  3. ExhaustedMD says:

    I read posts like this and wish I could have a “Regan” moment from ‘The Exorcist’ and projectile vomit over these salesmen/women championing for how health care can be so much better if we can just write the “cookbook” and stick to it like it seems so simple to do.
    Well, BS to you, sir, Dr Bottles, and while you are at it in minimizing our profession for the minority who have either sold out, burnt out, or just threw up their hands and just counted numbers instead of talked to patients as individuals, just answer this one simple question I have yet to read ANYWHERE in this health care deform legislation: WHERE THE HELL IS TOBACCO BEING OUTLAWED TO IMPROVE THE ODDS THAT HEALTH CARE INTERVENTIONS IN THE FUTURE CAN MATTER!?
    I won’t be holding my breath waiting for your answer.

  4. I did not read Dr. Ofri’s article as an objection to measuring quality. It was more an objection to HOW we measure quality.
    Right now we first find things we can easily measure and then define quality in those terms. A better approach would be to define quality first, and then figure out what indicators need to be measured. May be a bit tougher, but a lot more meaningful.

  5. L says:

    Reporting measures do not measure advice given. If a physician advises a retinal exam and the uninsured patient decides against it, why should the physician recieve demerits? Does the patient have a choice? This
    plan seems a surefire way to divide patients and caregivers. They pay administrators to think of things like this?

  6. propensity says:

    I know a diabetic specialist who works aggressively to tightly control blood glucose levels. There is not much worse than hypoglycemia in a patient who has just had a stroke or hear attack, nor is there any justification for treating the “infiltrate” of heart failure with antibiotics, or the heart failure of severe aortic stenosis with a beta blocker. You guys are a bunch of “do gooders” and need feedback too. Here it is: You fail to look at the adversity caused by your scrutiny and attempts to decalre quality.
    How many unnecessary breast biopsies were there? How many unnecessary lung biopsies are there? How many deaths from hypoglycemia?

  7. Gary Lampman says:

    Terrific article that shows that peer review is lacking and doctor report cards provides incentives that would otherwise maintain status quo. Doctors are concerned about meeting goals and showing low percentage rates on meeting Patient goals.However it seems to be more of an excuse to forego the premise that all is not well among the Sick Care Industry.
    Everyone should know that the problem is far more reaching than a Patient /Doctor relationship. Many varibles that are often hidden from view; play a tremendious role in patient behavior. Economics and Financial status (the ability to pay),insurance contracts that exploit patients and providers that provide a extended itemization that makes a art of extracting money from patients and minimizing the extent of Care.Even Corporate Agriculture and Corporate food and beverage makers have contributed to many of these health problems as well. However,lets not forget for many Americans; a pre-disposition toward certain Health events are unavoidable. A issue that Health Insurance has proplagated and Manipulated for decades. Stacking the deck from absorbing losses and Building a Empire of entitlements off the backs of their members.
    Certainly.Reporting on Doctor outcomes are important as teaching moments, as a measure of sucess and improvement. However, Such Transparency is not just relegated to Doctors alone. Every aspect of the industry needs to bear a report card that stands Public view. These institutions wish to remain under the veil of secrecy. Still without knowing our fate and bringing it to light.Our ability to make informed choices would be tremendously compromised.

  8. Kent Bottles says:

    I am no longer with the Institute for Clinical Systems Improvement (ICSI). This post was first written for my personal blog at kentbottles.blogspot.com.

  9. Terrific post. I know from quality improvement literature in other industries that measuring failures and seeking their causes is a sine qua non of improvement.
    I’m disheartened by the apparently angry or dismissive responses from physicians who seem not to understand this. Yes, if patients don’t do what’s recommended, that’s a failure. Are you giving up? Are you saying you just can’t get the job done? I’m no doctor myself, but how then do you account for better outcomes at some clinics than others? (I’m asking, not telling.)
    The skeptical commenters bring us to a difficult part of culture change: educating people about the errors in thinking. “PCP” says a quality measure is the wrong endpoint unless we prove that it correlates with death. How do we teach that this method of identifying causes of failure does, consistently, lead to better results with less effort in industry after industry?
    To say “I’m not making a sensible change until you PROVE it affects death rates” seems just plain stubborn. If we discover a cause of errors mid-process, are we to ignore it on that basis? Do we have no belief that what we do makes any difference?
    To bitch about tobacco is simply to change the subject. I hope ExhaustedMD will find a time in the future where better methods will let him/her produce better outcomes with less exhaustion.
    On the other hand, Kent, re Adcock’s great results – radiology and pathology have nothing to do with compliance, right?
    I wonder what’s different in Dr. Ofrio’s clinic between her doings and those of docs with top-tier ratings. I wonder if she’s interested in learning to do what they do. (Dr. Ofrio, your thoughts?)

  10. Kent Bottles says:

    http://ow.ly/2sNdj Thoughtful analysis of teacher report cards could apply to physician report cards as well.

  11. Bill Jones, MD says:

    There are problems with health care, no doubt. But the problems of the worried well such as the e patient above are not the problems. Every one is going to get illness.
    Recently, my colleagues and I are seeing the disease evidence of poor medical judgment exacerbated by the EMRs. The hospital activate an EMR and CPOE and watch out!
    These are experienced doctors who get excellent ratings by ordering the appropriate tests, but then exercise lousy judgment in their care strategies when they act upon the results.
    The results are train wrecks, made worse by the for profit ware houses for such train wrecks. The hospitals profit on the DRG and the ware houses profit from the care that cause these trainwrecks to be warehoused.

  12. Docserious says:

    The problem as I see it is the rules keep changing.
    I am graded on howm any of my pateints get a certain test every year-(ie pap test) but then they say we do it too often. Not too many years ago you would get a bad grade if you did not treat your hepatitis patients with steroids!
    The “Gold stanards” keep changing- fools gold is more appropriate.

  13. Reading through a debate on Twitter between Gilles Frydman (founder of ACOR) and ePatient Dave de Bronkart convinced me to re-review this matter. So, I’ve re-read and re-analyzed Dr. Ofri’s article. She doesn’t fare well in the re-analysis.
    Dr. Ofri does make some good points. She complains that her quality tests are digital–all either pass or fail. That’s a lousy way to measure quality. Yes, I think every value should have a pass-fail cutoff point, but the tests should also measure overall improvement. As she implies, she should get credit for helping a patient get her BP down to 140/85, even if she gets a failing grade for not getting it down to 130/80.
    I have a difficult time working up any sympathy for Ofri, however, when she makes arrogant statements like:

    Doctors who actually practice medicine–as opposed to those who develop many of these benchmarks–know that these statistics cannot possibly capture the totality of what it means to take good care of your patients. They merely capture what it is easy to measure.

    Meow.
    If your hospital is using quality measures designed by doctors who have no practical experience, yes, that’s pretty stupid. Easy to measure? Yes, it’s true, quality standards are usually forced to rely on measures that are easy to obtain. If they weren’t easy to obtain, who would obtain them? What would you use instead?
    Really, though, what I find egregious in Dr. Ofri’s article is, to mirror Dr. Bottles’s complaint, her insistence that she has

    yet to meet a medical student, nurse, intern, or doctor who doesn’t feel a powerful sense of responsibility.

    What bunk. How can anyone know that? She goes on to argue that we all pretty much know that health professional are smart, well-intentioned. That’s simply not the point. It doesn’t matter that you’re smart and well-meaning. What’s important is can you learn to do the best possible job for your patients.
    Dr. Ofri doesn’t get it. She says she thinks the idea is to weed out the incompetents. In Kent’s personal blog, I explained that

    even if Dr. Orfi’s claim is true that most doctors, as Kent paraphrases, “are smart and good people who are trying hard to help others,” that’s just not enough to ensure that they will do their best. In Atul Gawande’s 2007, collection Better, he includes an article titled “The Bell Curve,” which discusses smart and good people attempting to treat cystic fibrosis and–if not failing–not doing a very good job. In the article, Gawande discusses the effort of the CF team at the highly respected Cincinnati Children’s Hospital to improve the life expectancy of their charges by learning from the very best CF team, the Minnesota Cystic Fibrosis Center, at Fairview-University Children’s Hospital, in Minneapolis. I’m not going to repeat the entire article here, but suffice it to say Gawande demonstrates that sometimes intelligence and drive aren’t enough. Some illnesses require focus, aggressiveness, and the willingness to be absolutely uncompromising and goal-oriented.

    Dr. Ofri, seriously, do you think you’re too good to learn any more?

  14. ExhaustedMD says:

    No, to bitch about tobacco that is federally funded is exactly a point to this post. It shows how absurd and clueless our federal government is to create legislation to further intrude into the patient-physician relationship while it continues to support a behavior that is floridly counterproductive to health care, that will continue to create excess care needs for the minority of Americans that the majority will have to pay for, and these morons called representatvies should know better as of 2010. And this guy doesn’t seem to relate we as doctors can’t control patients’ behaviors and choices, but we sure can be penalized for others’ dumbass outcomes, eh?! God, this scapegoating bs never will end in this society!
    But, you idiots who so casually and fervently adhere to party principles first and real public needs last, show why such ridiculous acts are considered and enacted. I’ll let the politically correct and polite crowd try to engage you in alleged meaningful conversation, while those like me just stand to the side and shake our heads in complete disbelief such wasteful efforts are attempted in the first place.
    Again, will someone take a shot at my question? Why is health care legislation being shoved down our throats while real preventative measures like ending the dependence on a carcinogenic industry are ignored?
    You know why there is silence after my question, readers? Because no one with half a brain would try to defend such pathetic actions. Hence why we read the drivel from the usual suspects!
    Nice only goes so far, folks. Good column today written by Thomas DiLorenzo I read at http://www.baltimoresun.com called “Business ethics’s wrong focus”, that points out our failures as voters to elect true representatives. You find it and read it yourselves, and those with half or more of a brain might realize the writer is on the mark the last third of the article. Administrative commentary like this above post just echoes the thinking of politicians. You won’t read this kind of thinking and expectation from ‘in the trenches’ doctors, because we know better as a majority, but you all want to listen and believe the Bottles’ of the world, because they feed you the bs you want to hear and believe is true. I like Dilorenzo’s last sentence:
    “In short, universities perform a disservice with their relative neglect of the real ethical problem in America, the politicization of society and the growth of government, while greatly exaggerating ethical problems in private enterprise.”
    Or, how I can interpret to this arena, health care.

  15. George says:

    With the advent of the information age, I believe more and more people are turning to the internet rather relying on the advice provided by their physician.
    There’s lots of skepticism brewing about how knowledge many doctors are and if they have money on their minds.

  16. Mike Kunkle says:

    I am not a physician. I do work in Healthcare IT, but in this context, I’m primarily a patient.
    No one appreciates hearing about this desired level of accountability and results than me. Today, as evidenced by examples here and elsewhere, both health systems and physician practices can do better. It seems that EHR connectivity and better data capture, retrieval, reporting and follow-up will go a long way toward closing some gaps.
    As much as I believe that’s true, I also think there is a point of diminishing returns, where the lack of patient accountability trumps all other effort. Non-compliance with meds and recommended regimens, failure to keep follow-up appointments, and more, sits squarely on the shoulders of patients, as I see it.
    Don’t get me wrong… I agree with the vast majority of what’s written here and laud the desire for better medical results and progress on the parts of hospital systems and physicians. But a sign in a Dentist’s office 30 years ago truly stuck in my mind: “There is no work a Dentist can do, that the patient cannot undo.”

  17. Indeed, doctors need to be trusted – they’re professionals and we seek them because we know they can help. But, I don’t think we should forgo the report cards because it’s the only way doctors will learn their shortcomings.

  18. I thought I needed to write much more in response to this than space allowed here. This is my own post.
    http://wishfulthinkinginmedicaleducation.blogspot.com/2010/08/quality-measures-and-individual.html

  19. bev M.D. says:

    The thing that frustrates me in this whole debate is docs’ idea that this entire concept is invalid and should not be applied to them. Then, when it is (and get real guys; this is going to happen, period), they quibble with the metrics and behave as victims.
    Why don’t the specialty societies show a little initiative and responsibility and proactively develop quality guidelines themselves, then enforce them on their members?
    Could it be the “guild mentality” which I have heard other commenters accuse us of, is a reality?
    As Paul Levy repeatedly has commented on his blog, Running a Hospital, we need to get busy and do this ourselves – or it will be imposed externally by those who do not know how to do it. This is happening right now – wake up and get control, or be controlled!

  20. Michelle W says:

    To piggyback on what bev’s written, it reminds me of the issue of testing students in education. In many ways, education brought this situation on itself due to the lack of internal enforcement of standards. There have always been good teachers, but there was little incentive to go beyond the minimum of what would be tolerated by administration. Substandard or exemplary: all were paid about the same. So testing was advocated as a way to hold teachers accountable.
    But now that standardized testing is the norm, what do we also have? An environment where anything not on the test is not taught (cursive and geography are barely touched on in elementary school now), schools are held accountable for student performance on these tests regardless of other facts that might interfere with student performance, and teachers are accused of teaching “to the test” rather than to the student.
    Testing is not going away in education, and accountability is certainly needed. But testing in and of itself can not prevent students from doing poorly, nor accurately gauge the competency of a teacher. It’s not right to teach to the test, but if that’s where the incentives are, that’s where the teaching is going to be centered. Some things are gained such as a greater proficiency (on at least a superficial level) in mathematics and reading, while others are lost. It’s a contentious, experimental learning work in progress. One wonders what lessons could be learned from this history in the medical report world.

  21. As a partial echo of Michelle’s comments above (to which I agree wholeheartedly), I too don’t see much difference between scholastic standardized testing and what Dr. Bottles is referring to. The “standards” to which one is measured against is strictly that, a “standard”, and, in and of itself, is not a very useful yardstick to go by – particularly if we’re actually looking at the efficacy level of the treatment / education of “the individual”. Each case is unique in its own ways, so just how much meaning can be given to any measure that simply applies to the broader masses?
    It’s all in the formula chosen for use…and if that formula isn’t predicated on a particular patient’s own individual baseline, then the results are most meaningless. And yes, I know that means more work for the doctor…

  22. David C. Kibbe, MD MBA says:

    Nice job, Kent. This is hard slogging territory. DCK

  23. pcp says:

    e-patient Dave says:
    ‘ “PCP” says a quality measure is the wrong endpoint unless we prove that it correlates with death. How do we teach that this method of identifying causes of failure does, consistently, lead to better results with less effort in industry after industry?’
    But it doesn’t lead to better results in health care. It has been shown, over and over, that these arbitrarily chosen points in the entire life of a patient do not correlate with better health and increased survival. Yearly mammograms, yearly Pap smears, yearly PSAs, tight control of A1c in Type 2 diabetics, tight control of LDL cholesterol for secondary prevention: all been shown to be unrelated to long term health.
    You’re really advocating a “No Child Left Behind” approach to medicine, in which arbitrary measuring points are more important than the long term health of individuals. I’m just saying that I don’t practice medicine that way, and I would not be a patient of a doc who did.

  24. ExhaustedMD says:

    For what it is worth to the above commentor ‘pcp’, thanks for the last statement: “…in which arbitrary measuring points are more important than the long term health of individuals. I’m just saying that I don’t practice medicine that way, and I would not be a patient of a doc who did.”
    And this is what the “federalization” of health care is leading to. Here is another question I offer to colleagues who deal with peers who have clinical care to become administrators: do these colleagues who just hibernate behind desks the remainder of their careers really have the right to be directing care interventions and options when they do little if any hands on care?
    It is at best pathetic, if not worse disruptive and detrimental, to health care when doctors become administrators and just act like they forgot what is involved in treating people. Because a good many of their decisions reflect that basic tendency!
    Again, they just feed the scapegoating mentality that we as invested MDs need to put in its rightful place: the dumpster!!!

  25. Tom Leith says:

    Bev M.D. writes:
    > Why don’t the specialty societies show a little
    > initiative and responsibility and proactively develop
    > quality guidelines themselves, then enforce them on
    > their members?
    >
    > Could it be the “guild mentality” which I have heard
    > other commenters accuse us of, is a reality?
    Bev, I’m the guy here who uses the term “Guild” most frequently and I’m accusing “doctors generally” of ** NOT ** having a Guild Mentality. A healthy Guild develops quality quidelines and polices its membership. A necrotic Guild does not. The Laws of Thermodynamics being what they are, it is a lot of work to keep a Guild healthy and it isn’t being done.
    I have made the same rant about accountants, lawyers, and computer programmers, btw. Here’s the short version: the concept “professional” comes from religious vows, and the first duty of a professional is to the ideals of his profession, freely chosen. There ought to be something ontological about saying ego sum: “I am a Franciscan” or “I am a Lawyer” or “I am an Engineer” or “I am a Physician” ought to mean something like “I want to be judged as a human being by how well I model the ideals of my profession.” “I Am” ought to scare us.
    I sincerely hope The Medical Guilds (indeed all the Professions) manage to reform themselves because if they don’t we’ll have some truly blunt instruments applied to the problem. This is the proper Social Action of professionals in pursuit of Social Justice, properly understood. http://tinyurl.com/26x6wqu
    t
    PS: An easy place to start: revive the notion of “Ethical Medicine” and refuse to prescribe any drug marketed Direct To Consumer. Be noisy about it.

  26. @ Tom Leith
    I do think the guild days of medical professionalism are over. One of the most convincing descriptions of the current situation comes from Hafferty and Castellani. Take a look at this blog post with a good link to their diagram of the complexity of medical professionalism.
    http://sacswebsite.blogspot.com/2010/02/increasing-complexities-of.html
    And the medical profession is only one element in healthcare! How to go forward indeed?

  27. pcp says:

    ‘ And more upsetting is Dr. Ofri’s conclusion where “I don’t even bother checking the results anymore. I just quietly push the reports under my pile of unread journals, phone messages, insurance forms, and prior authorizations.” ‘
    Unlike every doc I know, who just tosses them in the garbage. The inaccuracy of the data distributed by insurance companies is appalling: they are no more able to collect “performance” data than to correctly process clean claims.

  28. Tom Leith says:

    @MsCunningham
    I see the complexity of medical professsionalism as the best argument in FAVOR of The Guild, not against it. Blunt instruments are not good at complexity.
    The Medical Profession is not “just one element” of medicine, it is the whole thing. The only question is “How can medical professionalism be adapted or developed maintaining the ideals of the profession and helping each individual to find his place?” Castellani & Hafferty’s paper (http://is.gd/eBdog) seems to be a good start in classifying attitudes concerning medical professionalism and how it is understood, but does not argue against against the idea.
    t

  29. @MrLeith You read this differently to me. The idea of the guild, and living up to the ideals of the professions, strikes me as being closest to what Hafferty calls the nostalgic form of professionalism.
    I am not making any claim that blunt instruments are the way to assess quality of care. Far from it. And that is why I pointed out that the medical profession was just one element of healthcare (not medicine). We have complex dynamic relationships between ourselves, and then we have to add in the complex dynamic relationships within the nursing profession, and within patient groups, and who ever pays for healthcare. We have a truly complex system where small changes may produce large effect- and not necessarily in the direction ‘intended’.
    My own view on this is that the medical profession is determining its own values less often now, as it is in a dynamic relationship with the state: what Foucault calls governmentality. Here is a book chapter by Johnson on this. http://bit.ly/cKDoxo But I live and work in the UK, a slightly different situation. (I’ve written an essay on this which might not make it any clearer but I’d be happy to share. I focus particularly on the concept of ‘patient as partner.’)
    Thank you for the discussion!

  30. I have felt very strange about this post from the beginning. The strong attack against Dr. Ofri just didn’t correspond at all to what I read in the same NEJM article that Kent Bottles referenced. I perceived Dr. Ofri as a very introspective and reflective doctor who seems to question at length the modern practice of medicine in an institution serving an exceptionally large percentage of underserved and outright poor people (more than 80% do not pay anything for treatment). An article, What does your doctor hear when you talk?, published in today CNN health blog confirms my suspicion. I am now convinced that this post is based on a misunderstanding of Dr. Ofri’s original post. A doctor cannot both be an uber-paternalist, who treats all docs like gods and then writes 2 days later:
    “Maybe I’m doing a disservice to my patients by acting as a filter. A growing body of evidence suggests that the gap between what patients say and what doctors document can be ample. Patients often report symptoms much earlier than did doctors. Several studies have shown that patients’ report of symptoms correlate more accurately to actual health status than did the doctors’ reports.
    Some researchers are suggesting that patients be given a direct avenue for their voices to be heard. For clinical trials assessing new medications, why couldn’t patients enter their symptoms directly into a drug database rather than telling the doctor and then having the doctor decide which symptoms should be entered?
    And for regular medical visits, perhaps there could be a section of the computerized medical record for the patients to access directly to list all concerns. This would be a legitimate part of the record, and then I would have my part in which I’d place my clinical impressions of these symptoms.
    Seems like a good idea to me. I bet that we’d uncover many more side effects sooner. It would also remind us, that doctors need to view patients’ words as primary data, and that we should be careful about filtering the patient’s voice too much.”

  31. I think some of the most valuable things physicians do can’t be measured on a scale. Further, some seemingly specific parameters we might evaluate in physicians, the efficacy of tools they use (including mammography) and drugs they prescribe are not well-analyzed, even though there may be published “facts” available.
    Erroneous data can be misleading and harmful.

  32. Kent Bottles says:

    I think Dr. Ofri and I agree that we do not want to be this kind of doctor. http://ow.ly/2ui3R. This discussion has been very useful and educational, at least for me. Thank you all for the comments.

  33. Tom Leith says:

    @MsCunningham
    > The idea of the guild, and living up to the
    > ideals of the professions, strikes me as being
    > closest to what Hafferty calls the nostalgic
    > form of professionalism.
    Probably, with one amendment. And please keep in mind this is a blog comment, not an essay. It isn’t clear to me whether Castellani & Hafferty’s Nostalgics think every single doctor they graduate should have complete personal autonomy or whether they limit it (more or less) to themselves and expect the rank-and-file physicians to follow their lead and submit to their judgments and dicipline. If the idea is that physicians should be accountable only to a toothless state medical board that’s not what I want at all — it ignores entirely the essential function of a Guild: internal standards and accountability.
    FWIW I object to the label “Nostalgic”. These putatively values-neutral academics denigrate this vision of Professionalism by the label they choose. I understand they needed a name for it, but I think “Classical” is better. I don’t see why Tuesday’s ideal should be less ideal just because it is Thursday or because it was not achieved on Wednesday. To steal shamelessly from one of your underappreciated countrymen, it is not that the Classically Professional Ideal has been tried and found wanting, it has been found difficult and left untried.
    > My own view on this is that the medical profession
    > is determining its own values less often now, as it
    > is in a dynamic relationship with the state: what
    > Foucault calls governmentality.
    We agree! The Guild abandoned its essential function and the state stepped in — over here everyone stepped in. I want the state out to the extent possible, but nature and politics both abhor a vacuum, hence my call for leadership from The Guild.
    > We have a truly complex system
    Yes we have, and if Professional Medicine classically understood is not driving “healthcare” I think something is wrong. It is probably the very tempting, practically bottomless pot of money attached nowadays to sick people: without it, the Classical Professionals probably wouldn’t recommend half of what they recommend because it would simply be out of reach for their patients.
    You and your colleagues in England have done a much better job balancing burdens and benefits than we have over here, but then you have the advantage of having got rid of your Calvinists. So here’s a question for you: which vision of professionalism in the Castellani & Hafferty typology do you think pervades England and the NHS, in the sense that it is considered normative?
    t

  34. Gilles, thanks for your thoughtful and informative comment.
    I often talk about the difficulties faced by today’s physicians. It *bugs* me that so many regulatory and bureaucratic and financial factors get in the way of patients & physicians just being able to *do healthcare* together. It just stinks after all the years of work one has to put in, to get the job in the first place.
    At the same time, the rate of improvement of costs (negative) and outcomes in medicine makes no sense, and if we want to improve, I continue to think we’ve got to start somewhere. And at very least, being frank about where we’re at is a reasonable step.
    Honestly, the resistance to change in this industry surprises me. When my hospital started posting its failure rates (e.g. hospital acquired infections) online for all to view, many were aghast, and some even accused the hospital of grandstanding for publicity.
    Let’s work TOGETHER, people, to improve care.

  35. James says:

    All human beings are different, so all doctors are different. This includes being better or worse at treating patients. As a patient, I have a direct personal stake in using doctors and other medical care providers who are clearly better at what they do vis-a-vis my chronic condition.
    It is reasonable for me, as a patient, to ask for some reliable tool to choose those who do a better job.
    While some may pretend otherwise, there are indeed wide variations in outcomes, quality, and costs between competing providers. This is validated by both research and the evidence of our own eyes.
    So, what are reasonable quality measures to assist patients in connecting to the best care?

  36. Tom Leith says:

    @James
    You’re asking about two different things: the best (individual) doctors, and the best care. Doctors like everyone else operate in a context. There’s a lot to be said for the idea that “care” isn’t provided by an individual doctor, but rather by the system he’s working in with some level of cooperation from the patient. Germany & Holland for example, move metrics to the level of what amount to big multispecialty groups, and let the groups worry (internally) about the individual doctors. But whatever is done, it ought to be Medical Professionals who set the standards and measure performance against them. Dr. Ofri is arguing against this — she’s saying that doctors who don’t see patients for a living aren’t “real” doctors and have no business setting standards. She has set her own standard, and she’s meeting it, and besides that she’s trying really, really hard and she’s nice. This is the crux of the professionalism debate: who sets the standards and what is done by the setter-of-standards when they are not met?
    t

  37. Charles Torres says:

    I think what doctors do is a great thing when it comes to figuring out what’s wrong and coming up with the appropriate treatment. Measuring how effective they are at doing that is just as important, for them, and for the patient. How would anyone know if they are improving how they are performing their job (any job) if they aren’t measuring it. Setting standards, whether appropriately done or not, should at least move performance beyond average or mediocre levels. But from what I understand, the problem with achieving the desired health outcomes lies not in who sets the standards or the measuring of results, but rather in the current economics of giving and receiving care.

  38. Kent:
    Well done, right on target. Might I suggest the following build. At least two problems need to be fixed in our “Sick Care” world? One problem we face is the lack of causality, efficacy and effectiveness. A second problem we face is the lack of a closed-loop learning capability that operates in real time; and promotes rapid response to failures, errors and omissions. What appears to be missing is a system that works? I believe that (1) we are missing a capability to obtain information quickly, at low cost, accurately and in relevant detail to link cause and effect; and (2) we are missing a capability to absorb information and relate that information through clustering, to domain specific situations by region; and (3) we appear to lack the will to stop doing that which may be causing us harm. Might I suggest that a federated, distributed health information technology (HIT) solution be used to meet these needs?

  39. Jennifer Warren says:

    What the author fails to address is that there is a vast difference between a physician misreading an x-ray, and a physician who is unable to force an unwilling patient to follow through with recommendations to have an eye exam, or follow a diet and exercise plan! It is entirely the radiologist’s responsibility to read an x-ray, but it is a SHARED responsibility between the patient and the physician, as well as other members of the support team, when it comes to problems like diabetic management. As long as it is a “free country” a physician cannot (and should not) FORCE a patient to do something against his or her will. The physician’s job is to educate the patient, recommend appropriate interventions including referal to other support team members, encourage the patient to follow the recommendations, follow up on results, and give the patient feedback. The physician should not be judged on things that are beyond his or her control – such as the willingness of a patient to “comply” with recommendations – but rather should be judged on the parameters over which he/she DOES have control – such as whether appropriate education, recommendations, and followup were completed.
    Some physicians ARE better motivators than others, I realize this; this is likely related to personality traits, and the support or lack thereof by the parent organization. For example, when I worked in practices owned by others (including hospitals), with relatively weak staff support for education, my diabetic patients had only average results. Once I opened my own clinic, and had complete control over the quality and quantitiy of staff for patient education, my patients’ numbers improved markedly.
    In order to address a problem, it is critical to fully clarify who is responsible for what, and hold the appropriate person accountable for specific actions that are within the control of that person. It is also important to differentiate ACTIONS from OUTCOMES. For example, a physician may perform identical actions with two different patients (recommend the patient see a diabetic educator, have a hemoglobin A1C drawn, etc) and have two entirely different OUTCOMES due to nothing within the control of the doctor; rather, the outcome is based on the patient’s decisions. Hold the right person accountable for their actions, and consequences.
    I agree with the statement that “Good leaders in my experience only do four things: they examine the environment and decide on a vision that can excite themselves and others. They translate the vision into strategies and tactics; they assign the strategies and tactics to someone to carry out; they then hold the responsible party or parties accountable for the results.” The problem for the average primary care physician employed by someone else is that he/she may not be able to excite their employer, enact a vision, have enough or adequate staff to whom to delegate tasks, or hold accountable for results. He/she often has to do all of these tasks by him/herself in an unsupportive environment. Nothing is more frustrating to any person than to be told they are held responsible, but have no control. I believe this is what many primary care physicians are dealing with today.

  40. I wonder if the report cards should / will take into account how Participatory the practice is (how interactive it is with patients as members of Care Team)

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