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Trust Me I’m a Doctor vs. Physician Quality Report Cards

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By KENT BOTTLES, MD

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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  46. 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.

  47. 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?

  48. 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.

  49. @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

  50. 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?

  51. 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.

  52. @MsCunningham
    > The idea of the guild, and living up to the
    > ideals of the professions,