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The True Measures of a “Good Doctor”

White

Measuring patient outcomes is one way to determine how “good” a doctor is – but it is far from the only way.  In our obsession with measuring performance, we seem to have forgotten that.

In medicine we measure a lot of things. We measure procedure times, length of stay in the hospital, complication rates. As a chief of cardiology, I’m involved in measuring a wide range of metrics, from how quickly the patient receives treatment (door-to-balloon time) to major adverse cardiac event (MACE) rates, and numerous other measurements. The medical field has spent the last decade developing metrics to assess quality of health care, and certainly these measures have value.

But by themselves, these metrics are inadequate to answer the patient’s most essential question, “Do I have a good doctor?”

We seldom measure whether a doctor is available after hours when their patient has a concern. We seldom measure doctors’ ethics or whether they are able to meet the emotional needs of a patient. We seldom measure a doctor’s willingness to refer a patient to another physician if that person can better meet the patient’s needs. Yet to a patient, these things can be every bit as important as outcomes.

Most health care professionals know a “good doctor” when they encounter one.  Being a good doctor is not the same as a career achievement award such as being named a “master clinician.” Often we recognize “good doctors” among younger physicians-in-training, or junior faculty members, as well as some, but not all, senior faculty members.  Patients can identify “good doctors” without ever knowing what they scored on their Board exams.

I heard a lecture about “leadership” last year at the U.S. Naval Academy and was struck by how the qualities required of future military leadership could be adapted to the best qualities of a health care provider.  At my hospital in New Orleans, we have a cardiology fellowship training program, and I try to communicate these measures of “physician quality” to these young physicians-in-training, which I call the “Five C’s”:

  • Character: Physician character can be measured by such traits as honesty, confidentiality, humanity, humor, candor and ethics.
  • Compassion: Compassionate physicians are emotionally driven to help their patients feel better.  They treat their patients as they would treat a family member.
  • Commitment: These physicians are available when their patients need them, and considered hard-working by their peers. They take “ownership” of their patients’ problems, and work to resolve them.
  • Courage: Physicians who do what’s best for the patient even when it’s not in the best interest of the physician, such as making a referral or giving up a procedure. Physicians with courage have difficult conversations and are able to make judgments in the face of uncertainty to provide the best care for their patients.
  • Competence: Physicians who have the required knowledge and technical skills and work hard to keep themselves up to date.

Unfortunately, most of our quality measures today focus solely on the final quality – competence – and fail to truly measure many of the qualities that make a good doctor.

What do patients look for in a “good doctor”?  First and foremost are strong intellectual skills.  Good doctors are life-long learners.  Good doctors must have the emotional maturity, clinical experience and judgment to make difficult and complex decisions under conditions of uncertainty and ambiguity. Among all health care professionals, good doctors must be willing to accept ultimate responsibility for medical decisions the guidelines will not address.

Securing the trust of a patient and of one’s colleagues is what “good doctors” do.  And they do the right thing for the patient, even if it isn’t always the best thing for their hospital, their practice or themselves. It’s not that good doctors never make mistakes – they do.  It’s not that they are all knowing or all seeing – they aren’t.  They may not have the highest exam scores or be the most efficient, but they are the doctors we trust to care for us.

Good doctors are an absolute requirement for delivering high-quality health care to a patient, but even a good doctor in a poorly organized or poorly financed health care system may not be able to deliver good quality outcomes.

As our national health reform discussion continues and we decide to seriously embrace quality of health care issues, it’s time we focus on teaching our medical students and physicians-in-training what physician quality truly means. And it’s time we develop a broader assessment of what makes a “good doctor.”

Christopher J. White, MD, FSCAI, is chairman of the Department of Cardiology and director of the Ochsner Heart and Vascular Institute in New Orleans. He serves as secretary of the Society for Cardiovascular Angiography and Interventions (SCAI). Dr. White graduated AOA from Case Western Reserve University and completed his specialty training in internal medicine and cardiology at Letterman Army Medical Center in San Francisco. He has been elected to Fellowship in the American College of Cardiology, the American Heart Association, the European Society of Cardiology, the Society of Vascular Medicine and Biology, and the Society for Cardiovascular Angiography and Interventions. He is editor-in-chief of the interventional cardiology journal “Catheterization and Cardiovascular Interventions.”

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22 replies »

  1. My VA doctor she’s not miss personality…but she ans. all my questions and takes the time to go over all my tests and explain things. I going to stay with her…I have confidence that she’s doing her best for me.

  2. Reputation is linked to outcomes.

    If we are to ber paid by outcome, then I get to pick my patients.

  3. Hold the pickle, hold the lettuce.

    Special orders don’t upset us.

    All we ask is that you let us serve it your way?

    Really? Is that what you want your doctor to be?

    You sound like John Edwards at his wife’s press conference abour her breast cancer.

  4. This profession can not be the same as that of corporate but slowly becoming so…We not only worship them as Gods we also give them our lives to work with lol.

  5. Does it have to be only one way or the other? Good doctors with good bedside manner still have to make the patient better. Why should he object to his results being measured if he is doing a good job?

  6. Personal care of another human being CANNOT be industrialized. Our current system exists as a failed experimental proof.
    At the center? The failed idea that it’s ok to be afraid that someone, somewhere, at any given moment, might receive care they didn’t necessarily earn. That they are not worthy of a doctor’s attention by virtue of having lost the job market foot race.
    Charity begins when we give to those who DO NOT deserve it.
    Lets make Medical Care a matter of human decency again.

  7. The left coast mountain folks missed the target again. This has nothing to do with the government or how well they will pay Intermountain to do business for them. This is written by a man who has spent his entire life training high quality doctors and does KNOW one when he sees one. Organized medicine and the government do not know how to measure quality but do know that having the best health insurance your money can buy helps them pick and choose one until each Senator or Congressman/women finds one. So many of these folks who blog all day, are experts at one thing, ….. blogging.

  8. Let’s see; character, compassion, commitment, courage, competence – all in a fifteen minute appointment?

  9. Medicine has become as much a victim of bottom-line mentality as any other industry sector – the hope of medicine lies in the humanity of its community members, also mirroring all other human enterprise.
    I’m glad Dr. White is teaching. Oh, boy, am I glad. We’ve reached the tipping point of complete unworkablity in the US health care system, and we’re sicker than ever. Doctors are at the heart – pun fully intended – of whatever fix gets crafted. Can we clone this guy?

  10. A good doctor learns to retain his basic humanity while adopting the superior skill. This is a very nice posting indeed. 🙂

  11. Bravo Michael Millenson!
    I’ll just point out another two massive problems with Dr. White’s piece (and similar pieces of the growing anti-measurement movement).
    1. There is no “good doctor.” This construct simply doesn’t exist, and it betrays an unfortunate doctor-centered view of the health care universe. The quality of care delivered by a given doctor varies according to the setting in which he or she practices, the type of condition being diagnosed or treated, the phase of illness, innumerable patient factors, and a large dose of random chance. As a PCP, I might be very good at diagnosis and lousy at motivational interviewing. A surgeon might be wonderful in the operating room but provide distrastrous post-op care. Anybody looking to the “good doctor” as the guarantor of high-quality health care is barking up the wrong tree, which brings me to…
    2. What matters is what happens to patients. Period. Quality of care is defined by patients’ outcomes and experiences of care, not by the nature of the provider–or health system–that delivers the care. This is why measures of clinical care are especially important: they are largely agnostic to provider type, and they therefore enable comparisons of care delivered by providers who have different training and systems that have different structures. In other words, they don’t rest on the fallacy that “good care” is equal to “care delivered by a good doctor.”
    Sure, existing quality measures provide an incomplete and inexact view of overall quality. Despite Dr. White’s straw man, in reality no thoughtful quality guru fails to acknowledge these shortcomings. But at least quality measurement has the correct, patient-centered conceptual model at its core.

  12. Dr. White talks about our “obsession” with “measuring performance” and then goes on to talk about all the important human qualities, and intangible skills, that make a good doctor.
    In doing so, he has managed to thoroughly demolish a straw man of his own making. The focus on objective quality measures is due to the failure of professionalism alone as a force sufficient to achieve adherence to evidence-based medical practices even in those cases where the evidence is utterly clear. Moreover, professionalism NEVER had the power that doctors today like to ascribe to it. I thoroughly reviewed the medical literature and the history in my book, “Demanding Medical Excellence,” and similar recent articles can easily be found if one looks, most notably by Dr. Donald Berwick, head of the Institute for Healthcare Improvement, and many other physician researchers.
    There is not a doctor in America today who has a majority of his compensation linked to outcomes; so much for “obsession.” There are perhaps some physicians who have a majority of compensation linked to various process measures, such as following evidence-based chronic care practices, but those doctors are in groups where the oversight comes from other physicians.
    All the intangibles Dr. White talks about are absolutely important. But his message is a dangerous one. By ignoring completely the death and injury toll of idiosyncratic medical practice, and focusing only on the “intangibles,” he is promoting the “old” definition of quality: “I know it when I see it.”
    That is not good enough, anymore. The alternative is not an “obsession;” the alternative is fair accountability. Accountability that takes into account gray areas while being firm on areas where standards are clear. Many leading edge health care organizations (e.g., Intermountain) are following that path. Dr. White’s earnests complaint looks to a falsified past, albeit one that many doctors believe in, rather than to a better future for professionals and patients alike.

  13. From a patient’s perspective, I would be interested in knowing the following:
    1. The standard information such as where the doctor went to medical school and received his or her training as well as board certification information would be helpful.
    2. How many years has the doctor been practicing and how many doctors and nurses does he have as patients? My understanding is that the less competent doctors don’t have many (or any) doctors and nurses as patients.
    3. For the routine issues, what is the lead time for getting an appointment and how long will I have to typically wait to be seen once I arrive?
    My real concern, however, is how will I be treated if and when I have a serious medical issue such as the need for major surgery, cancer treatment or, ultimately, end of life care? In this context, a doctor’s own honest (hopefully) self evaluation readily available on line that covers the following issues would be of keen interest:
    1. Do you believe in and offer shared decision making, especially with respect to surgery and cancer treatment options?
    2. Will you recommend, offer and support the use of palliative care consults to explain the options available in end of life situations and the quality of life implications of each whether or not they are covered by insurance?
    3. Will you respect and adhere to a patient’s clearly communicated wishes, either orally or in writing, regarding end of life care, including a desire for no heroic measures? Or will you override the patient’s preferences and impose your own judgment and preferred practice pattern instead?
    4. Will you manage pain aggressively in order to keep the patient as comfortable as possible if that’s what the patient wants?
    If I eventually wind up with severe dementia, Alzheimer’s, late stage cancer, ESRD, etc., I or my surrogate would like to know these things ahead of time so they can be taken into consideration in choosing either a PCP or an appropriate specialist.

  14. Dr. White,
    What a great concept….we need good doctors which cares for patient. I however take exception to your comment on the metric aspect. Too many measurements does not mean right measurement. You may have heard the saying “someone talks too much but says nothing”. I think it was in reference to congress. The point is that wrong kind of metric does not negate the need for metric.
    If done right, fewer measurements can provide better indication. Now if there are ethics, integrity types of problems – as you hinted – then it becomes difficult to get much achieved even through metrics as there accuracy is also in question.
    As for as ethics is concerned, this is one thing that can not be legislated…..Very difficult.
    thanks for the comment.
    rgds
    ravi
    blogs.biproinc.com/healthcare
    http://www.biproinc.com

  15. I agree with most of the above, but I think it is somewhat general – what constitutes a good doctor varies and depends on
    1. the required skills in a certain medical situation and
    2. what the patient expects.
    For instance, a PCP who is a poor diagnostician might be a better one than the wise guy if he motivates his/her patients taking their BP and diabetes meds.
    On the other hand, patients (and often other doctors not practicing the same specialty) frequently mistake the number of tests ordered as a sign of thoroughness (and the reverse conclusion).
    And moreover, a technically very difficult surgery might be best performed by a terrible communicator and certified a..hole.
    But of course, Dr. White is on the mark in the big picture. The conflict of interest issue (foregoing a procedure etc.) might be too big of problem to leave it just to the doctor’s character strength … reimbursement idiosyncracies (resultnig in doctors doing what pays, not what helps best) do matter and should be corrected.

  16. Dr. White:
    Excellent post. What you are describing is the “art of medicine,” or, on a less lofty level, basic professionalism. For me, that means the quality of my one-on-one interactions with my patients. Unfortunately, that cannot be quantitated, and is therefore considered of no value in the new model of health care. Sad.

  17. A good Doctor has to pass through tough exams to become one but that qualifies him for the post what makes him good is his capability to become as much human with the quality of expertise he has earned in life.

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