THCB

Finding A Quality Doctor

The New York Times recently published an article titled, Finding a Quality Doctor, Dr. Danielle Ofri an internist at NYU, laments how she was unable to perform as well as expected in the areas of patient care as it related to diabetes. From the August 2010 New England Journal of Medicine article, Dr. Ofri notes that her report card showed the following – 33% of patients with diabetes have glycated hemoglobin levels at goal, 44% have cholesterol levels at goal, and a measly 26% have blood pressure at goal. She correctly notes that these measurements alone aren’t what makes a doctor a good quality one, but rather the areas of interpersonal skills, compassion, and empathy, which most of us would agree constitute a doctor’s bedside manner, should count as well.

Her article was simply to illustrate that “most doctors are genuinely doing their best to help their patients and that these report cards might not be accurate reflections of their care” yet when she offered this perspective, a contrary point of view, many viewed it as “evidence of arrogance.”

She comforted herself by noting that those who criticized her were “mostly [from] doctors who were not involved in direct patient care (medical administrators, pathologists, radiologists). None were in the trenches of primary care.”

From the original NEJM article, Dr. Ofri concluded when it related to the care of patients with diabetes and her report card –

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. It’s too disheartening, and it chips away at whatever is left of my morale. Besides, there are already five charts in my box — real patients waiting to be seen — and I need my energy for them.

As a practicing primary care doctor, I’m afraid that Dr. Ofri and many other doctors are making a fundamental attribution error is assuming that somehow doctors can’t do both. She is also wrong in thinking that the real patients waiting to be seen are somehow more important that those whose blood pressure, cholesterol, and blood sugars are poorly controlled and the disease literally eats them up from the inside which could result in end organ damage to the eyes (blindness), kidneys (renal failure resulting in dialysis), extremities (amputation), and heart (coronary artery disease) and possibly premature death. They aren’t in the office and yet are suffering.

Until we as doctors begin to take responsibility for our performance in hard clinical and objective outcomes like glycated hemoglobin levels, cholesterol, and blood pressure, our patients will pay a price. We should not pretend that bedside manner should trump clinical outcomes nor that clinical outcomes should override the humanistic part of medicine.

It is possible to do both today. It isn’t theoretical. I only serve as one example.

I’m a front-line primary care doctor who also takes care of patients. I like Dr. Ofri also get a report card on my performance in caring for patients with diabetes.

Based on the medical evidence, my goals are set similarly to hers. For 2010, my performance wasn’t perfect but was 88.6%, 80.8%, and 70% at goal respectively.

I suspect critics will immediately begin to make a lot of assumptions of how these scores were achieved, when Dr. Ofri, another primary care doctor had very different outcomes. Is it that I am not a quality doctor? Perhaps I’m too driven by data and have no – “soft” attributes like attentiveness, curiosity, compassion, diligence, connection and communication. Perhaps I “fire” those patients who are not able to achieve good outcomes.

I can tell you many patients wish to join my practice and rarely do people choose to leave it. The organization I work for also takes the softer side of medicine, a doctor’s bedside manner, seriously. My employer randomly surveys patients on their experience. Does your doctor listen and explain? Do they know your medical history? Do they partner with you in your health? Do you have confidence in the care they provided you?

For 2010, 92.8 percent rated me very good or excellent on these elements.

So what does this all mean?

We should not automatically assume that doctors with great bedside manner cannot also provide great clinical care.

I can achieve the goals, which patients would want, and still be a doctor with great bedside manner because I work in a functional system like Kaiser Permanente. Primary care doctors are blessed with a comprehensive electronic medical record, are partnered with staff who help patients get the care they need, and are surrounded by specialty colleagues equally as focused to keep patients healthy and well.

So if there is any area of agreement with Dr. Ofri it is that simply giving doctors report cards and telling them to try harder will simply achieve mediocre outcomes. Until there is a fundamental restructuring on health care is delivered (and simply making appointments longer isn’t necessarily going to solve it either), then primary care doctors will continue to leave the specialty in droves. Doctors need to lead change and use tools and skills honed in other industries, whether the Toyota Production model or lean process, which has been utilized by the Virginia Mason Hospital, or usage of protocols and checklists based on scientific evidence as demonstrated by Intermountain Healthcare and Dr. Brent James.

Until we as doctors lead, we cannot or should not expect improvement in patient outcomes. We can no longer hide behind the reasons of our Herculean effort or bedside manner as what should really matter and account for something. Patients expect these attributes intuitively.

With already so many examples of success in the country marrying the art, science, and humanistic part of medicine, the only thing stopping us to re-invent American medicine in the 21st century is simply ourselves.

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24 replies »

  1. I think health care would be hpeacer to provide universally if people would not define good health care with highest trained provider possible. I had low-risk pregnancies, and received amazing care from midwives each time. People often disparage midwife care to me by saying but, no, I would want someone really qualified to attend my birth. right. Maybe that is why my midwife teaches at the medical school and med students trailed us around. Similar with check ups. I love when I can catch our family doctor. But I’m a healthy person. All I need is to check my cholesterol and vitals each year. I have found the physician’s assistant she works with to be very competent. It frees up our doctor to work with patients with more complex or chronic needs. Do my kids even need a pediatrician if they are healthy kids? Why wouldnt a PA or nurse practioner do well-baby checks and the dr handle sick kids or kids with chronic medical conditions? My next to last employer was major university with a top 5 med school and hospital. Yet the employee health plan provided nurse practioners for routine OB care. You saw an OB as necessary for a medic condition. So I’m on favor of blurring the lines between the nurses and MDs. PS: as a parent it is frustrating when you just want to speak to the Dr. But it seems like much of pediatrics phone triage is managing parents. I’ve probably called 2 dozen times and have been triaged to bring the child on question in about 20%. I call a LOT less now because I’ve learned from those nurses about fevers, pink eye, diarrhea, weird bruises. Other practices with more urgent concerns and patients that might understand when to call (say, the allergist) have Drs answer the calls themselves.VA:F [1.9.10_1130]please wait…(1 vote cast)

  2. Actually, a lot of doctors do sduzibise more than just free care because they want to work in a particular setting, say an academic medical center. I would make twice as much in the private sector as I do in my non-profit teaching hospital position (which is still a good salary overall, but if it was much less, it wouldn’t be worth the stress and time away from family and fear of lawsuits to me, so I wouldn’t do it. Yes, I expect some fair level of compensation, greedy doc that I am). Granted, I want to be here so I can teach residents, but people like me do sduzibise the system with our hard work. I generate hundreds of thousands of dollars for a non-profit hospital, none of which ever makes it into my pocket. It goes into the overall budget and running of this place, which provides a heck of a lot of free care. So, I benefit, the hospital benefits, the patient benefits. As a physician and a patient with multiple sclerosis, I think the problem with the medical system in the US is the feeling, from patients and doctors both, that there is no choice. It may be more choice than in other systems, but the rigidity chafes….at least that’s how I feel as both a deliverer and a ,er, consumer, of medical care. I am so locked in to the system. Any changes or improvements I’d like to make in my position are out of my hands and dealt with by middle-managers or I-only-care-about-the-next-line-on-my CV academic types. Hence, ‘youngsters’ like me typically last a few years in this sort of hospital and move on to private practice. Not so much for the money, as for the perceived *freedom* of it. Laugh, but that’s how it feels…..

  3. I don’t focus on the goal because the data doesn’t support focusing on a goal. Keep the sugars in a range that prevents symptoms and immediate medical complications. Try to minimize the med burden, adding insulin only when things are consistently worsening, etc. (Focus on diet, exercise, wt loss as by far the most important issues, I’m sure we agree on that)

    Defining quality care as how many patients reach a goal for which there is little evidence of improved outcomes is silly.
    It encourages robotic doctoring and misleads patients about what benefits they’re getting from treatment.

  4. As you may know, tight blood sugar control has shown to result in better outcomes for type 1 diabetics. The data is not as compelling for type 2 diabetics.

    Both Dr. Ofri and I didn’t indicate what the Hgba1c goals were for our respective institutions.

    So given the less than clear data for type 2 diabetics at this time, what HgbA1c goal do you suggest to your patients?

  5. Agree that as MDs we must be careful on who is implementing improvements to make health care better. We should be both care driven and data driven as we both need to be empathetic as well as scientific. This is why I highlighted Virginia Mason as well as Intermountain Healthcare which like where I work are physician led and physician run organizations.

    And no, we don’t cherry pick at Kaiser Permanente. Patients are either assigned to our practice if they don’t have a PCP (and can always opt to choose a different primary care doctor later) or can join a practice if open to new patients. As I concluded in the end, we should not automatically assume that doctors with great bedside manner cannot also provide great clinical care. We need functional and rational systems of care where PCPs can do what we do best.

    I recognize that for many doctors in the country this is not the case.

  6. Reading my earlier comment, I was a bit harsh, so I will apologize for the tone of the posting. However, that said, I do think most doctors are care driven, and this attempt to refocus on “data driven” is not physician created but just an effort by governmental and EHR policies to make the gray of treatment the black and white assessments of those two elements.

    I find comparing health care outcomes to business models the undoing of health care. I do applaud you for doing the best you can, but, I have to honest and sense you might be cherry picking your patient population a bit.

    If I am wrong, then good for you.

  7. I’d like to see your demographics, like Margalit asked.

    You didn’t address the A1C issue either. Do you think there is good evidence it’s important to get type 2 DM patients to goal with meds and insulin?

  8. I believe in evidence based medical care. None of my patients are on ZETIA. The vast majority are on SIMVASTATIN for the reasons you indicate. Rarely do patients need more than 3 blood pressure medications to get to goal.

    Note I didn’t say my outcomes were perfect, nor should they be for all of the reasons you indicate.

  9. I encourage you to investigate the evidence that controlling A1C with pills or insulin has any important patient oriented outcomes. When you find that it doesn’t, I then wonder how ethical your practice is when you are strongly encouraging patients to commit to the interventions you recommend in the name of making your performance scores look better.

    I also wonder if you are using zetia to help your aggregate cholesterol numbers, a medicine that has never been shown to help a patient with any clinically important outcome.

    I also wonder how many patients of yours are on expensive statins rather than Simvastatin because they weren’t “at goal” on their LDL. I assume you know the LDL number isn’t what matters, it’s just being on the statin at moderate doses that gives the benefit.

    Then I wonder how many blood pressure meds you “strongly recommend” to your patients, even if they are already on 3 or more meds, likely having side effects you downplay. I encourage you to find a study that adding a 4th BP med to those close to goal and already on 5-10 total meds improves outcomes.

    I could go on.

  10. Dr. Liu, could you describe your practice a little bit (how many patients per day, average appointment time, % Medicare, % Medicaid, % uninsured…..)?
    Not sure if there is similar information on Dr. Ofri’s practice, but it would be nice to compare side by side.

  11. Agree, it is complex. Obviously, patients must do the things you talk about. However, I would note that blood sugar control and blood pressure are things that doctors can help patients with to get better. Note a recent WSJ article.
    http://online.wsj.com/article/SB10001424052702304563104576355542170157276.html

    In regards to blood sugar control, note a 2005 article in Diabetes care – http://care.diabetesjournals.org/content/28/11/2673.full

    Physicians and nurses in a given country tended to have similar attitudes toward delay of insulin therapy. For example, the belief that insulin therapy should be delayed until absolutely necessary was strongly held in the U.S. among both physicians and nurses; …. Although we cannot link specific patients to their own providers, this pattern closely resembles that observed for patients’ attitudes toward insulin; U.S. patients were among the lowest in perceived insulin efficacy and among the highest in insulin self-blame. This suggests that beliefs about insulin are related to the cultures and health care systems of the different countries, and understanding beliefs about insulin will require an understanding of how these factors operate.

    …Providers can help patients who blame themselves for needing to initiate insulin therapy by making sure patients understand that diabetes is a progressive disease. Providers can also reduce self-blame as a barrier to insulin therapy if they avoid the strategy of encouraging more active self-care by pointing to insulin as a consequence of inaction. This strategy, which over half the providers in our study reported using, can make it more difficult to initiate insulin therapy subsequently.

    In other words, how doctors perceive the use of insulin to lower blood sugars and how quickly therapy is initiated will impact the likelihood of a patient adding it as therapy.

  12. I apologize if you felt that this post implied that primary care doctors are not working hard. That was not my intention.

    Dr. Ofri’s point of view is simply just one, yet has significant implications because of her visibility via her columns in the New York Times and the New England Journal of Medicine.

    I believe that patients and doctors should expect high quality both the bedside manner as well as the science.

    Since doctors are also data-driven, what does the “evidence” show mindset, I simply provide mine to contrast with Dr. Ofri’s.

    I know that a dysfunctional system will not allow doctors to succeed in these endeavors. For the majority of primary care doctors, this exists and is why they are leaving the specialty in droves.

    As I point out “So if there is any area of agreement with Dr. Ofri it is that simply giving doctors report cards and telling them to try harder will simply achieve mediocre outcomes. Until there is a fundamental restructuring on health care is delivered (and simply making appointments longer isn’t necessarily going to solve it either), then primary care doctors will continue to leave the specialty in droves. Doctors need to lead change and use tools and skills honed in other industries, whether the Toyota Production model or lean process, which has been utilized by the Virginia Mason Hospital, or usage of protocols and checklists based on scientific evidence as demonstrated by Intermountain Healthcare and Dr. Brent James.”

    So there are other examples, besides Kaiser Permanente, where primary care is doing better.

    Kaiser Permanente also does community benefit to help those in need.

    http://info.kp.org/communitybenefit/html/our_stories/northern-california/2010report/index.html

    http://info.kp.org/communitybenefit/html/about_us/northern-california/index.html

  13. All the evidence points to the fact that meeting the goals the original poster is so proud of only increases costs and complications, but does not improve long term health or life span.

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  15. Even though it’s not a new insight in this thread, I need to agree with those who found this self-congratulatory post nauseating.

  16. When it comes to patient satisfaction, I think most patients are likely to rate doctors based on the three A’s – affability (bedside manner), availability (lead time to get an appointment plus time in the waiting room before being seen), and last and LEAST, ability (to produce positive outcomes). The first two are easier for the patient to measure, at least subjectively. The third one is influenced by patient compliance, especially in the areas of HbA1c, cholesterol and blood pressure control. While I don’t know, I suspect that the poor and the elderly are likely to be less compliant at the population level in taking their medications, controlling weight, not smoking, etc. as compared to the educated middle class, upper middle class and wealthy non-elderly. When patient compliance or lack of it is a significant issue, it’s not appropriate to attribute 100% of patient outcome results to the doctor’s clinical skill or lack of it.

  17. How long is that arm of yours in patting yourself in the back per this post?

    “I can tell you many patients wish to join my practice and rarely do people choose to leave it.

    For 2010, 92.8 percent rated me very good or excellent on these elements.

    Based on the medical evidence, my goals are set similarly to hers. For 2010, my performance wasn’t perfect but was 88.6%, 80.8%, and 70% at goal respectively.”

    Congratulations on your accomplishments, and letting us all know. Please do not follow up with telling us less patients die under your care, because at that point it will challenge those of us who are also at the front lines taking care of all elements of our population, not just those who can access Kaiser.

    Didn’t think I picked up on that little point?

  18. Unfortunately for Dr, Ofri, proposed payment models do not take into account patient satisfaction, which agreeably is an important variable in providing optimal health care value.

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