The Destructiveness of Measures

A little box pops up before him asking if he asked the patient about the exercise.  He mumbles something under his breath, clicks a little box beneath the question, then moves on.

This is what medicine has become:  a series of computer queries and measures of clicks.  It must be measurable, quantifiable, and justifiable or it didn’t happen.

Do they ask if I asked them about if they used cocaine?  Of course not: too politically incorrect.

Do they ask if I really listened to their heart?  Of course not – this activity is not a paid activity.

Do they ask about the myriad of phone calls and e-mails to arrange for a procedure?  Nope.

Do they measure my time with the patient when I go back to see them on the same day?  Nope – not paid for.

So what’s the motivation for doctors to be doctors?  Are we retraining our doctors from care-givers to data providers?  What are we losing in turn?

An excellent opinion piece by Daniel Henniger appeared in the Wall Street Journal. In it, he references an important article by Drs. Christine Cassel and Sachin H Jain published in the June 17th issue of JAMA entitled “Assessing Individual Physician Performance: Does Measurement Suppress Motivation.” Cassel and Jain are two shapers of the Pay-for-Performance movement but acknowledge the danger this movement has on physician behavior:

Overstating the value of discrete quality measures has the potential to demotivate and demoralize physicians who appropriately view their job as much more than simply meeting a standardized measure set.

This point cannot be overemphasized.

Doctors are losing their motivation to diagnose in favor of sitting at a computer.  Doctors, I also dare say,  are losing their skills in favor of sitting at a computer.  Clicking buttons has such importance to health care systems that these performance measures are being linked, in part, to doctors’ salaries.  As a result, young doctors are losing their complex problem solving skills in favor of making sure they click on every result that comes to their inbox, lest they be seen as nonproductive.  This, you see, is what matters to employers.

We are reshaping medicine away from the bedside to the computer.

We’d better understand the damage this shift is causing before our young physicians of tomorrow don’t know any better.

Westby G. Fisher, MD, (aka Dr. Wes) is a board certified internist, cardiologist and cardiac electrophysiologist practicing at NorthShore University HealthSystem in Evanston, IL. He is also a Clinical Associate Professor of Medicine at the University of Chicago’s Pritzker School of Medicine. He blogs at Dr.Wes, where this post originally appeared.

11 replies »

  1. “Private radiology practices owned by radiologists were usually the last to adopt the changes, and then often only after the owners experienced digital systems in other places they worked.”

    I’m not meeting many private practice physicians that are adopting EMRs because their experience with hospital systems has been so delightful!

    My basic point is that some areas of medicine (such as radiology and pathology) lend themselves very readily to being digitized, and those involved in those areas (on both the technical and the professional side) made the transition because the immediate benefits were quite obvious.

    Those of used who are being forced by the government to become data processing specialists don’t see much, if any, benefit during our careers.

  2. It’s more like Granny Smith’s and Delicious.

    Actually, for the most part the digital revolution in radiology was forced on practicing radiologists by hospital and clinical systems based on the notion that large amounts of money could be saved for the hospitals and clinics — which generally pay for and control the technical end of radiology –by more accurately tracking work for record keeping and billing purposes, by saving on filing, storage, distribution, and retrieval costs, by savings from eliminating the cost of film, and by medico legal considerations involving potential liability for loss of patient exams. Private radiology practices owned by radiologists were usually the last to adopt the changes, and then often only after the owners experienced digital systems in other places they worked.

    As I noted above, there were very few working radiologists who adopted this “voluntarily” — dragged kicking and screaming was more often the case. However now, to most of our chagrin, we could not imagine being forced to go back. And of course radiologists trained in the digital era literally cannot imagine another way.

  3. That radiologists adopted “digital record keeping and storage” voluntarily without government mandates, subsidies, or Meaningful Use criteria describes a very different situation from what docs are now being forced into. Comparing apples and kiwis.

  4. Been there, done that.

    As a diagnostic radiologist, I work in a field that was well ahead of the curve in adoption of digital applications for record keeping, data storage, and actual work — as well as making certain that all competing systems could communicate with each other.

    I do not know a single experienced radiologist who was not very resistant to and annoyed by this change. I also do not know a single radiologist who after some experience would not say that the digital systems are better than the old systems, improve care, increase throughput, and in general are far preferable to the now extinct older ways of doing things.

    I do know many people who found the “prompts” and field requirements of the new systems annoying, but most of those people can now cite experiences where those same annoyances saved them from making significant mistakes or oversights as they charged along through a busy and confused workday. I certainly experienced that myself.

    Like an experienced tech or nurse, if you listen to the prompts they will help you in the end. In radiology, we used to say that there was a term for a radiologist who refused to ever listen to techs who were trying to help. They were called “the defendant.”

  5. Payers will not find this thought pleasurable,
    But certain clinical skills are immeasurable,
    The time and skills it takes to solve problems,
    The knowledge it takes into context to put them.

  6. So great that y’all can be so philosophical about this. “My hope that this will eventually bring about change for the better gives me faith in this new technology.”

  7. I have seen the same happening at my work place. We have new EHR that require us to measure all the points that fulfill the requirement for the incentive program and that takes up most of the physician’s time. Lot of time patient’s complains of waiting too long because the physicians are busy completing the charts in the EHR with all the click and checks. but, I also feel that it does make physician ask lot of things to patient and check on things that would have bypassed otherwise. May be all this EHR are work in progress towards a more comprehensive product that will reduce repetitive work and give more meaningful time with doctors for patients.

  8. My own docs have mentioned that using computers aren’t making them more efficient, however, this (I think) is part of the growing pains of technology in medicine. The hope is that technology will eventually (and soon) give back the time taken away from the patient bedside.

  9. “young doctors are losing their complex problem solving skills in favor of making sure they click on every result that comes to their inbox.”

    I’d love to hear what Lawrence and Lincoln Weed would have to say about this.