Being Graded

Munia Mitra MD“Lawyers aren’t graded.”

“CEOs aren’t graded”

“How would you feel if I tracked every e-mail you sent and tracked how many people responded to them? You wouldn’t like that very much would you?”   

“The people who make EMRs. Why aren’t they graded?”

If there’s one negative I hear time and time again from doctors when the subject of quality measurement comes up, it’s this one near-universal complaint. The world is unfair, the cards are stacked against us.

As a specialist at a busy urban medical center I hear the complaints almost every day from colleagues and peers at other hospitals. We’re being singled out for unfair treatment:  They’re out to get us. It’s the world against the doctors.

Many of the so-called experts I’ve talked to at meetings around the country express disdain when the topic of physician resistance to quality improvement programs comes up.

But it shouldn’t be terribly surprising that the idea that one’s performance is being tracked can be seen as intrusive and threatening. The reaction is in many ways completely predictable.

The issue is one I’ve had to deal with time and time in my day job as a management consultant as I go into health systems across the country and work on physician engagement projects designed to improve system efficiency and optimize outcomes.    

Improving outcomes? Physicians get it. Better healthcare at lower cost? Physicians are on board.  Better technology? Physicians want it. Despite what you may have heard.  But tracking their performance? Not so fast. 

Let’s take this up to thirty thousand feet for a moment.

As health systems move to accountable care based models, physicians are increasingly becoming the focus of quality measurement programs. This is because conceptually, the aco model  asks individual physicians to serve as a proxy for how well the system is performing.

The model tasks us all to take accountability for the quality of the care we deliver.

We could track anything.  There are other models we could use. In theory, we could tie quality metrics to any member of the care team.  We could track nursing metrics.  We could track track hospitalist performance.  When you stop and think about it, in theory we could even track patient performance. 

But we track physician performance. Why? Because we’re in early days. And we haven’t figure out how to do the really complicated stuff yet. physician performance is the best number we have. And therein lies the problem.

“The problem has to do with how people take and give feedback.” John Haughom, a senior advisor at Health Catalyst told me. “On the other side. If anything, there’s a tendency to point fingers. In my experience that leads to resistance and frustration.”

That’s exactly what I’ve found.  I hear it time and time again as I talk to doctors.

“The key is explaining the big picture to people. Helping them understand this is all going somewhere. This isn’t about them. It’s about something bigger than them.  It’s about how they fit in and how we make it better.” Haughom adds.  

When people get the purpose of the exercise, resistance magically melts away. And surprise, surprise: the numbers typically get better.

Healthy Competition

I’m a geek.  I am one of those people who like being graded.

Other kids sat up all night waiting for Santa Klaus. I sat up all night waiting for my grades.

Why? I love grades. That’s because, like a lot of people, my grades help me understand how I’m doing. They help me highlight my strengths and identify my weaknesses.  If I’m doing well, give myself a pat on the back. If I’m not doing well, I study harder.

Most doctors I know are the same way. Give us a playing field and we’ll compete on it.  Throughout high school, through med school,  we lived grade-based lives.  

In theory, harnessing doctors’ competitive natures to get that done shouldn’t be hard. 

The economic theory behind the accountable care organization model ties efficiency and cost gains to our taking accountability for our patients progress. By taking ownership of our patient’s’ progress, doctors make the system better, improve the quality of the care we deliver and cut health care costs.

“We’re results oriented-people,” explains Haughom.

“The giant irony here is that we get numbers. We’re used to working with them. We were honors students in high school. We pushed our way through medical school. We deal with patient data every day of the week.”

The key to getting through to folks is to get the message across about what this is all about  and  tap into that competitive nature, without creating a non-productive environment. That’s a balancing act. This is a tr“ Haughom told me.  

“We’re individual players playing a team sport and that’s not always easy,” he adds.

“Part of this is about translating the accountable care team concept. And that takes some work. Despite the fact that we should know better, many of think of ourselves as solo performers. For doctors, that’s a cultural thing. It’s changing. But slowly.  I’m optimistic that we’re getting there.  ”

Munia Mitra, MD is a physician in private practice in San Francisco.

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7 replies »

  1. The least the pro-raters can do is to tell us what you have in mind. What are you interested in? How would you want us to improve? You can’t be vague here, because there can be contradictory goals. E.g. say you want us to be able to manage a thousand random patients in the most cost-efficient way….because you believe we are inefficient economically. This latter effort might be quite impossible if you desire our goal to be to reach the most accurate diagnoses, or to make the patients most pleased with the encounters or to achieve the most qalys or the lowest morbidities or mortalities.

    So tell us a goal….and give us the opportunity to critique.

  2. I understand docs are upset. The system is changing, because it is unsustainable (errors, safety, poor care, unnecessary care, and costs). Change is hard. I’m glad docs like Dr. Mitra are out there trying to explain to other docs why it’s essential to “grade” them. But, yes, we are still figuring this out, and as Michael M says below that is happening with a lot of input from the physician community. Almost too much at times, I would argue. Among all the reasons to measure physician (individual or team) performance, the most compelling is that they do life and death stuff. It’s in no way acceptable to have that be a solo I’ll-do-what-I-want-don’t-bother-me thing. Those days are over. Accountability is not an option. The real on-the-ground problem in this area is that doctors are human and it’s always hard to motivate humans to want to improve and do better when what they are doing is sort of working FOR THEM. We went along with that for decades until it became very clear the whole system was not working that well FOR PATIENTS.

  3. One of the biggest strawmans in the quality world is the conflating of “quality cannot be meaningfully measured” with “quality is not important” (I realize that this allegation, too, is a strawman).

    Quality is culture. If the doctor is not practicing quality medicine when no one is looking, no amount of measuring will overcome that. Measurements cannot substitute for professional culture.

    This, of course, brings up a conundrum. If we don’t look to see if doctors are practicing quality medicine how will we know that they are practicing quality medicine?

  4. Take your word “progress”. What do you mean? LOS? Qalys added to life? Mortality decreased? Patient happiness? Patient OOP expenses reduced cf benchmark during course? Precision in diagnosis? Societal-family ramifications of patient’s illness considered? (e.g. sickle cell trait testing in relatives) Patient’s personal life and employment life more rewarding?

    If you are evaluating you have to measure something definable. Are you leaving these definitions to others?

    Imagine you could evaluate perfectly. You could answer every conceivable quality, scientific, and efficiency query about a physician…and you could get this information to all
    consumers. Question: What would be the statistical distribution of acceptable physicians? Do you know whether there would be enough acceptable physicians so that the health care sector could survive? There might be so few winners that the system would halt. Eg if we rated airline pilots, I can see most folks waiting months to get on certain flights and the entire system would collapse. Shouldn’t you know a little about the unintended side effects before you begin rating en masse.

  5. I agree with Dr. Dawson. First of all, along with the medical self-pity (“No one else is graded”) there’s the confusion of “I feel this is true” with “It is true.” (Ben Carson, anyone?) EHR vendors are graded, through KLAS. Lawyers, like everyone else, can have Yelp comments, but if you don’t think the Big Payers for legal services are into accountability, you’re wrong. And how about teachers? Talk about unfair — where’s the risk adjustment for my pupils!

    Second, and more importantly, is that legitimate accountability can involve measures available to the public and measures that physicians themselves see and then use to improve. So, for instance, the alternative quality contract of BCBS of Massachusetts uses detailed individual physician measures (often process ones) with feedback for self improvement. At the same time, some measures (say, CABG outcomes by surgeon) have been shown to be valid even though surgeons are convinced they are not.

    No one likes to be measured, certainly not publicly. These days, “metrics” abound for all of us, sometimes from our corporate bosses, sometimes in public. Many conscientious physicians are working on making sure good measures are used appropriately. Their colleagues should support them.

  6. Whenever I read a commentary like this one – I am stunned by the political naivete of physicians. To minimize the fact that nobody else is graded or subjected to other more onerous management techniques is somewhat incredible. Many of the metrics at this point are pulled out of thin air or as your commentary points out measure many things that physicians have no control over including ineffective “customer service” metrics put on them by the very administration who claims to “grade them”. Anyone who claims that customer service has anything to do with medical quality doesn’t have a clue about the concept. I don’t think that quality is a dimension being measured currently. Physicians are generally not being given what they need to provide quality care and their time is routinely wasted by their own administration and the administrations of health care organizations. Many metrics are used either as penalties or false incentives such as: “If your group makes this metric we will pay you the 5% holdback from your pay.”