More on performance measures

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Category : Medical Rants

As often happens, when I post on performance measures I elicit two varieties of comments. The first variety implore us to find measures to guarantee better medical care. The comments suggest that we can decrease health care costs through the use of performance measures. They also believe that we must be able to identify the best physicians through a scoring system. These comments assume that with hard work we could find performance measures that would work for those goals.

The second group tends to support my views. They speak to the complexity and breadth of what physicians do. I will try to clarify my view in the hope that readers will understand my position more completely.

How do we define excellent medical care? What do we expect physicians to do? Can we measure the qualities of a great physician?

I repeatedly write about this issue. What makes a high quality physician?

Both groups stressed knowledge. The admire smart physicians. I must confess that this answer requires more granularity. How do we define a knowledgable physician? Are we concerned about test scores? As I consider this issue, my main concern is whether the physician can apply that knowledge to clinical problem solving. I would love some readers thoughts on this issue. Please identify yourself as a physician or not.

Physicians more often used words like compassion and communication, while non-physicians seemed to stress bedside manner. The physicians may underestimate the importance to patients of the many aspects of bedside manner. I read terms like respect, partnership, lack of condescension in the non-physician responses. Physicians stress compassion and communication. I suspect the difference in word choice stems from our accustomed role in the doctor-patient relationship, but would appreciate physician thoughts on this concept.

The non-physicians more often cited intuition or decision making than the physicians. I suspect that many physicians assume clinical judgement/decision making is part of knowledge, but I personally would separate those two concepts. Again, I would love more discussion of this issue.

More physicians than non-physicians worried about humility. As physicians we are easily seduced by the power of our positions. The best physicians that I know do a good job of not overreaching. I worry about physicians who start to believe their press clippings.

Finally, many patients worry about timeliness and availability, while this did not make any physician list. This issue seems obvious, and something that we physicians should give focus.

Only one non-physician was interested in “report cards”. Several non-physicians mentioned charges for visits.

What do I believe are the most important characteristics?

I value making correct diagnoses highly. As an inpatient teacher, I too often see patients admitted to the hospital with incorrect diagnoses. Now before the critics yell that I see a biased patient population because I am an academician, please consider that I see VA patients and patients at a large community hospital. Making the correct diagnosis drives the entire management process. But how can we develop a performance measure for diagnostic acumen?

Second I value communication. Clinicians must do a good job of explaining diagnosis, diagnostic testing, test results, treatment plans, etc. We must determine our patients’ goals, and fit the treatment plan to those goals. We should help patients prepare for end of life issues, respecting their beliefs and desires. We must know when paternalism is appropriate – Longing for days when doctors still advised – and when patients want to control the decision making process.

Third, I value parsimony. We should do diagnostic tests that matter. Before ordering a diagnostic test we must always ask what are the possible results, and how would those results change our treatment plan? Diagnostic testing must reflect a careful thought process.

Finally, we need to develop rational evidence based treatment plans when possible. Sometimes we must improvise, because the needed evidence does not exist.

Our jobs have greatly complexity. Our patients differ in many ways – diagnoses, past medical history, existing medications, religious beliefs, belief in supplements, socioeconomic status, trust in physicians, etc. We must treat patients individually, yet performance measures encourage us to meet arbitrary standards.

I have previously quoted Onora O’Neill, a noted British philosopher. She worries about the impact of the very performance measures that many want. She said,

Bogus numbers can be more than an expensive irrelevance. They can create perverse incentives, especially when numbers are published in league tables for the public without the complex information needed to set them in context.

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Yet faith in performance indicators is hard to dislodge. Every time one performance indicator is shown to be inaccurate, shown to encourage perverse behaviour, or shown to mislead the public, eager people imagine that they will find other performance indicators free of such adverse effects. Experience suggests that they are as mistaken as those who produced the last lot of indicators.

These words come from a philosopher, not a physician. She worries about developing a culture of distrust as a natural sequel to performance measurement and “league tables”.

Can we distinguish great physicians from good physicians from bad physicians? We can, but not through performance measurement. Performance measurement only encourages playing to the test, not providing great medical care.

We can grade physicians much like we grade dancers or actors or lecturers. We need experts to observe a physician through a variety of interactions and observe their decision making.

Critics will continue to search for a magic set of performance measures. We want to believe that we can measure excellence easily. We cannot. Being a great physician is too complex to model through performance measures.

I know that my answer is very frustrating to many readers. They desperately want to measure physician performance. We will continue to invest resources into performance measurement because this is a “sticky idea”. Too many payers and politicians believe that performance measurement will improve quality and reduce costs.

I challenge them to test their hypothesis. If we believe in evidence based medicine, then we must measure the impact of performance measurement. I doubt that medicine differs from other avenues. Whenever economists examine performance measurement, they find that these measures do change behavior, but too often the the changes are disappointing.

I know that I am trying to swim upstream against a strong current. I write constantly about this issue because I feel great passion about medicine. I fear the impact of this movement. We must yell that the emperor has no clothes. We cannot remain quiet.

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Comments (6)

DB,

I appreciate your answer as well as the complexity of the issue. As a non-physician and a patient who has had more than my share of interaction with the healthcare system, I would be more than pleased to have access to a peer developed evaluation system that assesses doctors based on intangibles like dancers or actors are judged. Classifications might include something like: Outstanding, well above average, average, below average, and too inexperienced to evaluate. Perhaps cost effectiveness metrics that attempt to get at defensive medicine and utilization driven by doctor owned equipment, labs, ASC’s, etc. could be disclosed separately. I would place very little value on patient evaluations because I think they put too much emphasis on affability and availability whereas I am most interested in clinical ability and cost-effectiveness. Pricing transparency, especially for expensive hospitalizations and surgeons’ fees would also be helpful. For commodity services like MRI’s, drugs and the like, doctors should have price transparency tools at their disposal so they can steer patients to the most cost-effective imaging centers, drugs, etc.

I feel opposite to BC in that I value patient evals more than anything else. It does me little good to see a physician who may be accredited as an expert and be very intelligent but is so rude, so uncaring, and so poor at listeneing that they cannot assist me.

Already patients put together lists of physicians for chronic health problems and discuss the attributes of those physicians on message boards. We quickly learn who is worth seeing. Make this a formal process. Issues physician scales on a provider website.

As for pricing I don’t think my poor docs even understand how much hospital procedures will end up costing. The insurance companies are really the problem here.

I think affability and availability are certainly desirable and I would like to have them from a doc, but not if I have to sacrifice significant clinical ability to get them. Obviously, if several docs are roughly comparable on clinical ability, affability and availability would win the day in making a choice assuming the information is there to assess in the first place.

I’m still a med student, but I find that a lot of patients respond well if I explain to them what I’m thinking. I feel like it lets them know that I understand their problems and have a handle on what to do.

Would it matter if every single physician practicing today yelled at the top of his/her lungs that the emperor had no clothes? Do actual practicing physicans (“real doctors”) have any say in this?

P4P is coming from insurance companies and governement. The payors. They have created a way to limit fee increases to a small percentage of “performing” physicians who know how to play the game. Genius. It doesn’t matter one bit if we have evidence or not that it helps patients.

Until doctors can unionize or find some other way to exert some influence in the decision making realm ( the AMA seems rather impotent these days), they will continue to watch from the sidelines.

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