How do I judge physician excellence?

5

Category : Medical Rants

Last night I went to a retirement party for a surgeon. He taught medical students while doing private practice. Our students honored him with many teaching awards. They all have told me what a great surgeon and role model he is.

As I drove home, I thought about physician excellence. How do I judge excellence? Here is my report card:

    Characteristics of physician excellence

  • Making correct diagnoses – Patients present with various problems. The excellent physician diagnoses the etiology of those signs and symptoms. This is not a trivial task. Jerome Groopman’s book (How Doctors Think) is devoted to the difficulties of diagnosis. No guideline or performance indicator matters if we do not know the correct diagnosis.
  • Ability to communicate with patients – Excellent physicians must have the skills of acquiring information through history taking and explaining various things to patients. We must explain tests, diagnoses, why we prescribe the medications we prescribe, etc.
  • Intelligent use of testing – The physicians I most admire have a logical reason behind each test. The physicians who I disdain order tests as reflex action. We should never order a test unless the results will have an important impact on our understanding of diagnosis or a guide for treatment.
  • Intelligent use of medications – Too often we see physicians just add medication after medication until they reach the unlikely 13th med. We should strive for parsimony. We should try to use medications informed by data. We should use less expensive medications unless the newer more expensive medication carries a demonstrable advantage.
  • Caring for the patient – Read this excellent post by retired doc – The good doctor worries about his patient

Yet current “quality” schemes do not include the issues which I have enumerated. I will debate vigorously anyone who thinks they can rate physicians without considering these issues.

Recently in the BMJ (subscription required) comes a wonderful quote from this article – Measuring performance and missing the point?

Evidence based care was never meant to be a substitute for clinical judgment but, combined with the inducements of the quality and outcomes framework, it becomes so. Mechanistic blanket management strategies, embedded into computer software, become fixed and static with the danger that innovation will be stifled. Interventions become routine, and practitioners are no longer required to grapple with the innate uncertainty of each different clinical situation. Most randomised trials systematically exclude patients’ symptoms, functional status, comorbidity, severity of illness, ideas, and preferences. Yet these are the factors which should fundamentally affect decisions about appropriate treatment.2 Within large study populations, there will be smaller populations sharing different characteristics whose response to a given treatment will differ from that of the larger group. Such groups could be systematically harmed by the intervention, and there are currently no robust systems in place to measure or monitor this.3

The quality and outcomes framework diminishes the responsibility of doctors to think, to the potential detriment of patients, and encourages a focus on points scored, threshold met, and income generated. To give just one example, the failure to make any allowance for age means that doctors are encouraged to overtreat hypertension in old people4 with the danger of causing fainting, falls, and fractures.

The whole initiative is based on reductive linear reasoning that views the body as a machine and assumes that a standardised treatment will produce an equally standard unit of beneficial outcome. However, any practising clinician knows that the same treatment applied to two people with the same diagnosis can produce very different outcomes. Complexity theory suggests that the body is more usefully regarded as a complex adaptive system, characterised by rich interactions between multiple components that produce unpredictable outcomes. This analogy makes much more sense of clinical experience. Psychological states and social contexts exert measurable effects on the functioning of the body. Standardised treatments ignore all of this.

Focusing on performance measures could, and probably will detract from the issues I list above. I will not stop writing about this. I will try everything I can to spread the word about these issues. I believe it is a professional responsibility.

Comments (5)

How about outcome for the patient? That seems to me the best indicator but then what do I know – I’m just a patient……

Judy,

As a patient I have learned there is a difference between good medicine and patient outcomes. Often we desire the best possible outcome, and even with the best medical care this is not achieved. This is not a free pass for doctors to practice sloppy medicine, but the recognition that there are limits to medical knowledge.

The converse of this is that even with poor medical treatment some people will recover from their illness. We need to also recognize that standards of care are constantly changing and what is good today may be considered poor in the future.

Doctors hate to recognize that you can only do what you can do. Recent posts on this blog have focused on medication levels. My personal reality is that practicing “good medicine,” and practicing to the standards of the time, doctors would have killed me a long time ago.

Steve Lucas

outcomes are great, just make sure you’re measuring them accurately and realizing a “good” outcome may be defined differently by different patients. Is quantity of life the desired outcome? Quality of life? Do monetary concerns matter for the patient, or are they relatively inconsequential? Are the side effects of the treatment no big deal or a dealbreaker?

These are individual issues for the patient. Defining quality without taking unique patient preferences into account is simplistic and misleading.

[…] I have written about this often in the past.  Please reread this "classic" post – How do I judge physician excellence? […]

[…] T suggests, albeit implicitly, that physicians who have overall excellent quality will have excellent samples of quality as measured through performance metrics. I wrote 2 years ago about my opinion of excellence. How do I judge physician excellence? […]

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