db’s medrants 2007 considered – the year of quality


Category : Medical Rants

Allow me some time to consider my main messages over the last year. My blog has evolved significantly since starting in May 2002. Originally I focused on finding health related links. I would make some commentary, but rarely wrote essay style entries. Now I probably spend more time exploring ideas. This year I have focused my obsession on quality. I hope to synthesize my overall thoughts with this entry. Quality remains an elusive concept. We all desire high quality medicine. Many researchers believe that they can measure quality. Many insurers (including single payers like the UK) believe that they should measure quality. But quality may not be measurable. We can measure performance. We have many studies which decry physician’s performance on "quality measures." We could measure patient satisfaction. We could measure outcomes. I will assert that none of these activities can define quality. Quality is multidimensional. Physicians have multiple tasks, and address multiple concerns. If one tries to measure one or several performance measures, what is revealed represents a small part of quality. Blindmen and an elephant From my experience, a high quality physician excels in most of these attributes: diagnosis, doctor-patient communication (which includes eliciting information and explaining medicine to the patient), physical examination, ability to interpret laboratory tests, treating disease appropriately, asking for the proper consultations, balancing multiple diseases. For me the most important concept is that the high quality physician thinks. Jerome Groopman wrote skillfully about this topic in his book – How Doctors Think? Here is one of many entries that I made relevant to that book – Crichton on Groopman

I believe that the big message of this book comes from the 3rd word of the title. Doctors must think. Thinking is our forte and our raison d’être. Patients come to us for answers. They expect us to figure out what the problem really is. Unlike some of my colleagues I do not believe that we should emphasize management of chronic illness. Management of chronic illness follows from complete diagnosis. When I use the word diagnosis here I am referring to this definition: a determining or analysis of the cause or nature of a problem or situation. Physicians make disease diagnoses, but we also diagnosis the patient’s social context, the impact of multiple diseases, and their belief systems. Designing a management strategy requires a complete diagnosis of the patient who has the disease(s). I praise Groopman because he champions the role of physician thinking. I agree.

Now thinking takes time.  We can not do high quality medicine if we do not have and take enough time with each patient.  Quality health care requires time. Yet our current reimbursement system incents physicians to keep visits short, and substitute testing or consultation for thinking. I believe that the best way to save health care dollars is to invest in excellent primary care. Our best hope in 2008 comes from the retainer medicine movement.  While we probably will not adopt this model for all patients, we must learn from the model.  We must learn to optimize patient panel size, and allow physicians to deliver the care that patients’ desire.  We need to make telephone calls and emails a routine and desirable activity. I believe that well trained generalists , given appropriate time, can minimize unnecessary testing and consultation.  This will not happen unless we elevate their job financially and emotionally. 

We must abandon the gatekeeper image, and elevate the Happy Hospitalist’s more accurate conductor image. The most important attribute of the excellent generalist comes from a consideration of the whole patient.  We need the partialists – those who know a great deal about one organ, but too often they forget that the organ represents only one part of a greater organism. I have great hope as this year ends.  We have a new focus on defining quality.  Most physicians have rejected the P4P concept – and (as Dr. RW so nicely summarized recently) increasingly studies show that performance measurement does not lead to improved outcomes.

After 5’½ years of blogging, I have learned a great deal about expressing ideas.  My writing has improved.  I continue to enjoy the many comments that I receive.  I love engaging in debates with other bloggers.  Finally, I believe that my blog has some influence in the community of ideas.  I hope that I have influenced you, or at least made you think this year. Happy New Year!!!

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Comments (9)

Perfect! “But quality may not be measurable. We can measure performance. We have many studies which decry physician’s performance on “quality measures.”

One definition of “quality” is value/cost. But, defining “value” is inherently complex and frought with difficulties. Value changes (to some degree) upon context and perspective. What one patient values may be very different from what another values and so on.

We measure a variety of proxies for quality. But, these proxies are interpretative, contested, and debatable. Good job.

Thanks for all your effort DB. You have definitely added the “community of ideas.”

More than just some influence.A continuing stream of thoughtful contributions. Your comments early on in my blogging career really encouraged me to keep on writing about medical issues that I think matter.Thanks for your efforts.

Thanks for the Blog! Always thought-provoking.


Your blog is one of my favorites. I enjoy and in fact look forward to reading what you have to say. Keep up the great work.


I noticed that my blog, Miami, MD (http://medicalweblog.blogspot.com) it not on your “Blogs that I read” list on your sidebar. I wanted to email you and let you know about my blog however I could not find your email. So I decided to comment on this post. Hope you check out my blog. I also hope you like it enough to put it on your list. Let me know what you think.


Miami, MD – Medical Weblog

Speaking of “quality,” I have opened the Asthma Guidelines released in December. After I printed the 440 page document, got some lunch, stilled my stomach and took a Rolaids, I have now made it through the first 57 pages in 1.5 hours. And, I must say that there is nothing I have read in this document that could not have been said in 5 pages.

I’ve had it. Certainly, well-written, concise & PREcise guidelines have improved patient care. But, 440 pages, on just asthma? I’m sorry, but have we lost our collective minds? For WHOM exactly are 440 pages written? Or, might I humbly suggest that these 440 pages are written only for those who wrote them?

I think an important part of being a doctor is continuous learning. I have a good doc, when I see him (once a year like it or not) he always takes the time to talk with me. I don’t have any health issues, so we talk about new things in medicine that I bring him. I talk to him about new clinical trials, new tests, new thinking. He gains more from me than I do him, but soon (as I get older) I know he will take the time to listen to my health issues.

[…] and you will find results galore.  I want to highlight my concluding piece of 2007 – db’s medrants 2007 considered – the year of quality – in which I […]

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