Physician rankings could be perverse

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Category : Medical Rants

Yesterday's NY Times had a wonderful Op-Ed – Want to Ruin Teaching? Give Ratings

This type of system shows a profound lack of understanding of leadership. Principals need to create a culture of trust, teamwork and candid feedback that is essential to running an excellent school. Leadership is about hiring great people and empowering them, and requires a delicate balance of evaluation and encouragement. At Harlem Village Academies we give teachers an enormous amount of freedom and respect. As one of our seventh-grade reading teachers told me: “It’s exhilarating to be trusted. It makes me feel like I can be the kind of teacher I had always dreamed about becoming: funny, interesting, effective and energetic.”

Some of the new government proposals for evaluating teachers, with their checklists, rankings and ratings, have been described as businesslike, but that is just not true. Successful companies do not publicly rate thousands of employees from a central office database; they don’t use systems to take the place of human judgment. They trust their managers to nurture and build great teams, then hold the managers accountable for results.

While this piece is about teachers, it applies wonderfully to the idea of physician ratings. 

A government-run teacher evaluation bureaucracy will make it impossible to attract great teachers and will diminish the motivation of the ones we have. It will make teaching so scripted and controlled that we won’t be able to attract smart, passionate people. Everyone says we should treat teachers as professionals, but then they promote top-down policies that are insulting to serious educators.

If we don’t change course in the coming years, these bureaucratic systems that treat teachers like low-level workers will become self-fulfilling. As the great educational thinker Theodore R. Sizer put it, “Eventually, hierarchical bureaucracy will be totally self-validating: virtually all teachers will be semi-competent.”

We live in a culture that loves attaching numbers to abstract concepts.  We have laughable medical school rankings, business school rankings, etc.  Now we are talking about physician report cards, implying that we can measure our complex profession with simple scales.

This concept is bankrupt.  It ignores a fundamental understanding of physician quality.  Our jobs are multidimensional.  Some patients require diagnosis; some require disease management; some need pep talks; some need referrals.  This list is incomplete.  How can we measure all those attributes, and the many more that make us professionals.

Performance measurement can help me reflect on my own practice, but only if we measure things that I have control over and care about.  We should not use performance measurement as a proxy for quality, as a method of adjusting pay, or as an excuse to provide inaccurate public reporting.  We have an obligation to speak out against the madness.

Comments (7)

As a primary care physician these report cards and performance measurements have a psychological tole. It leads to job dissatisfaction because our bosses dont understand that I have little impact on the numbers. Most of what I am measured on requires mostly work from the patient…but its all my fault. Patients in our system can refuse interventions but it looks to the eyes of adminstration that I didnt do anything. I get dinged when the patient refuses a flu shot, I get dinged when the patient doesnt want colon cancer screening, I get dinged when they refuse insulin and their A1C stays high. Its my fault when the LDL is not at goal and they have seen cardiology 6 times this year compared to seeing me twice. Subspecialists seem to have measures that they control more….like time to cath, time to colonoscopy once its ordered. They seem to have no patient care measures only process measures.
I wish it would all go away.

All the above measures promote "mediocrity" but in today's world, mediocrity equates excellence.

Physicians who overstate the benefit of additional drugs or testing are the ones with higher quality scores in our system.  (If you want to be high quality, you've got to use all the tricks possible to get the patient to cooperate.) 

Joshua's Law – "The only winning move is not to play."

When the ACP policy committee meets, why not bring up a proposal officially opposing all P4P programs? If nothing else, that would certainly give practicing physicians a sense that someone has their back.

State Supreme Court Hears Online Doctor Rating Defamation Suit SEP 2012
 
 
Excerpted from Star Tribune, September 4, 2012, Maura Lerner

 

 
Two years ago, a Duluth neurologist, Dr. David McKee, sued the son of an elderly patient for defamation over some negative comments that were posted on rate-your-doctor websites.
 
 
On Tuesday, the state's top court was asked to decide whether the lawsuit should finally go to trial, after the case was thrown out by a lower court and reinstated on appeal. The lawsuit is one of a growing number of legal battles testing the limits of free speech on the Internet.
 
 
A good portion of the oral arguments were devoted to the meaning of the words that Dennis Laurion, 65, used to describe his family's encounter with McKee in April, 2010, when Laurion's father, Kenneth, then 84, was hospitalized with a stroke.
 
 
John Kelly, Laurion's attorney, noted that Internet sites are a "free for all" for people to share opinions and that his client's comments were perfectly appropriate. "We have a word, the word 'tool,'" Kelly told the justices. "When you look at the word, you have to ask: Is it defamatory?" He argued that the phrase, while "it clearly is not a compliment," is no worse than "calling someone an idiot or a fool."
 
 
During questioning, some of the justices seemed to agree. "Saying someone's a 'real tool' sounds more like an opinion than a statement of fact," Justice Christopher Dietzen said. Chief Justice Lorie Skjerven Gildea had a similar reaction. "The point of the post is, 'This doctor did not treat my father well,'" she said. "I can't grasp why that wouldn't be protected opinion."
 
 
Full Article:
http://www.startribune.com/printarticle/?id=168552176

Article by: ABBY SIMONS , Star Tribune, Updated January 30, 2013 – 9:59 PM

Finding no harm done, justices toss out lawsuit by Duluth physician.

Dennis Laurion fired off his screed on a few rate-your-doctor websites in April 2010, along with some letters about what he saw as poor bedside manner by his father’s neurologist. He expected at most what he calls a “non-apology apology.”

“I really thought I’d receive something within a few days along the lines of ‘I’m sorry you thought I was rude, that was not my intent’ and that would be the end of it,” the 66-year-old Duluth retiree said. “I certainly did not expect to be sued.”

He was. Dr. David McKee’s defamation lawsuit was the beginning of a four-year legal battle that ended Wednesday when the Minnesota Supreme Court ruled the doctor had no legal claim against Laurion because there was no proof that his comments were false or were capable of harming the doctor’s reputation.

The unanimous ruling reverses an earlier Appeals Court decision and brings to an end the closely watched case that brought to the forefront a First Amendment debate over the limits of free speech online.

It’s a frustrating end for McKee, 51, who said he’s spent at least $50,000 in legal fees and another $11,000 to clear his name online after the story went viral, resulting in hundreds more negative postings about him — likely from people who never met him. He hasn’t ruled out a second lawsuit stemming from those posts.

“The financial costs are significant, but money is money and five years from now I won’t notice the money I spent on this,” he said. “It’s been the harm to my reputation through the repeated publicity and the stress.”

He said he offered to settle the case at no cost after the Supreme Court hearing. Laurion contends they couldn’t agree on the terms of the settlement, and said he not only deleted his initial postings after he was initially served, but had nothing to do with subsequent online statements about McKee.

The lawsuit followed the hospitalization of Laurion’s father, Kenneth, for a hemorrhagic stroke at St. Luke’s Hospital in Duluth. Laurion, his mother and his wife were also in the room when McKee examined the father and made the statements that Laurion interpreted as rude. After his father was discharged, he wrote the reviews and sent the letters.

On at least two sites, Laurion wrote that McKee said that “44 percent of hemorrhagic strokes die within 30 days. I guess this is the better option,” and that “It doesn’t matter that the patient’s gown did not cover his backside.”

Laurion also wrote: “When I mentioned Dr. McKee’s name to a friend who is a nurse, she said, ‘Dr. McKee is a real tool!'”

McKee sued after he learned of the postings from another patient. A St. Louis County judge dismissed the lawsuit, saying Laurion’s statements were either protected opinion, substantially true or too vague to convey a defamatory meaning. The Appeals Court reversed that ruling regarding six of Laurion’s statements, reasoning that they were factual assertions and not opinions, that they harmed McKee’s reputation and that they could be proven as false.

The Supreme Court disagreed. Writing the opinion, Justice Alan Page noted that McKee acknowledged that the gist of some of the statements were true, even if they were misinterpreted. Page added that the “tool” statements also didn’t pass the test of defaming McKee’s character. He dismissed an argument by McKee’s attorney, Marshall Tanick, that the “tool” comment was fabricated by Laurion and that the nurse never existed. Whether it was fabricated or not was irrelevant, the court ruled. “Referring to someone as ‘a real tool’ falls into the category of pure opinion because the term ‘real tool’ cannot be reasonably interpreted as stating a fact and it cannot be proven true or false,” Page wrote.

Tanick said the ruling could present a slippery slope.

“This decision gives individuals a license to make derogatory and disparaging statements about doctors, professionals and really anyone for that matter on the Internet without much recourse,” he said.

Jane Kirtley disagreed. The professor of media ethics and law at the University of Minnesota School of Journalism said the ruling stems from “an elementary principle of libel law. I understand the rhetoric, but this is not a blank check for people to make false factual statements,” she said. “Rather, it’s an endorsement that statements of opinion are protected under the First Amendment.”

Laurion’s attorney, John D. Kelly, said the fact that Laurion’s speech was made online was inconsequential to the ruling, which treated it as a standard defamation case. “It’s almost as if things were said around the water cooler or perhaps posted in a letter to the editor,” he said. “I think the principles they worked with are applicable to statements made irrespective of the medium.”

Full article:
http://www.startribune.com/local/189028521.html?refer=y

Comments: http://comments.startribune.com/comments.php?d=content_comments&asset_id=189028521&sort=E&section=/local&page_nbr=2&ipp=10

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