A P4P story


Category : Medical Rants

During my India trip, one physician told me this story. I will try to get the gist of the story correct. He told the story in response to my lecture on the dangers of guidelines and performance measures.

He was practicing in England at the time this incident occurred. England had just started their P4P project. An older woman was going to see her physician. She was having symptoms of uterine prolapse. Her daughter accompanied her, but she did not let the daughter come into the examination room because of embarrassment.

The physician comes into the room and starts reviewing each of her known medical problems with a focus on those issues that would impact his performance measures. He never asks for her agenda, and abruptly finishes the meeting.

The woman goes back to the waiting room, and has to tell the daughter that she never had a chance to seek help for her concern.

Performance measures can change the physician patient interaction. We are told that medical care should become more patient centered, while focusing on performance measures changes the physicians priorities. We do not have a good measure this concept.

Since quality has many dimensions, we must worry that focusing on some dimensions will decrease our attention to other important dimensions. This story describes a bad medical visit. But the physician likely scored perfectly on his measures.

Comments (7)

Did the patient fill out a satisfaction questionnaire somewhere along the line?
Patients have problems which they may not understand or communicate poorly. The good physician sees through the patient’s story to the nub of the problem. Actually, that is what the word ‘diagnosis’ means. I now sit on the other end of the stethoscope in my retirement. Contemporary physicians look at the computer screen and enter clicks rather than looking at the patient. To me that is the big danger of EHR. I agree that it is easy to create a perfect medical record while not solving problems.

This reminds me of a situation where being paid per injection a doctor declared there was no pain in receiving multiple injections and broke vaccinations down into single doses. This doctor then went on to complain that they could not keep staff that were responsible for these multiple injections, often in infants.

Family was not immune. An adult child had a very scary medical emergency that could have been treated as an outpatient, but the doctor parent insisted on a hospital admission. The doctor then ordered blood draws one hour before the attending physicians blood draws so they could have the blood work before the actual care team.

This resulted in the hospital hiring a patient advocate to prevent this type of treatment.

Accidently I ended up in the middle of a confrontation between the child and parent as the parent was chastising the child for going for a follow up blood draw to a person they felt comfortable with, was about the same age, and they had pizza. The parent never understood this was one way for this adult child to take control of their situation.

We also had a heated discussion where I supported the child’s need to know and understand their condition so at some future date they would be able to deal with any questions or follow on issues. The parents totally dismissed this idea as I was not a physician.

The one parent made it very clear they did not welcome my opinion; after all, they were a good doctor.

P4P has many unintended consequences in not just shaping a practice, but also attitudes.

Steve Lucas

The physician practicing in England was simply following the rules defined by his employer. The patient is a template on which to carry out these rules in a large population based quality program.
He would be labeled a bad or low quality physician if he spent less attention to the metrics and more attention to the reason the patient made the appointment.

You have restated my implied point precisely.

It’s the medical equivalent of “teaching to the test”.
Very hard to prevent in any reward-based system; that’s just human nature.
That’s why reward-based systems, while often a good business strategy, are antithetical to what medicine is supposed to be about.
If I had to guess, I’d guess that medicine will become subservient to business in this case.

That is why we must write frequently and passionately about the unintended consequences of performance measurement.

My preferred phrasing of the same point:

We (and the institutions that govern and fund us) allow the measurable to drive out the good.

One possible response is to try to make the good measurable, but because the “good” is nearly infinite, the optimum measure for all of it will always be imperfect. Just asking a patient “did I help with what concerned you when you came to see me” might be a step toward covering the bases..

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