The first patient was very complex. He was in the ICU after an in-hospital arrest. He had multiple medical problems, and develop ATN 2 days later.

The second patient died the next morning. My resident and I spent 30 minutes preparing the family for the inevitable. Our time investment brought reality to a family, and helped the nursing staff greatly (their report to us).

The third patient was admitted for a TIA and happened to have elevated troponins. Her stress test was negative.

The fourth patient did very well – he had a minor amputation of the tip of his toe. His response to IV antibiotics was dramatic.

The fifth patient had a rapidly improved sodium level. We worried about how fast her sodium increased and spent significant time designing ways to slow down the sodium increase. We discharge her 2 days later with a total return of her baseline mental status.

The sixth patient did not have achalasia, rather he had diffuse esophageal spasm. The challenge we had was finding an acceptable treatment for his DES.

The seventh patient had his biopsy, and then we discharged him for outpatient radiation therapy.

The eighth patient continued to improve and was eventually discharge to a rehab facility.

The final patient was discharged after being afebrile for 48 hours. She responded well to antibiotics, but no firm diagnosis was made because blood cultures and throat cultures were negative.

I ask again – how should we judge quality for these patients? We had diagnostic problems, unusual management problems, social situations and end-of-life discussions. I believe we did a reasonable job last Monday, but I also do not believe that anyone could provide me a measurement of our quality.

This is the problem with quality measurement. We have too many diverse situations that we address each day. Often we care for unusual problems. Often we have diagnostic issues – achalasia vs. DES, etiology of hyponatremia, reason for high fever in a tonsillitis patient. We have management problems that do not easily fit into performance measures.

Any quality measures that would pertain to these 9 patients would paint an incomplete picture of our care and our tasks. We should challenge all attempts to measure something and call it quality of care. To repeat one of my favorite quotes from Donabedian

Judgments of quality are incomplete when only a few dimensions are used and decisions about each dimension are made on the basis of partial evidence.

Related Posts

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3. Quality measurement – a delusion

Primary care physicians are cheering—and radiologists are jeering—a new CMS proposed change to the Medicare Physician Fee Schedule that will cut reimbursements for imaging services by as much as 30% and use the savings to raise reimbursements for primary care by as much as 8%.

“I am surprised. We all kind of knew this sort of thing was coming, but until you see it in writing you don’t believe it,” says Ted Epperly, MD, president of the American Academy of Family Physicians. “We’ve been there before and never saw it. Putting it out now in the heat of the debate is a big deal. It sends a strong message.”

“I’m impressed that CMS is actually doing stuff to reformulate the system toward primary care. Of course, the devil is in the details and we will see what the final product looks like, and it’s not a total fix, but it’s a step in the right direction,” he says.

The AMA has always argued that enhancing primary care should not come at the expense of other physicians.  I have remained skeptical, because they have benefited at the expense of family physicians and non-procedural internists.

I like much of what CMS is proposing:

CMS is also proposing to:

• Remove physician-administered drugs from the definition of “physician services” in anticipation of enactment of legislation to provide fundamental reforms to Medicare physician payments. While the proposal will not change the projected update for services during 2010, CMS projects that it would reduce the number of years in which physicians are projected to experience a negative update. AMA President J. James Rohack. MD, called the proposal “a major victory for America’s seniors and their physicians.”
• Implement a mandate in the Medicare Improvements for Patients and Providers Act of 2008 that suppliers of the technical component of advanced imaging services be accredited beginning Jan. 1, 2012 by designated accrediting organizations. The accreditation requirement would apply to mobile units, physicians’ offices, and independent diagnostic testing facilities that create the images, but would not apply to the physician who interprets them.
• Implement provisions to promote improvement in quality of care and patient outcomes through revisions to the Electronic Prescribing Incentive Program and the Physician Quality Reporting Initiative. Professionals or group practices that meet the requirements of each program in 2010 will be eligible for incentive payments for each program equal to 2% of their total estimated allowed charges for the reporting periods. CMS is proposing to simplify the reporting requirements and is also proposing a new process for group practices to be considered successful electronic prescribers.
• Refine Medicare payments to physicians, which are expected to increase payment rates for primary care services. The proposals include an update to the practice expense component of physician fees. For 2010, CMS is proposing to include data about physicians’ practice costs from a new survey, the Physician Practice Information Survey, designed and conducted by the AMA.
• Stop making payments for consultation codes typically billed by specialists at a higher rate than evaluation and management services. Physicians will instead use existing E/M service codes when providing these services. The resulting savings would be redistributed to increase payments for the existing E/M services.
• Increase the payment rates for the so-called “Welcome to Medicare” visit to be more in line with payment rates for higher-complexity services.
• Refine how Medicare recognizes the cost of professional liability insurance in its payments. These changes would have a modest impact, but they will promote payment equity by redirecting the portion of Medicare’s payment for professional liability insurance to those physicians that have the highest malpractice costs.

Taken together, CMS says refining the practice expenses, eliminating payment for the consultation codes and revising the treatment of malpractice premiums would increase payments to general practitioners, family physicians, internists, and geriatric specialists by between 6% and 8%.

I have not read the CMS proposal, but this morning it looks very interesting.

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Medicare May Shuffle the Deck on Doctor Payments

Most of the money that Medicare pays physicians is for doctor visits, medical procedures and the like. But Medicare also pays physicians directly for drugs that are administered at doctors’ offices. Today, the agency that runs Medicare said it wanted to move the payments for those drugs out of the bucket of money allotted to physician payments, and into a different bucket.

The AMA has been pushing for this shift for years, because the cost of physician-administered drugs (which include expensive new cancer drugs, for example) has risen faster than the cost of doctors’ services.

But beyond making the a powerful lobby happy, the shift could make it politically easier for Congress to wade in, get rid of SGR and replace it with a new system, as many have called for.

If those drug costs are no longer included in the overall cost of payments to physicians, then Medicare’s total cost of paying physicians could fall by $87.5 billion over the next decade, according to a CBO estimate cited today by The Hill.

That would make any fix to SGR a bit easier to swallow — even if didn’t reduce Medicare’s overall spending.

I hope that helps others.

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As I’ve argued before in this space, one result of this unduly heavy reliance upon third-party payers is that almost everyone who consumes medical care does so irresponsibly. That is, the typical American is unresponsive to the burdens that his or her medical-care choices impose on others. This unresponsiveness — this irresponsibility — exists because we’ve socialized too much of the costs of medical care. Why should I give close attention to the price of some recommended medical procedure if I, personally, am paying out of pocket none (or only a tiny fraction) of the price of that procedure or drug?

With everyone irresponsible, resources are wasted. And with massive waste comes unnecessarily higher costs.

It’s a mystery why medical care cannot be supplied in the same way that, say, accounting services and food are supplied. Like medical care, these things are valuable. (Indeed, food is even more essential to life than is medical care!) Also like medical care, some types of accounting and some types of food are more crucial than are other types — and accounting services and food are supplied on a fee-for-service basis.

And yet, America suffers no “accounting services” crisis or “food supply” crisis.

Some proponents of the idea that medical care differs so much from other products that it cannot be compared to things like accounting or food say that “in matters of life and death, people aren’t willing to make the trade-offs that they make when deciding how much of other things to buy.” The idea is that a person on his or her deathbed will not care about the price of the costly medical procedure required to prolong life.

This “deathbed” tale is likely true. But it’s difficult to see how it counsels that we socialize medical-care payments. Does anyone seriously suppose that decisions by government bureaucrats over who will get, and who will be denied, some expensive lifesaving procedure would be better than having such decisions made according to each patient’s willingness and ability to pay?

Supply and demand really works. If one has no restrictions on demand, then some will abuse that demand. I addressed this issue 3 years ago - The tragedy of the commons

Health care is rather following the logical path that the Tragedy of the Commons predicts. As long as neither physicians nor patients have economic accountability (because of the middle common ground) then we cannot possibly fix our system. Note that this explanation fits all one payor systems as well.

We should transform our health care system using solid economic principles. It will not happen because we would have to make financial decision making explicit. It will not happen because we have too long fed at the insurance trough.

Our health care crisis is economically predictable. The solution is likely too painful.

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He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all – Sir William Osler

I believe most educators have known this since Osler’s time. As I reconstruct my career, I strongly believe that I have continued to improve as I have cared for more patients.

I have known of this study for some time, as several of the authors are friends. I have referred to the principles of this study often in this blog. Internal Medicine Clerkship Characteristics Associated With Enhanced Student Examination Performance

Results: In school-level analyses (using a reduced four-variable model), independent variables associated with higher NBME subject examination score were more small-group hours/week and use of community-based preceptors. Greater score increase from USMLE 1 to 2 was associated with students caring for more patients/day. Several variables were associated with enhanced student examination performance at the student level. The most consistent finding was that more patients cared for per day was associated with higher examination performance. More structured learning activities were associated with higher examination scores for students with lower baseline USMLE 1 achievement.

We should take these findings into appropriate context. If you are a learner, you want to train at places with sufficient patient volume.

Some have advocated “competency based training.” I reject that philosophy. Medicine is never learned. We all should grow each day. How can we establish arbitrary goals in learning medicine when learning medicine will always remain a process not an achievable endpoint?

I encourage students and residents to seek out patient care opportunities. Each patient brings valuable teaching.

I am encouraged that small group teaching also does make a difference, since I love small group teaching. However, I am cognizant that teaching is best when it builds on actual patients.

Several years ago we had our residents rate teaching sessions in the Department of Medicine. Morning report was the clear winner and Grand Rounds was the clear loser! The reasons seem obvious. Medicine is best learned when given a patient context. Morning report, when done best, explores the intellectual process of diagnosis and management. When linked to the patient presentation, most residents learn important texture, even when they know much about the disease or symptom.

So my advice to students persists. Do not choose “easy residencies.” Choose residencies with the appropriate volume to allow you to grow as a physician.

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The Expresso Bike allows one to register and connect to the internet so that one can store workout data. Each day you can work to improve our time, power, calories etc. on a variety of interesting bike rides. You have an LCD screen with simulated courses ranging from 1 mile to 20 miles. Most courses have elevation changes, and as you ride the bike, the pedaling resistance adjust for the slope (up or down.) You have 30 gears to choose amongst.

This month (I started June 6) I have these results:

Miles:333.45
Time:0d 20h 4m
Calories:14225

Yesterday, for example, I pedaled almost 19 miles in 65 minutes, burning almost 900 calories.

If one reads about practicing any skill, feedback is important. Each day on the bike I am competing with myself, trying to improve. The Expresso web site provides data that enables you to chart your progress. I know my speed on each course in the past, and even can race the “ghost” of my previous best ride on that course to gauge my progress.

This exercise bike pushes my competitive buttons. I look forward to competing each day.

So, I believe that I will last the entire year, and not need to do another Thanksgiving challenge, because I will just be continuing my continued commitment to exercise. I have a resting heart rate of 56, not bad when your resting heart rate is less than your age.

As a physician, I believe that I have a responsibility to embrace a healthy lifestyle. I believe my exercise obsession helps my health and provides a good role model for my students and residents. Perhaps I can even challenge you, my readers, to enhance your exercise program.

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One argument for health care reform involves comparing our health care provision (I will try to avoid the word system, because we do not have one) with that provided in other countries.  These analyses point to the waste in US healthcare and opine that we should emulate other countries.  We certainly should study the strengths and weaknesses of other countries.  A medical economics article and a WSJ editorial strongly suggest that we should also look at malpractice in these “best practices” countries.

Malpractice: Do other countries hold the key? and How Other Countries Judge Malpractice

Litigation in the U.S. has at least four distinctive procedural features that drive up malpractice costs. The first is jury trials, which can veer out of control and in any case introduce significant uncertainty. The second is the contingency-fee system, which allows well-heeled lawyers to self-finance litigation. The third is the rule that makes each side bear its own costs. This induces riskier lawsuits than are undertaken in most other countries, such as Canada, England and most of Europe, where the loser pays the legal costs of the winner. The fourth is extensive pretrial discovery outside the direct supervision of judges, which occurs far more readily here than elsewhere.

Even these features aren’t the whole story. American judges frequently let juries decide whether honest mistakes are negligent. Judges in other nations are less likely to do so. American courts commonly think it proper for juries to infer medical negligence from the mere occurrence of a serious injury. European judges usually will not.

American plaintiffs are sometimes spared the heavy burden of identifying particular acts of negligence, or of showing the precise causal connection between a negligent act and an actual injury. Lastly, damage awards for lost income and medical expenses in the U.S. tend to dwarf awards made elsewhere — in part because governments elsewhere provide this medical care from their nationalized systems. In sum, the medical malpractice system provides incentives for plaintiffs that really do matter. Americans, for example, file claims about 3.5 times more often than Canadians.

I have not blogged explicitly about malpractice in the recent past, but I have many times during the past 7 years. I expect the usual harangues from trial lawyers, but they should first read this hilarious satire – Obama Plan Calls for Making the Health Care System More Efficient by Having Trial Lawyers Provide Medical Services More Directly. But then, I am giving these critics credit for a sense of humor.

Our malpractice environment likely has a major influence on costs. Trial lawyers will deny it, but ask almost any physician if they believe that expensive tests are done to protect against malpractice. Defensive Medicine at Work We all know it.

How do we really decrease health care costs? We must use technology more intelligently. We should not order tests just because we can – or worse yet – just to be sure.

I do blame our tort laws, which are clearly out of sync with our peer countries, for our over testing, especially in the ER. Unnecessary testing has both direct and indirect costs.

So I will state again that malpractice reform could save numerous health care dollars. I also believe that the Democrats (who seem to love the trial lawyers) will not include substantial reform in their bills. Do they want to improve health care and decrease costs or win political points?

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1. Summarizing my thoughts on malpractice
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1. Stabilize acid-base status
2. End-of-life discussion
3. Nuclear medicine stress test in woman with recent NSTEMI
4. Cellulitis which followed a traumatic amputation
5. Hyponatremia secondary to psychogenic polydipsia and (perhaps) thiazides, presented as altered mental status
6. Achalasia – needs myotomy
7. Lung cancer with bony metatases – needs biopsy documentation
8. Patient s/p below knee amputation for gangrene – awaiting rehab placement
9. Severe tonsillitis – probably bacteremic  – responding to clindamycin

Did I do a good job?  Would any of the current performance measures apply?

I can provide a similar list almost every day I make rounds.  What is the point of performance measures if they do not relate to the main issues that I see on daily rounds?  How would you judge my quality?

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When we talk about health care reform, we are really talking about dozens of different issues. Is health care reform about covering the uninsured, or about cutting costs for employers? It is about having a publicly-funded health plan, or changing reimbursements to doctors? Is it about longer life expectancies or creating insurance cooperatives? Is it about caps on medical malpractice awards, or comparative effectiveness? Is it about healthier lifestyles, or cutting the cost of prescription drugs? Is it about cutting administrative waste, or incentives for more people to go to medical school? Is it about implementing new health care IT, or preventing insurers from making excessive profits?

It’s about all of these things, and more. And that’s the problem, if you’re an ambitious reformer. There is no simple way to get all of these things under one roof.

Well, until Atul Gawande introduced us to McAllen.

True health care reform should be complex. We have an illogical payment system that has perverse incentives. This has resulted in a maldistribution of our workforce – too little primary care (IOM definition) and too many subspecialists. We have divorced financial decision making from patients through an insurance industry that has not had incentives to really control costs, because they just increase their rates.

We have no free market in health care, and yet many worry that we will lose free market principles. We have accounting definitions of quality, and rarely explore the components of true quality health care.

We have an incredible plethora of expensive regulations, written under the guise of protecting patients and privacy. We are overwhelmed with unfunded mandates.

Too many physicians and entrepreneurs “game” the system, finding the profit opportunities without regard to our health. They can do this because they deal with bureaucracy rather than individual patients.

We have too many observers who do not understand that finding a way to provide care for the uninsured will actually save money. We will decrease ER visits and admissions through universal coverage. This likely would offset the costs (in my opinion), and it would be the right thing to do.

We have unreasonable documentation requirements that take the physician away from direct patient contact (our strength) and towards buffing the medical record. We have a tort system that worries almost every physician. Physicians clearly order unnecessary expensive tests because of their fear of lawsuits.

Yes we need health care reform, and I have no confidence that our current politicians will get more than 30% correct. They are bound to make mistakes that will make things even worse for patients.

Fortunately, we also have physicians who care deeply about patients. We will continue to do our best regardless of the changes. Some changes will be good and some will be horrid. And we have a responsibility to do our best for our patients.

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Patients are smart. They understand the value of having a physician who knows them well. I wonder how prevalent this sentiment really is.

Most articles about the value of hospital medicine focus on the hospital and the care received there. I am sensing a growing skepticism amongst patients.

I write this as someone who has eschewed the outpatient clinic. Most patients that I see really have no choice. I help care for “unassigned” patients in a community hospital and VA patients (who have never had comprehensive physician care.) My hospital experience is clearly skewed because of the patient population I serve.

But I do believe this is a legitimate concern. I hope that this rant will stimulate some commentary from hospitalists, outpatient physicians and comprehensivists.

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