Quality or Conformity?

Yesterday I received something in the mail about how I might be judged by certain “Quality Indicators”, such as my patients’ mammography rate. This struck me as very odd, since just a few weeks ago the U.S. Public Health Service Taskforce reversed their longstanding recommendation that all women should have annual mammograms from age 40.

This is a striking example of how yesterday’s truths are tomorrow’s fallacies in modern medicine. A doctor who orders annual mammograms this month could be viewed as practicing poor quality medicine, even though the same behavior might have earned him or her bonus payments and honorable mentions last month.  

I think it is time we speak honestly about what the agenda really is here. If we, or those who pay us or regulate us, choose quality indicators that are not based on solid scientific principles, but instead on expert opinions that could – and do – change at any moment, we are not measuring quality at all. What we are measuring and rewarding in that case is conformity. How fast and how consistently today’s physicians can implement new guidelines is certainly easier to measure than how well their patients are feeling.

We aren’t measuring how often doctors make the correct diagnosis on the first visit or how well they handle difficult clinical situations. We aren’t measuring how often we are able to reassure or comfort another human being who would otherwise keep circling within the health care system at great expense in search of peace of mind.

No, the things we measure are only the underpinnings of quality in health care. It is fine to measure doctors’ compliance with official guidelines, but we need to look well beyond such low hanging fruit if we want to be serious about quality. 

Frankly, there are ways we can let our office staff, our disease registries or Electronic Medical Records handle a lot of the housekeeping items people think of as quality indicators. The quality measures of physicians’ work would then reflect how we practice the art and science of medicine. We need to look more to clinical results (outcomes) and appropriateness of care.

Just like in school, we can strive to master the subject or just pass the test. If we just want to pass the test, we can change the subject when our patients bare their souls to us, fumble with the chart or peer into the EMR and start talking about tetanus shots and cholesterol and mammograms (or perhaps why we won’t order a mammogram), or we can push the paper chart or computer screen aside, look them straight in the eyes and say:

“We’ll let the system catch up with you about those things. Tell me what’s bothering you…”

4 Responses to “Quality or Conformity?”

  1. 1 David Royal December 15, 2009 at 10:09 am

    You have hit the nail square on the head here. From a UK perspective “quality” is the current management buzzword and General Practice is being suffocated under the weight of quality indicators and performance targets. All of these measure process and conformity with current opinion rather than the actual performance of the art of primary care. Still as long as the boxes are ticked we must be practicing good medicine mustn’t we?

  2. 2 drtombibey December 29, 2009 at 12:31 pm

    One time I took the Boards. We got ready to start, and they asked if we had any questions before we took out our number two pencils and broke the seals.

    The ‘new’ hypertension guidelines had just been issued. I raised my hand.

    “Do you want us to answer the blood pressure questions by what was the right answer when you wrote up the test or by what was issued last month?”

    The moderator knew me well, and knew I had a smart a^^ streak. He told me to just shut up and take the test.

    I made the 94th percentile. I told one professor I’d done as well as him if they’d let me write the questions.

    I never cease to be amazed by people who are so arrogant that they believe their paper from last week will change how human beings have lived and died for tens of thousands of years. I can not understand anyone that narrow-minded.

    Dr. B

  3. 3 a.nonymouse November 29, 2013 at 5:58 pm

    Each patient is a unique individual, and every second of their lives, they change, becoming another unique individual. What separates us physicians from another is how we each focus on different parts of each patient and how quickly they change: In the ICU, changes may occur over seconds(rarely), minutes, hours(more commonly), or days. For primary care providers, patients change over days, weeks, or years. Each patient is like a stream or river-One Greek philosopher(perhaps Aristotle) said, “You cannot put your foot in the same river twice”(the river changes over time?). Werner Heisenberg(20th century physicist, Einstein contemporary) in his ‘Uncertainty Principle’ said, “You cannot put your foot in the same river ONCE!” (putting your foot in the river changes the river). Thus when we treat
    our patients(even if we don’t prescribe pharmacologic treatments), we have changed them, irreversibly! With more and more non-physician(or non-practicing physician) control, who is responsible for patient outcomes? Do physicians ONLY bear the responsibilties for ‘Quality’ care? How much quality responsibilty do patients and these ‘Administrators’ bear?

  4. 4 Harley Schmidlap, MD May 3, 2016 at 6:14 pm

    “Quality” in Medicine or Surgery today lists only ‘Process’ measures, as you imply and NOT “RESULTS” measures, rather similar to Government Regulations as mentioned by Attorney Philip K. Howard in each of his books.

    ‘Quality’ isn’t filling out or ‘checking’ a box on a chart, “QUALITY of CARE” is how each patient survives whatever pathology brought them to the hospital, how functional they are when back in the community, how each physician, nurse, or other bedside provider acted toward them during their stay, whether or not they received correct treatments, helpful information, answers to their questions, and how/if their patterns of personal health care changed for the better(less or no alcohol, no addictive drug use, and better exercise patterns), and ultimately if they were healthier people than priot to their admissions, AND many other measures-“Quality of CARE” is difficult to measure…Much easier to check a useless box on a their chart…thus a measure for ‘thoughtless, uncaring, bureaucrats, whatever their degrees or initials behind their names. The final and perhaps penultimate questions of TRUE “QUALITY of CARE”: 1) Would each patient and their family return to this facility and to each bedside provider AND Bureaucrat who cared for them. 2) Would this institution, these individual caregivers, and the bureaucrats ‘sign’ off on the care rendered to each patient AND post 1 & 2 on the facilities website with a copy to either “Consumer Reports” or another web site showing potential patients, including the facility’s real true costs so potential patients can be “Informed” consumers???

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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