When Uncle Will needed a hip replacement, he chose an orthopedic surgeon, Jason Brockman, and Mountain Memorial Hospital because of their excellent reputations for low complication rates and satisfied patients. The process reminded him of when he bought his first brand new truck.
Norm and Clara Anderson chose Dr. Wheeler as their family doctor once they had made the decision to relocate to Maine and raise their family away from the big city. The process of choosing a doctor reminded them of working out where to live. That was twenty years ago, and Dr. Wheeler has seen them and their two daughters through childhood illnesses, one heart attack, two cancer scares, Clara’s bouts of depression and irritable bowel syndrome, and their youngest girl’s struggles with migraines. A graduate school student near Boston now, Holly still checks in with Dr. Wheeler when she visits her parents. The Andersons sometimes reflect that Dr. Wheeler is like a pastor and a friend, and not just their family doctor.
Dr. Brockman is part of a big group of orthopedic surgeons now, and Mountain Memorial has merged with Countywide Health Systems. Uncle Will’s children know that Dr. Brockman still does top-notch work, because his outcomes are posted on the Internet.
Dr. Wheeler also works for Countywide Health Systems these days. He sometimes jokes that he is a healthcare factory worker now, and the Andersons get to rate him every year in Countywide’s patient satisfaction survey. Asked if they thought Dr. Wheeler delivered high quality care, they answered unequivocally yes.
Dr. Wheeler gets graded on how many of his patients reach targets like immunization rates, blood pressure levels and average blood sugars. He also gets graded on how many of his diabetic patients are prescribed ACE inhibitors, and how many men with heart disease, like Norm, are taking aspirin and beta blockers.
The Andersons understand the importance of these quality metrics but they are confused about why Dr. Wheeler’s diagnostic skills aren’t on his report card. He was the one who diagnosed Clara’s IBS after two of her previous doctors failed to do so. He also found Clara’s pheochromocytoma, the very rare tumor that presented as a slight vibration Norm could feel when he put his arm around Clara’s waist in bed at night. He also seemed to know the diagnosis the instant Norm arrived at the clinic with his heart attack, even though his only symptom was nausea and even though Norm had passed a stress test for work the month before.
Clara thinks Dr. Wheeler has worked miracles with Holly, her youngest daughter. She was a shy and insecure girl with crippling bouts of vomiting. Dr. Wheeler diagnosed the spells as migraines, tried and succeeded in preventing them with medications and he gave Holly a sense of control over them by helping her identify her triggers. He seemed to spark a scientific talent in Holly that is now becoming her career and life passion.
On TV the other night, Norm and Clara saw the Chief Executive of Countywide Health Systems talking about the future of healthcare. He pointed to statistics from their surgery department that outperformed every other health system in the region. Then he spoke of primary care. He showed the rates of compliance with dozens of guidelines, and he pointed out that the new systems Countywide had begun to put in place throughout all of its primary care offices were going to bring quality in primary care to new and even higher levels.
The executive went on to say that healthcare cannot rely on mom-and-pop individual doctors offices or exceptional efforts by superclinicians to deliver the quality healthcare America needs now and into the future. Just like in aviation and manufacturing, process design and quality measurements are the key elements that will raise quality standards and eliminate human error as well as unnecessary variability in healthcare.
Next up on the evening news was an in-depth story on the corporate culture within General Motors that allowed faulty ignition switches to be installed in millions of cars over so many years.
The next story was about the Veterans Administration scandal over forged waiting lists that had tried to cover up the long waits for access to healthcare in the VA system.
Right before the weather was a piece about how long it has taken this country to recover from the collapse of the banking industry and the fines paid by some of the top banks in recent years.
“I wonder how all this corporate medicine and process design talk will affect Dr. Wheeler. They may not think they need superclinicians, but I’m grateful we’ve had one for the last twenty years”, Clara said and turned to her husband.
A Country Doctor Writes: 
Sad. I’m glad to know that even if my high rankings for my primary care doctor aren’t impressing anyone, at least the outcome of my compliance with his suggestions is.
Your last two posts draw an accurate picture of the life and challenge of being a primary care physician in these times. And we have every right to ask, “Why aren’t diagnostic skills on the report cards?” and similarly, why not recertify PCPs using evidence of their daily journeys of “walking that fine line between failure and success.” Simply stated, there may never be adequate metrics for assessing clinical judgment!
PCPs like Dr. Wheeler might, nevertheless, truly appreciate the practice-based venues for the ongoing refinement of clinical judgment that my colleagues and I have created in the San Francisco Bay Area. Since 2005, as part of the University of California, San Francisco CME ‘Practice Inquiry’ program, once or twice monthly, PCPs meet in their offices and clinics to present real-time individual patients that perplex or frustrate them. TOGETHER they search the literature for relevant evidence, examine decision making heuristics to reformulate strategies, return to the patient with new ideas, and follow the patient over time to recalibrate judgment and learn. This approach and other small group learning methods, are described in our new book, “Clinical Uncertainty in Primary Care: The challenge of collaborative engagement.” http://www.springer.com/medicine/book/978-1-4614-6811-0) Constituting primary care versions of ‘time-outs,’ these colleague collaborations provide critically important communication opportunities that support collegial learning, hone clinical judgment, and sustain professional wellbeing.