Quality Medicine: Showing the Math

Medicine is a lot like grade school mathematics. The days are long gone when instantly knowing or quickly arriving at the right answer was enough. Now it’s all about showing your calculations. Process is everything. It’s almost like having the right answer doesn’t matter anymore.

If you ask a patient with a given symptom, like tremor, lameness or a skin eruption, only a few questions and then conclude that they have a rare disease you happen to have seen before during your years of training and experience or read about in your diligent study of the leading medical journals, you get paid next to nothing. If, on the other hand, you ask a hundred questions and examine them from head to toe and then decide to refer them on to someone who knows more than you do, you can charge a bigger fee, at least a 99214 instead of a 99213.

We get reimbursed for complexity that is sometimes a result of incompetence. That is one definition of value in health care delivery.

These days, quality in healthcare is also measured in “outcomes”; how many people comply with our recommendations by eating better, quitting smoking or exercising more. Or at least whether we documented that we told them to.

Of course, you could talk about more things in greater depth in your precious fifteen minutes together if you didn’t also have to document everything you touched on in a Byzantine electronic record better suited for billing than patient care. But, if you didn’t document it, it didn’t happen.

Diagnostic accuracy doesn’t figure prominently in the quality literature, only sometimes when it comes to missing heart attacks and cancer, but in my world, primary care, you can still achieve great quality scores from documenting sometimes meaningless housekeeping tasks like annual microalbumen tests for diabetics, even if you don’t manage to decrease the kidney damage.

Good quality measures are ones that are easy to collect and manipulate statistically. But does a good and tidy measure convey better quality?

We are still stuck in the Deming manufacturing mindset. But people are not machines and diseases are not manufacturing processes.

Do we ask how a teacher managed to inspire a young student to become a great scientist? Do we demand an explanation of how a priest brought a distraught parishioner from the brink of suicidal despair? Do we ask how Da Vinci held his paint brush when he painted Mona Lisa’s smile? Do we value an athlete with “good” technique more than one with good scores?

I think our health care quality debate has a myopic view. We are often ignoring the big picture and the real purpose of caring for the sick. That’s because healthcare is a business now…

11 Responses to “Quality Medicine: Showing the Math”

  1. 1 Lippman, Marc E, M.D. August 2, 2017 at 1:56 am

    This is brilliant.
    I am a great admirer but this is truly superb.
    In my view we are well into the process of leaving medicine worse than we found it
    When we trained and that is so regrettable.
    Keep up what you are doing !!!

    Marc Lippman MD, MACP FRCP
    Leonard M. Miller Professor of Internal Medicine, Psychiatry and Behavioral Sciences
    Deputy Director, the Sylvester Comprehensive Cancer Center
    University of Miami Miller School of Medicine
    Ph. 305-243-9122

    From: “A Country Doctor Writes:”
    Reply-To: “comment+p6q3bx70szeyzgj-7jhbj1@comment.wordpress.com”
    Date: Tuesday, August 1, 2017 at 9:23 PM
    To: Marc Lippman
    Subject: [New post] Quality Medicine: Showing the Math

    acountrydoctorwrites posted: “Medicine is a lot like grade school mathematics. The days are long gone when instantly knowing or quickly arriving at the right answer was enough. Now it’s all about showing your calculations. Process is everything. It’s almost like having the right answe”
    Respond to this post by replying above this line

    New post

    • 2 acountrydoctorwrites August 2, 2017 at 2:27 am

      Thanks for your kind words of encouragement. In my tenth year of writing this blog, I have to admit harboring some thoughts of ending my blogging on the day I hit the ten year mark. But then someone tells me my musings are worthwhile…

  2. 3 Mary Symmes August 2, 2017 at 1:58 am

    You’re right, again, unfortunately.

  3. 4 Kenneth Faw MD August 2, 2017 at 2:13 am

    So well said!

  4. 5 Barak Raguan August 2, 2017 at 5:02 am

    Long time fan, first time commenter.
    Beautiful writing and something I, like all physicians, encounter every day.

    Tiny correction: Mona Lisa’s smile was shaped by Da Vinci, not Van Gough.

  5. 7 Brian Pierce MD August 2, 2017 at 9:43 am

    Healthcare has always been a business. The difference now is that the physician works for a payer, not the patient.

  6. 8 Janet G. Smith August 3, 2017 at 11:41 pm

    Unfortunately, just like with medicine, teachers have to document everything now too. More time spent on documentation than inspiring!

  7. 9 Jed Constantz August 30, 2017 at 6:01 pm

    Healthcare became a “business” beginning with the Hill-Burton Act of 1946 and picked up real steam with the passage of the Social Security Act Amendments of 1965 (aka Medicare/Medicaid), both of which provided artificial sources of funding for healthcare service expansion and service delivery. The challenge today is to drive a level of innovation that re-positions primary care as THE decision maker (in collaboration with the patient) in the care and treatment of patients, focused on the answer, not the math.

  8. 10 Kierney August 30, 2017 at 7:26 pm

    I had a meeting just yesterday in which I was told
    1: I have to specifically say aspirin (not antiplatelet),
    2: I have to address a patient’s hypertension in the note, even if it is just “well controlled,” or “being managed by PCP,”
    3: I have to send at least one referral electronically in a 90 day period (not by paper or fax or phone),
    4: I must send rx’s electronically when at all possible, and before the note is signed otherwise it doesn’t count,
    5: my notes, according to one insurance provider, must be completed within 24h of seeing the patient,
    6: I must document at least 1 diabetic foot exam in 90d (I do not treat diabetes in my specialty),
    7: starting Jan 1, any controlled substance written by me (or my doc) must be manually entered into a database within 24h


  9. 11 Stephen Croughan, M.D. August 30, 2017 at 8:22 pm

    Excellent article. Well written. Don’t let it get you down. Just keep doing good descent family medicine.
    How you doing Jed?

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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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