I graduated near the top of my class from the second oldest university in the world, and one of the best medical schools on the planet. I have 44 years of post graduate experience in a part of the United States, where there is a severe lack of specialists and where a small cadre of primary care doctors see more and do more than in many other parts of this country.
If and when I look at my personal report card in my new Epic EMR I find that I am average or worse. What that means is that I’m not real quick in responding to routine messages and other such things.
I almost get the feeling that clinical competency in primary care doctors is so much taken for granted and so commoditized that the only thing that matters is how fast we are at getting patients out the door and clerical tasks completed.
Metadata, as I call the majority of items in my EMR report card, is the typically invisible information on a CD, for example: Recording date, copyright holder, maybe the album cover photo for displaying on your device. But imagine if this was all you got, if the piece of music wasn’t there. That’s what it feels like sometimes in primary care: The clinical work we do is invisible while the metadata blocks the view of what really matters.
Would you pick a brain surgeon, if you needed one, based on their speed in the operating room or at the computer? I suspect neither.
There are a few clinical measures also in these report cards, but they are set as if they are absolute, immutable laws. And do they really reflect the quality of our care?
Quality measures in medicine are basically substitutes for the real information we wish we had.
We measure surrogate outcomes, like hemoglobin A1c and blood pressures. But the person with perfect numbers could suffer a fall one day from hypoglycemia or hypotension and break a hip. The diabetic could get urosepsis from their Jardiance pill that causes them to excrete more glucose in their urine. And the perfect blood pressure person could develop kidney failure or a life threatening arrhythmia from spironolactone or valsartan, or lupus from their hydralazine. In studies, such things are tracked and judgements are made that, for a majority of patients, the benefit of a particular treatment outweighs the risk. But, in practice, we don’t know who they are. If our patient is almost “at target” and the next drug we add could be the one that will harm that particular patient, is it worth doing? Polypharmacy is a dirty word some of the time, except when patients have several medical problems and are supposed to meet several numeric targets.
There is nothing in my report card about whether my diagnoses are correct, whether my workups are appropriate, whether my patients trust me or even like me, and what my clinical batting average is when it comes to actual outcomes.
Medicine is full of decisions, judgement calls, that should be made together by physicians and informed patients. The word patient-centered has become meaningless, because doctors who let their patients in on clinical decisions and respect their refusal to do certain tests risk getting bad quality scores.
A Country Doctor Writes: 
Going from a Healing Art to a money making market has changed the medical field. The value of a well trained physician has been diminished. Sad times.
Amen, Doc. Your words echo so true, even down in Tennessee. Our priorities are obviously backwards as a national healthcare system, and the entire purpose of our existence has been buried in bureaucracy. I constantly remind my coworkers, most of whom are new grads and 20 years younger than me, that their main focus daily should be on the patient-provider relationship and their outcomes from those interactions are all that matters in the end; not metrics. Because if they die, or acquire an aforementioned condition in your article, what difference does it really make if my businessmen superiors are happy with my “performance”? It’s nice to find some camaraderie and solace in your articles, and take comfort in knowing I’m not the only “old guy” who has a problem with the way things are going. To see the decay, know the future, and feel unheard is such a helpless feeling.
That’s why I mostly ignore my metadata, my patient experience survey data, and whatever other metrics I am measured by. I focus on connecting with patients, one at a time, to get their diagnosis correct and to collaborate on a treatment plan they will accept. I also focus on getting out the door at a reasonable time to go home, where I can think of other things than just medicine.
Excellent metaphor: grading a piece of art (music, etc) by the accompanying information only!
The ART of medicine requires a soul. None but the doctor can practice this art… skillfully, with humility, experience and wisdom.
No metadata can accurately capture that!
Ignore your report card: no one is coming to fire a beloved PCP!
(and don’t complain about bonuses and metrics… that’s a non-clinicians arbitrary metadata. Let’s all ignore them, giving them the attention they deserve!)
I am semi retired and only see patients one day a week. Yesterday for the first time I worked with the military’s new electronic medical record called Genesis. I had heard it was bad. But it is even worse than I ever could have imagined.
My question is why have Physicians allowed the insurance industry and computer programmers to take over? I certainly would never buy a computer system for my home that ran like Genesis. As far as I can see, there are absolutely no redeeming features. My iPhone is intuitive and I can do so much more with it easily. Why can’t we have electronic health record programs that work with the ease of an iPhone?
I can’t blame everything on the insurance industry. I think doctors need to unify and fight this. Why have we allowed such a thing to happen? I went through medical school in the 70s and we were told this was coming. I think everybody just ignored it and thought it wouldn’t happen or wouldn’t be so bad. But it is ruining a field that I have truly loved and dedicated my life to.
I read your posting with interest.
I am a 68 year old family physician in SW Louisiana working in a community much like yours with very little specialist coverage.
Like you, I was trained abroad and recruited to this area as a primary care physician.
The use of digital health information is a huge step forward in healthcare – PACS, lab online. But the use of mandated EHR is a complete disaster. Using that data to imply quality compounds the disaster.
Quality is like art – I know it when I see it. You can measure numbers but to use those to imply quality is to misuse the term. Might as well use likes on Google.
Thanks for writing this