Search Results for 'Quality conformity'

Quality or Conformity Revisited

In 2009 I wrote a post titled “Quality or Conformity“, where I pointed out that many of the quality measures in primary care have more to do with whether doctors follow guidelines than if they deliver care that helps patients live long and well. There is a tendency to focus quality efforts on measuring what is easy to measure, rather than what matters the most.

That phenomenon is called the Streetlamp Effect, named after the man who was found searching for his car keys not in the dark alley where he lost them, but under the corner streetlight where he could see better.

Last night and tonight I read four articles in The New England Journal of Medicine and JAMA that made me think again about how elusive an ideal quality is in primary care.

The Case Record of the Massachusetts General Hospital for the week of May 23 was a 12-year-old girl with celiac disease, behavioral symptoms and fatigue. Her final diagnosis was Addison’s disease, a deficiency of the body’s natural steroids. The piece mentioned that most sufferers of this condition live with its often-debilitating symptoms for 2-5 years before diagnosis. The girl in this article had been hospitalized several times before the correct diagnosis was made (at MGH, of course!).

The other piece in The New England Journal was about how Fee-For-Service payment was going to go away and be replaced by payment schemes based on relative value units and adherence to clinical guidelines for chronic disease. This piece specifically mentioned that treatment of (acute) illness would have far less value than managing chronic diseases.

I thought of the man who had been to the emergency room twice before I diagnosed him with scabies a few months ago. Doesn’t accurate diagnosis with new presenting symptoms count for anything anymore?

The first article in JAMA was a very broadly written piece about the future of quality measurements under Obamacare. The second article, written by a group of primary care doctors, was titled “A View From the Safety Net”. These doctors described the difficult choices they had to make between doing what mattered most to their underserved minority population or scoring better on quality measures dictated by outside authorities when they didn’t have enough staff or money to do both. The Obamacare article mentioned striving for patient-centered measures, but it remains to be seen how patient-centered we are going to be allowed to practice in the future.

Quality is still in the eye of the beholder. People in Government, insurance and academia prefer easily quantifiable data and still hold on to arbitrary or outdated numeric targets, even when the evidence to support them is controversial or refuted by science. They are often like the man under the streetlight.

Doctors on the frontlines, who live and breathe the complexity of health, disease and patients’ everyday socioeconomic challenges, know that for every clever metric someone can think up to measure quality, there are countless other factors that can render the quality parameters meaningless. What good does it do to prescribe the right medications for someone with chronic illness when the patient can’t afford them or keeps forgetting to take them?

In the same month my original post was published in 2009, for example, the American Diabetes Association revised its blood sugar targets for older diabetics. The evidence has shown that our usual targets were low enough to cause harm to many frail patients, yet doctors in this country are still given poor report cards if they practice with their patients’ safety and the new evidence in mind.

So, what is quality?

Quality is easing suffering and giving hope, not crunching numbers.

Quality is treating each patient in a sensitive, caring and competent manner.

Quality is serving the patient’s best interest with societal good in mind, not serving society with only an eye toward the individual patient.

Quality is having not only systems to promote safety and good practice, but people who care and invest their talents and abilities for the good of the patient.

Quality is diagnosing a rare disease like Addison’s early enough to give an adolescent girl her teenage years before they are gone.

Quality is making the diagnosis of a common disease like scabies in five minutes in a patient who has already cost himself weeks of discomfort and his insurance the dollar value of two emergency room visits and three prescriptions.

Quality is doing what matters to the patient. If we accept, even endorse, patients’ right to decide whether or not to be resuscitated if their hearts should stop, aren’t we then also allowed to listen to our patients and together with them formulate a care plan that they feel comfortable with for their chronic illness without fear of retribution by some Government or insurance reviewer for not following some more or less arbitrary guideline?

Quality is a word that lacks universal meaning. Every dictionary I have looked in has scores of definitions. It is a word people use for their own purposes.

We must be careful about letting others define the standards for our profession. If people with a more financial and less scientific and humanistic viewpoint set all the standards, technicians and computers will replace doctors.

The quality of a church service is, in my opinion, not adequately measured by how freshly painted the murals are, how well matched the choir uniforms are, how well-shaven the minister is or how clear his voice is when he puts his notes aside and speaks from the heart. If the Government were to set quality standards for churches, those things might be major quality indicators.

Fortunately, Church and State are separate in this country; health care and Government are no longer.

Health care, like religion, has a lot of intangibles, and even its substance is the source of many disagreements. I think that just like people go to church for different reasons, they seek health care for enough different reasons that our quality measures need to be very patient-centered, without losing sight of our “substance”, our foundation of science and humanity.

Quality is about addressing both the intangibles and the substance. Most of us know it when we experience it ourselves; the problem is building systems that guarantee it.

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…”

There Are Too Many Back Seat Drivers in Medicine Today

“Your patient may benefit from X”, “Your patient may be due for Y”, “Your patient may be non-compliant with taking their Z”.

“Care Considerations” is one of the many names for a phenomenon that seems to be exploding. Insurance companies are more and more acting like back seat drivers, hoping that such communications will improve “quality”, “compliance or “conformity” – whatever you want to call it. They are trying to tell us what to do.

Most of the time, there is some sort of admission that we are the doctors and that we may know something about our patient that they don’t. But the underlying idea is that we are not doing our jobs. Ironically, the more reminders we get, the more distracted and ineffective we might actually become.

There are two problems with what these middlemen are doing: They spew out generic data that may or may not be relevant for our patient’s unique circumstances and they try to steal our attention away from the patient’s we are actually scheduled to see today.

These back seat drivers are essentially babbling about which way to turn on a different road trip from where we are driving in the moment and saying things like “you might be out of gas” because they must have been napping when we stopped to fill up a little while ago – trying to be helpful, but ultimately doing the opposite.

This is because today’s primary care doctors are essentially working in synchronous mode, scheduled to see one patient at a time. The dirty little secret in primary care is that anything to do with patients who are not present in our clinics, physically or in a telemedicine appointment, happens “between patients” even though there are no breaks between patient appointments in our schedules. Not infrequently such tasks are done after hours, during what is quaintly called “pajama time”. (Can you spell burnout?)

Clinic driven messages are generally fairly specific and appear in our electronic records linked to each patient’s “chart”: If I get a question if a patient could increase their dose or get a refill or get a referral to go back to their specialist, all their information is there, linked to the request.

But the “Care Considerations”, arrive on paper, sometimes even in a format with several patients’ information on the same page. In order to consider any of them, we have to locate the patient’s electronic file and spend more or less time searching for their relevant information. This is time consuming and basically interrupts the workday of busy primary care doctors whose working conditions make no allowance for asynchronous communication or considerations.

In a different world, if clinics become reimbursed for managing patients and populations, maybe we could look at these kinds of letters, but in today’s reality they are essentially junk mail, trying to interrupt our clinic flow.

Most of us just toss them in our shred basket. Can you blame us?

Between Patients: The Myth of Multitasking

The Call to Be a Primary Care Doctor

I suspect the notion of calling in narrower specialties is quite different from mine. Surgeons operate, neurologists treat diseases of the nervous system, even as the methods they use change over time.

Primary care has changed fundamentally since I started out. Others have actually altered the definition of what primary care is, and there is more and more of a mismatch between what we were envisioning and trained for and what we are now being asked to do. Our specialty is often the first to see a patient and also the last stop when no other specialty wants to deal with them.

We have also been required to do more public health, more clerical work, more protocol-driven pseudo-care and pseudo-documentation like the current forms of depression screening and followup documentation. And don’t get me started on the Medicare Annual Wellness Visit. How can we follow the rigid protocol and be culturally and ethnically sensitive at the same time?

We are less and less valued for our ability – by virtue of our education and experience – to take general principles and apply them to individual people or cases that aren’t quite like the research populations behind the data and the guidelines. The cultural climate in healthcare today is that conformity equals quality and thinking out of the box is not appreciated. The heavy-handed mandates imposed on our history taking and screening constantly risk eroding our patients’ trust in us as their confidants and advocates. The finesse and sensitivity of the wise old fashioned family doctor is gradually being squeezed out of existence.

The call to primary care medicine, if it isn’t going to pave the road straight to professional burnout, today needs to be a bit like the call to be a missionary doctor somewhere far away:

To go into a sometimes hostile environment, without the right kind of resources, where people don’t speak your language, where you never feel you can do everything you hoped to do for your patient, and where some of the things you want to do might even encounter cultural or political taboos.

In other words, to do what we can in the moment for each patient, regardless of the system and the circumstances.

That is a very noble call, but not one for the faint-hearted.

A Country Doctor Reads: May 19, 2019

“The physician–patient encounter is health care’s choke point” -NEJM

This week’s Journal has a very profound article about why healthcare has not evolved through its technology the way other sectors of society have.

My take, and extrapolation, is that there are three reasons why healthcare has failed to evolve in usefulness of both our product (the care we deliver) and our technology (our EMRs), our customer centeredness and the value/cost relationship of the services we provide.

1) Healthcare is not at all customer centered. Even the required operational framework for Patient Centered Medical Home recognition is completely top-down. We are being crushed by mandated screenings for everything from obesity to domestic abuse (see my postBrief is Good”). The whole notion of Quality is arbitrary and paternalistic. Cash practices are appearing and evolving to meet patients’ needs without the mandates of Medicare and the private insurance industry, but are in essence duplicating cost and effort because of Obamacare’s insurance mandate.

2) Our technology was not created with the purpose of speeding up or simplifying documentation so that clinicians can deliver better care. Instead, there was a dual focus of maximizing billing and controlling the “Quality” in clinician performance. Since we basically don’t have a clue, let alone agreement, about what Quality really is (see my 2009 postQuality or Conformity?”), any effort to promote or require Quality through templates and “hard stops” becomes cumbersome and potentially meaningless.

3) Healthcare is still practiced as if we were all solo practitioners without technology, seeing one patient at a time, in person, in the office, which is marginally more efficient than housecalls. So far, we have no incentives to do anything different. A silly example: A patient with perfect blood pressure at home on their internet connected sphygmomanometer doesn’t help my Quality ratings one iota, since my “grade” for the year is the last blood pressure recorded in the office for the calendar year (see my postDon’t Do Chronic Care in December”). And, as the NEJM article points out, there are no financial incentives to have nurses or other non-providers manage routine problems like hypertension in our current system.

Here is an eloquent section of the article by Asch, Nicholson and Berger:

“Information technology is changing medicine, but electronic health records (EHRs) are mostly demonized by clinicians, and the promised customer efficiencies seen in the retail, financial, entertainment, and travel industries have been largely absent in health care.

These approaches will improve with time. It’s worth noting, however, that the transformations seen in other industries have followed a different path. In these cases, aligned financial incentives, better customer centricity, and technology have been motivating and enabling forces for change, but the transformations themselves came from operational changes that enhanced productivity — mostly by finding ways to use fewer people.

The movement from bank tellers to automated teller machines to cashless digital transactions has reduced effort all around. Because of easy-to-use software, fewer people now use travel agents. Yet despite increased use of EHRs by clinicians and smartphones and wireless technology by patients, the fundamental approaches to managing hypertension, diabetes, and chronic lung disease have remained the same for 50 years. The drugs are better, but the way patients engage with doctors during office visits and hospital stays is unchanged.

The physician–patient encounter is health care’s choke point. So long as we continue to think of health care as a service that happens when patients connect with doctors, we shackle ourselves to a system in which increased patient needs must be met with more doctors. Other industries overcame similar constraints in various ways — McDonald’s pioneered a production-line approach to fast food, for example — but more recent transformations have come from facilitated self-service. Taxpayers abandoned tax preparers when TurboTax created a new pathway to what they wanted. Until we invent the TurboTax of health care, we won’t achieve the kind of productivity gains needed for transformative change in quality, access, or cost.”

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”.


CONDITIONS, Chapter 1: An Old, New Diagnosis

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