nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
See here for more discussion.

Thursday, August 12, 2010

Judging How Good A Doctor Is: Quality Measures, Best Doctor Lists, Or Trust?

If my report card as a doctor shows that only a third of my patients with high blood pressure are achieving a normal pressure, does that make me a bad doctor?

The assumption behind these report cards is that I am (a bad doctor).  A superb article in the New England Journal of Medicine talks about the danger of taking quality measures for the patient population as a whole and applying them to judgments about individual practitioners.

It's been common for public health officials to look at measurements of effectiveness at the national or state level.  It makes good sense to know that only 75% of children are getting the immunizations they should, and whether they are getting them on time.   It's almost as clear that when only a small percentage of diabetics are reaching a set of objectives that give them the best care--like nutritional counseling, foot care, hemoglobin A1C measurements, etc--then we need to look for better ways to care for them.

But when institutions take these same criteria for effectivenss and set standards for each of the doctors, it can be self-defeating, because most of the time it's the doctors are doing what they should.

I can tell my diabetic patients how important it is that I monitor their care with all the elements listed above, but that's as far as I can go.  If I still get a below-standard report card for my diabetic patients, what would you suggest?  As the author describes his practice,
"And although these quality measures focus on diabetes in pristine isolation, my patients inconveniently carry at least five other diagnoses and routinely have medication lists in the double digits. Practicing clinicians know from experience that micromanagement of one condition frequently leads to fallout in another."
The impact can become pernicious if plans to tie physician payment to meeting these goals is carried out:
"I appreciate the efforts and good intentions behind the report cards, and I'm certainly not saying that we shouldn't have any data at all. But I think we need good evidence that the data measure true quality and that providing data is actually helpful. For individual doctors — as opposed to institutions or countries or populations — the evidence is not convincing. The possible mandatory use of these quality measures for reimbursement raises a host of other concerns."
The progressive reformers all have a love affair with scientific methods of health care measurement.  Reading the grandiose plans of some of these folks gives you the impression that they think of people as objects or machines, without frailties or weaknesses...or if they have them, they should be disincentivized or forced to act against them.  But surely in their own lives they see themselves as human and acknowledge the power of "all too human" needs?
"I've always wanted to ask these analysts how they choose a physician for their sick child or ailing parent. Do they go online and look up doctors' glycated hemoglobin stats? Do they consult a magazine's Best Doctor listing? Or do they ask friends and family to recommend a doctor they trust? That trust relies on a host of variables — experience, judgment, thoughtfulness, ethics, intelligence, diligence, compassion, perspective — that are entirely lost in current quality measures. These difficult-to-measure traits generally turn out to be the critical components in patient care."
I'm a great believer in population-based analyses of health care quality.  But what works for a large group, rarely translates down to the individual, one-on-one interaction in medicine.

I want the latitude to decide--with my patient--what the best approach is, recognizing that people are not a collection of criteria and standards, but unique individuals.

Doc D

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