What gets measured gets managed.
—Peter Drucker
Let me start with a true story I heard from a radiologist at a tertiary medical center. The radiologist was called by the emergency department physician to read an ankle x-ray. The radiologist asked, “What part of the ankle did the patient say was painful?” The emergency department doctor responded, “I haven’t examined the patient!” What has happened to American medicine? Have we forgotten the patient? Have we become so focused and dependent on technology that we have forgotten what we learned in medical school—to use the history, physical exams, and lab tests and imaging to support our diagnosis and then embark on a treatment or plan of action? We are facing a seismic shift where medical diagnoses will be made with deep data and artificial intelligence. The doctor will not be needed for cognitive decision-making. Instead, the doctor will be taking on the role of implementing advice from an algorithm. No doctor spent 15 years of training and incurred several hundred thousand dollars of debt to become an automaton subservient to an algorithm!
Healthcare is trying to make the quantum leap from quantity to quality. With healthcare costs in the United States exceeding $4 trillion per year and representing nearly 20% of the gross domestic product, we must move to a system that places a premium on healthcare quality—i.e., outcomes, patient satisfaction, and cost reduction. The fee-for-service model is on life support.
With the current fee-for-service basis, the system promotes physicians increasing their incomes by doing more (more tests, more treatments, more of everything). This approach to healthcare requires physicians to see more patients, spend less time with each patient, avoid those health aspects that aren’t well compensated, and go home to complete paperwork and medical records late into the night. The result is the doctor feels tired, unfulfilled, and on a trajectory for burnout and early retirement.
To make the leap to quality of care, we must develop measurements of treatment based on measuring outcomes, readmission rates, and quality of life. Currently, we have a measurement and documentation requirement for nearly everything. Although the EMR can capture these data, the use of the EMR must extend beyond data collection for billing and coding. Quality measurement in healthcare has become an industry unto itself. Hospitals and healthcare systems across the country pay money to have their quality of care scrutinized and made transparent to the consumer, our patients.
Unfortunately, some bad-quality measurement actors distort, distract, and obfuscate using inaccurate data. Deborah Stone, PhD, from Brandeis University, gave a lecture and announced to her audience, “Numbers are figments of our imagination, fictions really, no more true than poems or drawings. In this sense, all statistics are lies.”(1)
We need to ask whether we are offering the right information and whether everything valuable in healthcare can be easily measured. Indeed, some important things are easy to quantify. For example, even if my office is clean and my readmission rate is a respectable 1%, that only sometimes translates into how well I educated patients about their disease and treatment.
Quality should also include the doctor’s ability to communicate effectively and empathetically when delivering bad news. Unfortunately, with the quantity model, physicians often are required to see a specific number of patients each hour. But measurements only sometimes offer dispensation when a physician misses their patient quota because they devoted extra time to a single patient who needed more attention and care. Remember, doctors cannot understand patients if they are not understanding!
These questions echo others raised in a recent study headed by Arnold Milstein, who directs the Excellence Research Center at Stanford University. In the study, Milstein and his colleagues used commercial health insurance claims to identify physician practice sites across the country that delivered high-quality care with a lower overall cost. They then conducted extensive site visits to determine what these practices were doing right.(2)
The researchers found some common themes, including implementing a concept called “care-traffic control.” As Milstein describes it, “We found that physicians at these sites were thinking more deeply about what each patient needs to navigate in the periods between primary care office visits.” The researchers measured whether patients followed through on laboratory tests. They looked at medication compliance. They recorded whether the doctors communicated their treatment plans to all the doctors and specialists a patient sees. These stellar quality practices would refer patients to a pharmacist to conduct an annual comprehensive medication review to avoid drug-drug interactions. Many of the attributes that Milstein describes are only sometimes measured by quality measurement organizations. For example, the researchers found that high-value practices encourage patients to complain about poor service. As the marketing genius, Marshall Field, said over 75 years ago when he commented on receiving complaints from customers, “Those who entered to buy, support me. Those who come to flatter, please me. Those who complain, teach me how I may please others so that more will come. Those only hurt me who are displeased but do not complain. They refuse me permission to correct my errors and thus improve my service.” Stellar practices encourage patient feedback, respond to customer complaints, and offer same-day appointments and expanded hours in the early morning or late afternoon. (It is of interest that these unique practices often are housed in spartan office spaces.)
Guidelines and checklists have received a bad reputation, because contemporary physicians feel that those concepts are akin to cookbook medicine. Atul Gawande, MD, however, has shown that checklists can ensure female patients receive mammograms, Pap smears, and other regular screenings, thereby enhancing the quality of care. Regular screening tests according to guidelines are reasonable ways to measure quality.
Quality of care can be determined if surveys ask questions such as, “Did your doctor listen to you? Did they take the time to explain the plan for your health? Did they speak to you in non-medical jargon that you could understand?” The take-home message is that patient surveys are valuable. They help ensure that the staff does things because they’re right for the patient. And often, what’s right for the patient goes right to the bottom line and may reduce healthcare costs.
No one can deny that it is easier to measure performance using tools such as the Objective Structured Clinical Examination, where students are asked to perform histories and examinations on standardized patients. However, measuring performance for physicians who are no longer monitored and are in practice is more complicated.(3)
Perhaps. But the physician and writer Atul Gawande suggests an out-of-the-box approach. In an article in The New Yorker, he discusses his experience performing surgery under the watchful eye of a coach, who helped him identify ways to improve his technique. Gawande said that a coach helped him reduce his complication rates.(4)
It may not be practical for every physician to have a coach or proctor present for every patient encounter. But Gawande’s experience reminds all health providers that checklists, standards, and protocols are only partially effective in ensuring quality in our healthcare system. In an era when nurse practitioners are doing the work of doctors, generalists are doing the work of specialists, and specialists are doing the work of sub-specialists, we must have strong, common-sense supervisory systems that bring a quality culture to the exam room.
Medicine historically has been resistant to change. As a result, the defense of the status quo has hampered new innovations and new approaches to medical care. To take back control of our profession, we must start by reassuring our patients that we are both good people and doctors.
The Argentine doctor Juan Carlos Giménez says, “To be a good doctor, you must first be a good person.” This statement shows how being a doctor requires both knowledge and exceptional attitudes. He writes further, “Being a doctor is having to deal with the patient’s suffering, knowing that there will not always [emphasis added] be a solution.”(5) Those who practice medicine, and those who are recipients of our services, will surely agree that medicine is not an elitist issue. It is much simpler: being a doctor means we care for people’s health and illness. To do it well, you must know many things and behave in a certain way. The doctor must love his patients. He must be a good person.
To affirm that to be a good doctor, you must be a good person is a derivative of the aphorism that says, “We cannot give what we do not have.” A doctor must look for the best for his patients:
Take care of them individually and simultaneously consider the general context;
Know how to prioritize the most relevant issues;
Understand their patients; and
Let them know that he understands them (be compassionate and empathetic) and gives excellent care.
It is not possible to do all this without effort, without being a good person.
“A person can give happiness and not be happy; can be scary and not be terrified, and he can give wisdom and not have it.”(5) Someone can indeed do or give things without having them. A doctor cannot understand patients if he is not understanding. He cannot comfort if he is not compassionate and cannot connect with the patient if he doesn’t have communication skills.
You can only give the best treatment if you are continuously learning and updating your knowledge. You can fool people once, but not day after day, patient after patient. That’s why doctors must set an example both emotionally and physically. An obese doctor cannot advise a patient to lose weight. The same is true with smoking; a doctor who has an ashtray on his desk full of cigarette butts can’t recommend smoking cessation.
If we try to base the idea that to be a good doctor, you must be a good person, we can resort to the ethics of virtue, which represents the gold standard of Aristotle.(6) The ethics of virtue indicates that what is important in actions is the character of the person who performs them, their disposition (intention), and focusing on a goal. The goal of medicine is to heal the sick, and the doctor must be committed to enhancing their health. It is not about only filling a job, of merely being a good professional; it is about attending to the needs and requirements of the sick person. The medical act forces professionals to put their knowledge and skills at the service of each sick person.
The ethics of virtue says not what needs to be done, but what kind of person to be—in this case, a doctor. A virtuous doctor will possess the virtues that allow him to exercise the profession fully. As the virtues (i.e., habits or traits of character) are acquired by effort and practice of being virtuous, an adequate education is essential to acquire them. In our case, this education comes in the form of the professional virtues of medicine, including intellectual honesty, benevolence, humility, trust, compassion, and prudence or responsibility. Having a clear objective offers the best possible care to the sick. The hard part is to keep doing it continuously.
The current system of training medical students has neglected the formation of a doctor’s surface; therefore, many physicians focus exclusively on technical aspects of the profession—like the emergency room doctor who ordered the ankle X-ray without first examining the patient, forgetting the true objective. Future doctors must be chosen and educated to think about the ideal they will serve, not just to make money, be famous, or live comfortably. Instead, we need to produce doctors who provide excellent care to the sick person in all dimensions.
During residency and afterward, the doctor’s commitment to the patient must continue to be emphasized. From this commitment will arise the attitudes and dispositions (i.e., the virtues) he or she must have to be a good doctor. To offer one last comment from Juan Carlos Giménez: “Being a doctor is not another profession; it is a philosophy of life. He who chooses medicine does not choose a profession but a way of life.”(7)
Bottom Line: The critical question is: “What has happened to American medicine?” Have big Pharma, insurance companies, and politicians caused us to lose our moral compass? Has our North Star disappeared from the sky? Let’s hope not. We still have an opportunity to take the high road and get back to the basics, i.e., putting patients first. But we must take our focus off bean counting. Instead of having our noses on the computer screens, let’s go back to having our eyes on our patients. If you take the road less traveled, you will gain more of your autonomy and ability to practice unbridled by government interference, oversight from payers, and having medicine controlled by algorithms. The ultimate bottom line is that we must shift our focus from quantity to quality care.
References
Jain SH. How do you measure quality in healthcare. Forbes. June 25, 2019. www.forbes.com/sites/sachinjain/2019/06/25/how-do-you-measure-quality-in-health-care/?sh=70844bdf5bdc .
Simon M, Choudhry NK, Frankfort J, et al. Exploring attributes of high-value primary care. Ann Fam Med. 2017;15:529-534. https://doi.org/10.1370/afm.2153
Miller B, Carr KC. Integrating standardized patients and objective structured clinical examinations into a nurse practitioner curriculum. J Nurse Pract. 2016;12(5), e201-e210. https://doi.org/10.1016/j.nurpra.2016.01.017
Gawande A. Personal best. The New Yorker. September 26, 2011.
Hurwitz B, Vass A. What’s a good doctor, and how can you make one?. BMJ. 2002;325(7366):667-668. https://doi.org/10.1136/bmj.325.7366.667
Madigan P. The virtue of Aristotle’s Ethics. By Paula Gottlieb. Heythrop Journal. 2011; 52(1). https://doi.org/10.1111/j.1468-2265.2010.00624_8.x
Shanafelt TD, Sloan JA, Habermann TM. (2003). The well-being of physicians. Am J Med. 2003;114:513-519. https://doi.org/10.1016/S0002-9343(03)00117-7