The Medical Quality Conundrum

Different constituents can come to an issue that concerns them both in a manner that sabotages their ability to work with the other. There are many stakeholders in health care, not the least of which are patients (or the consumer, in another parlance), management, nursing and so on. The central constituents is the physician, who has taken a remarkable beating in recent decades.

I doubt there is a physician alive today who would not wish to improve the level of care she wants to provide. There may be disagreements in how to achieve such improvements, but browbeating is frequently counter-productive. Personal experience suggests that there are at least as many people out there who like to blame physicians for all the ills of the health care system as there are enlightened, inclusive systems-oriented people who work at developing consensus.

Physicians dread the moment when some quaint individual in a business suit calls a meeting so that we can talk about improving quality of care. The first shudder is caused by the simple notion that someone is to judge you work. Sometimes it takes a physician to understand the angst of a physician contemplating a bad outcome. There are memories of surgical grand rounds as students when the only things not flying were the scalpels.

The second shudder is the one that reminds physicians that they are the ones that will be sued, brought up on charges, reamed by administration or blamed by the community for outcomes they know full well depend on an entire system of care; a system which frequently appears too busy criticizing to see that it itself is broken.

What is quality of medical care anyway? The deeper I look into it, the more convinced I am that nobody knows. From a physician's perspective I can tell you with considerable certainty that it remains undefined and unmeasured.

That does not mean we cannot make some feeble attempts at understanding the beast! Patient satisfaction is a muddy concept borrowed from marketing. It is hardly "quality" as a physician thinks of it. It seems to be influenced by things like cleanliness, the age of magazines in the waiting room, the receptionist's attitude and other things unrelate to the physician's performance. In fact, many of these "Disney" factors are unimportant to many physicians. It's part of the administrative headache that needs to be taken care of by somebody else so that they can do their job.

Despite the lack of credibility and scientific weaknesses of the patient satisfaction paradigm, it is not a bad place to start. It helps us understand the patient's experience and work within it more effectively.

Wrong site surgery is not the be-all of quality. It does not effectively tell us how good the surgeon is, how she handles tissues, secures hemostasis, obtains a good cosmetic result when necessary or their ability to "get all the tumor". But it's a good place to start.

Overall health outcomes are a complex thing to study. Population health may be unaffected by provider practice patterns (I'm referring to the Dartmouth studies), but this is not necessarily a bad thing or something for which physicians are to be blamed. It is a fact to be taken into consideration when making overall policy decisions. But every physician knows, from bitter experience, that heroic measures have been wasted on patients whose own behavior keeps putting them in the way of harm. The cirrhotic who still drinks, the smoker with cancer or the welfare mom who gets pregnant in a drug-induced haze. Most docs know the best way to avoid poor outcomes is pick your patients, which is often as easy as picking your neighborhood. There is nothing wrong with helping the chronically over-served, but such people have better outcomes than their socio-economically deprived brethren, no matter what.

We may not yet be able to adjust for all the determinants of health outcomes, but I get a feeling from the literature that we can predict better than 50% of those factors. It's not up to the usual scientific standard of certainty, but given the extremely wide range of outcomes, it's not a bad job.

The problem with medical quality is when we approach it as an incontrovertible truth and use it as a weapon to flog the heck out of the most visible and central instrument in the provision of care: the physician. Nobody is going to improve the delivery of health care in America without the active participation and involvement of those people who deliver medical care and whether you call these people doctors, physician assistants or PhD nurse practitioners, those people will resent being beaten with the product of their own work.

Maybe acknowledging the limitations of our ability to understand, measure and improve medical outcomes and quality would yield a better result.

Costco, Fashion and Health

I share a lot with the society in which I live.

Shopping at Costco, you always notice the overstock items run in a small number of sizes. Somebody overestimated the number of items manufactured in a given size. Sometimes it's easy to find your size, which probably means it was either butt-ugly or mis-priced.

My size is not easy to find. People with 18 inch necks are not usually 34 sleeve. You can find 18/36 and 17/34, but 18/34 just ain't easy.

I have message for the "shmatta" industry: America is getting fat! I'm not proud of it, but facts is facts and I'm not getting any younger, thinner or hairier on the top of my head. America is getting fat and the population's obesity no longer looks like a bell curve. Stop making clothes for the ideal of the human form and you will lose less money in unsellable overstock.

One good thing: tomorrow is the day I will start to exercise, knowing I finally found an 18/34 and will have a shirt I can wear to my next interview!

It's The Economy, Stupid

over the years, I have been asked some interesting questions about a general reluctance amongst some people with medical degrees to actually practice medicine.

For example, I was recently asked in an interview for a medical management position why "doctor's didn't do as they were told?"

Nearly a decade ago an administrator asked me "why all us doctors wanted to do was anything but see patients."

I was confronted by a patient and told I was greedy, that's why I spent so much time on the golf course. (There is a non-sequitur in this statement that I am at a loss to counter. Not only do greedy people spend little time recreating on the golf course, I gave up golf years ago because I couldn't get the ball past those little windmill blades on the mini-putt!)

It probably does relate to the landscape of economic activity and how it has come to treat the healing profession. After all, Arnold Kim's story shows that it is possible to make more money writing a blog than practicing nephrology. I guess you just have to put your mind to it and be ruthlessly realistic.

Don't get me wrong, I enjoy seeing patients. It's the noise that bothers me; the administrative, governmental, para-health professional pandering BS that gets in the way of simply being a diagnoser, counsellor, treater and hopefully confidante to another human being.

At some point it becomes possible to gain more professional satisfaction working as a blogger than a physician.

Yes it IS the economy!

Hell-Bent

I was hell-bent on coming out West, knowing that coming to a turn-around could be dangerous. I recently discovered that my 6-month tenure as Chief Medical Officer was beaten on the short side in recent company history. So the worst-case scenario of living here for six months to decide if it would finally become a long-term living decision has come to pass. The cost was living through some emotional turmoil for a few short months, rather than wild success at a company that was ready for the things I am passionate about (quality improvement and care for the under-served).

Interviewing is always a fun activity, and one which I am getting good at, with some mixed feelings. Physician groups with a strong professional streak talk about independence and the lack of managed care in their practice, important people in town who come through their doors and unlimited compensation based on how hard one is willing to work. We never hear about the price on one's family and loved ones of giving up nearly all leisure time to "properly" take care of people. Sometimes medicine can have a strange culture.

Service organizations, especially with public governance tell you their civil service salaries up-front and proceed to tell you about their wonderful government benefits. Intangibles count, I guess.

Teaching groups always talk with pride about full-spectrum family medicine, including ward service for children and adults, maternity care, nursing home, etc etc etc. It's a bit like an extension of professional pride with a service twist, but this is a rural area and family docs can get away with being "stem-cell" physicians. Any city worth its salt has enough specialists to prohibit the practice of being a true generalist. It seems vaguely unfair, but the other concern is that physicians are now guarding their lifestyles a little better than they did a couple of generations ago. Why would anyone want to be an internist, a pediatrician, a hospitalist, an obstetrician, a teacher, a manager and a business-man at the same time, even if they may be capable of doing some of those things on some occasions?

All I want is to sip wine from my deck at home on top of a desert river gorge with snow capped mountains off in the distance at the end of a reasonable day's work with some challenge but a minimum of heart-ache!

I know, I'm nuts!

A Little Nursing Tiff

Wow! What started off as an apology by the fairly delightful Guitar Girl, RN turned into a slugfest after a somewhat provocative comment by The Happy Hospitalist. It's worth taking a gander at the comments, although it strikes me as an old story.

My surprise is that, in this day and age, any animosity between nurses and physicians still exists. Notably, a physician points out that the medical knowledge base is different from that of nursing's and that our training is complimentary. This appeared to unleash accusations of arrogance, apparently interpreting Happy's comments as an assertion that physicians are better than nurses.

I find it interesting that the accusation came from nurses. In the post-modern world, meaning can come at us from so many different directions. It is funny how an assertion can contain a strange, almost metaphysical evidence of the contrary.

To Guitar Girl RN, I say, Rock On. I'd work with you any day of the week.

A Peek Inside Quality of Care

The last time I needed general anesthesia, I was five years old. The last time I needed an IV was thirty one years ago! Knock on wood, for real!

I'll keep the juicy details to myself, but the procedure I underwent today was interesting to say the least. I suppose every interaction with the health care system, upon which I pontificate with such earnestness, becomes an opportunity for reflection.

I was at an out-patient surgi-center accredited by The Accreditation Association for Ambulatory Care, not the Joint Commission. Yet another reminder that there are alternatives to the current accreditation structure enshrined in Congress' instruction to CMS. The principles of patient safety are straightforward and best practices are not intended to be expensive secrets.

The first thing I noticed was the regularity of all the questions required to assure safe surgery; name, DOB, surgeon and procedure were verified ad nauseum. Well, three times to be exact. It was busy and you could tell. The nurse that called me in from the waiting room butchered my name while carrying on a conversation with someone down the hall on the way to my changing room. She was one of those old-school nurses who has the answers for anyone on the floor who needs a hand. I trained with nurses like that and they're great. They are all business and have little time for molly-coddling. Everyone else acted with requisite sensitivity and professionalism, but you couldn't help but notice the fact that they were hurried.

The surgeon came highly recommended. He was one of the first in the valley and is known as a consummate, fast, precise proceduralist. Again, he is a no crap kind of guy; my wife's response was "No bedside matter. None. Whatsoever." It made me think of the Joint Commission again and their "bad boy" witch-hunt. Just to be clear, my surgeon is not the type to throw temper tantrums and such behavior is not acceptable under any circumstances, but there are better responses than a bureacratic regulation by an accreditation agency. As an aside; there's no crying in baseball and no whining in medicine!

Across the street is a Planetree affiliate hospital where my wife had her surgery a couple of months ago. They were every bit as professional as the surgery center , but the level of hand-holding compassion, empathy and care was just what my wife needed. This "patient-centered" approach is what gets you designated a Planetree hospital and I appreciated it more that I can ever articulate. This is the quality that most consumers see and what they frequently understand as quality of care.

I was more concerned with the manual skill and judgment of my surgeon and even that is purely subjective information gleaned by word of mouth. I was looking for qualitative information which cannot be expressed in numbers or percentages. Either way, I have regualry been impressed by the level of skill and compassion to be found in this little Western desert town. It's a darn sight better than anything we had in Maryland. And Atlanta... puh-lease!

I think the wave of consumerism overtaking health care is a good thing; after all we are all in it for the patients. But we would all be well-served to remember that quality has many nuances. Patient satisfaction is determined by "soft" features of health care delivery; things like compassion, caring and cleanliness. They offer dignity, more than anything else. Important as dignity is and as much as I appreciated the Planetree experience, it is not "right patient, right intervention, right time" which is all we know how to measure accurately.

Given my interest in quality of care, the uninsured and the public health impact of health care, it raises some other interesting questions. I believe that everyone is entitled to basic quality health care, but quality costs money. Oak-panelled walls and Louis XV chairs in wating room with a library of 19th century first editions make me happy, but if we define quality in terms of hotel services, speed of service and Planetree-style amenities, we may not be able to afford Healthcare for All. There is a fundamental conflict between two currents which I see as part of the same consumer-based movement.

Quality costs money and at the end of the day, we have to decide how much of it we can pay for and perhaps try to define what aspects.

Weekend Blues

So, now it's official. I am unemployed.

On vacation, with internet access problems, a market melt-down and the intense heat... oh the heat. Well, I'm the guy who wanted to live in the desert!

This is the summer of our discontent.

I was having a discussion with a colleague about the option of going into practice for myself versus being an administrator at a larger organization. This is probably a good time to evaluate what I've been doing.

I spent over a decade in medical education, got the admin bug and realized that primary care and universities had such disparately aligned incentives that university-based residencies did not represent a fruitful future. In fact, university-supported, community-based affiliations appeared to be the best compromise for a primary care training program.

Armed with an MPH and a desire to develop my management skills, I found an FQHC and had a great 3-year ride where I helped stabilize and grow an organization that served 10,000 of a potential population of over 100,000. I started yearning for greater growth, a larger organization and most definitely a smaller town without any beltway-style traffic.

Unfortunately I did not heed the words of an adviser who made the point that the majority of organizations in this country make medical practice and medical management particularly unpleasant. The last six months must be characterized as a failure, although the challenge was huge and clearly evident at the start.

So, in this context, my colleague was asking why I wanted to continue working in management. It is a good question, given that I believe that good management is invaluable to physicians. Perhaps I can be forgiven for having a bad taste in my mouth for the people I have worked with and for generalizing to the world of medical management. The sad part part is that "good medical management" is awfully hard to find and I am nobody's cavalry. The good organizations don't need me and the bad ones will chew me up.

But it's due to be a beautiful and hot weekend here in the desert and remember, it's not the heat... it's the humidity! Have a great 4th of July.