Saturday, January 24, 2009

Measuring Physicians' Performance

Over the years I have had countless conversations on how to select a competent physician. Advice on this issue is easy to find, but the desired result is more difficult to achieve. In the last posting, I listed many of the recommendations of ‘experts’ and indicated the pitfalls of their advice.

The New York Times recently published a column offering their advice on choosing a physician. If you review the piece, make sure to peruse also through the deluge of readers’ comments, including one from your humble blogger.

While the Times piece is informative, it does not offer a surefire prescription for selecting a high quality physician. There simply is no easy formula to assess physicians’ competence, like the magazine Consumers Reports might use to rate microwave ovens. Nevertheless doctors are being evaluated and compared by insurance companies, employers, the government and now even on Angie’s List! The reason that this task is so challenging, and the results so suspect, is because two fundamental questions cannot be answered accurately.

What is the definition of a high quality physician?

How do you measure this objectively?

Consider these questions yourselves. How would you answer them with regard to your own physicians? Prepare a list of what you think constitutes medical quality in a doctor. How would you measure the attributes you selected? You will soon discover that there is no simple yardstick to measure medical quality. Doctors are not like microwave ovens or kitchen appliances.

I've struggled for years to answer the above two questions, but I can't solve it. In the next postings, I’ll explain more about this conundrum.

Sunday, January 11, 2009

Is My Doctor Any Good?

Medical quality is like pornography, it's hard to define but we know it when we see it. Every participant in the health care arena - physicians, pharmacists, insurance companies, hospitals, pharmaceutical companies, our government and the public - all support the mission to enhance medical quality. What paralyzes the effort is that no one agrees how to get there or even how to accurately measure medical quality. You can test this yourself. Ask your friends and relatives about the quality of their physicians. You will likely receive glowing testimonials about their 'excellent' physicians. Yet, if you ask the important follow-up question, How do you know your doctor is so good?, then your smooth talking neighbor may start stuttering. Don't be too hard on him. If quality experts can't figure out how to assess medical quality, then I doubt that your neighbor or your Aunt Mathilda can do better.

Here's a sampling of tips from 'experts' on how to select a high quality physician. After each of their recommended questions to ask, I will comment in italics to provide a tincture of skepticism.

Is your doctor is board certified?

While board certification is of some value, in no way does it guarantee that the physician is a high quality practitioner. In addition, most physicians today are board certified anyway as most hospitals and insurance companies require it. If I am a decent physician, it has nothing to do with my board certification status. Nevertheless, many patients like to see certificates on their doctors' walls. Take a closer look at them. From a distance, you might not realize that they are for bowling tournaments, barbecue contests and dance marathons.

What is your doctor's complication rate for the procedure he is proposing?

First of all, he may have no idea what his complication rate is. I certainly don't know what mine is. Additionally, operations can have dozens of complications. Which specific complication would you be referring to? Keep in mind that a higher complication may simply mean the doctor treats sicker patients. A superb surgeon, for example, may have more complications because he accepts critically ill patients who other doctors won't operate on. Complication rates, therefore, can be very misleading. I'd be more suspicious of a physician with a 0% complication rate. This doctor must have very little experience.

How many times has the doctor performed the operation or procedure?

This statistic makes some sense. Numerous medical studies demonstrate that physicians who perform procedures and operations regularly have lower complication rates. It is not clear what volume of procedures is necessary. For example, is a gastroenterologist who performs 2000 colonoscopies yearly better than one who does 500? Not necessarily. In addition, a high volume of cases does not mean that the procedures were appropriate or medically necessary. Who wants to have a gallbladder expertly removed if it should be left alone?

What is the doctor's success rate for the treatment proposed?

Good luck defining success in medicine! Doctors and patients often define success differently. A doctor may feel successful because the high blood pressure is well controlled, but the patient is disappointed because he is still fatigued. In addition, physicians' offices are not research institutions that study their patients' clinical data. Most doctors may have a sense that they practice sound medicine and have favorable outcomes, but most have no scientific basis for this assertion. A doctor's comment, "I've had lots of success with this treatment", may reassure you, but I'd be cautious about assigning too much weight to this optimistic statement.

What is your doctor's medical malpractice history?

Now my blood pressure is rising. Excellent physicians are sued everyday who have done nothing wrong. Many of them settle their lawsuits for business reasons, not because they were negligent. We live in a society where many expect and demand compensation and reward for any injury, even if no one is at fault. I may not be able to unravel the medical quality riddle, but I know for sure that a doctor's medical malpractice history is the wrong tool.

Which medical societies does the doctor belong to?

Society membership means the doctor has sent in a check and has received a certificate to hang on his wall to impress his mother and his patients. While the societies may disagree, I don't think that membership implies medical quality. I belong to 4 professional societies and I doubt that my medical quality is four times better than a doctor who has joined only one.

Is there a fish tank in the waiting room?

Yes, I know this sounds silly, but it may predict quality as accurately as any of the questions above.

Next posting: Whistleblower Quality Tips

Wednesday, January 7, 2009

Give me the 'Surgery for Dummies' book please!

I was flummoxed that the man designated as my trained surgical assistant needed me to ‘talk him through’ the procedure. I wonder if he would be willing to be ‘talked through’ flying an airplane or defusing a bomb for the first time. I’m sure that the patient’s family seated nervously in the waiting room would be reassured by his brash confidence to proceed on their elderly relative.

Was I nervous? Not at all because I knew that this man wasn’t going to touch my patient. I relieved him on the spot and arranged for the procedure to be performed by an individual trained to do so.

What if I had decided to ‘talk him through’ the procedure?
What if he didn’t disclose that he was inexperienced?
How much do patients really know about the competence of their physicians and those who assist them?

Studies have shown that most patients believe that their personal physicians are highly qualified, but how do they really know this? The scary truth is that they don’t and they can’t. Even experts in quality assessment can’t agree on how to measure medical competence, so I doubt that ordinary patients have cracked the code of this enigma.

Next posting I’ll offer some the ways that experts measure medical quality and why they don’t quite measure up.

Thursday, January 1, 2009

A Peek Behind the Medical Curtain

This blog launches today, but it’s been germinating in my mind for at least 10 years. I am a full time physician for 20 years and have seen the good, the bad and the just plain ridiculous. I’ve finally decided to blow the whistle. These postings will take readers ‘behind the curtain’ to see an insider’s view of the medical profession. I warn you – much of it is not pretty.

My purpose is not to highlight physician billing scams or outright fraud, although if reader comments lead the conversation there, I will respond. I will concentrate instead on what has gone wrong with legitimate medical care in America. There is not a day in my practice that I don’t confront another symptom of our broken health care system, and I am only 1 doctor. Imagine what the collective observations and anecdotes of our nation’s physicians would amount to. I hope that we hear from some of them. It is staggering how much excessive, inappropriate and unnecessary medical care is delivered – nearly all of it justified by skilled medical professionals. Why does this happen?

Obviously, there is superb medical care in this country. However, focusing on our flaws and failures is essential if we are to ultimately reform and reengineer the medical system. So, while some may decry this ‘whistle blowing’ as another whining doctor, I reject this. I’m going negative with the hope to create knowledge and momentum to move us forward. Clearly, one lone blog can’t prevail against an entrenched medical establishment, but grass roots efforts all started with just a single blade.

Consider the following anecdote from my own practice.

Last month, I arrived at my hospital, a state-of-the-art medical institution, to perform a medical procedure on a patient. One day previously, I had requested that a surgical assistant from the operating room assist me. These are trained medical personnel who assist surgeons in complex operations every day. The gentleman was present at the appointed time in surgical dress. I was about to begin and he remarked, “you’d better talk me through this, doc, I’ve never done one of these.”

Next posting I’ll share what occurred and give another patient care vignette that you won’t find in your hospital’s glitzy PR announcements.