Monday, February 23, 2009

Are Prestigious Physicians the Right Prescription?

If it were easy to know how to choose a good physician, then everyone would have one. As discussed in prior postings, it’s tough just to define a good doctor, let alone find one. There is no surefire way to select a high quality physician. Methods and advice that sound like a winning strategy, just don’t reliably deliver. For example, you are ecstatic to have an appointment with a renowned doctor at a prestigious medical center, but his fame might be from rat research, not from patient care. You feel privileged to consult with a medical school’s chief of surgery, but it may be residents and other training physicians who are actually doing your operation. You feel fortunate to have an appointment for your asthmatic son with a specialist who lectures widely on lung diseases and has authored several textbooks. However, he might be a much more skilled writer and public speaker than he is a treating physician. You are reassured that your cardiologist is a wizard at placing stents in clogged coronary arteries. However, while he might be a technical magician with his medical gadgetry, he might be less skilled in determining who actually needs them. While technical skill is important, medical judgment is paramount. I’d rather have no stent, than to have one placed by the world’s leading stent placer. The irony is that a patient, who receives a stent that is not truly needed, feels that he has received excellent care and has averted a catastrophe. The doctor, the patient and his family and the hospital all feel like winners, but I’m not so sure.

So, if fame, notoriety and prestige are not the prescriptions for choosing a doctor, what should patients do? Check the next posting for some pointers.

Sunday, February 15, 2009

Quality Physicians - The Real Deal

Here’s a list of attributes that define high quality physicians. This is not a controversial posting. After each entry, you will be nodding in agreement that it is an essential element of a high quality physician’s skill set. Here’s the unsolvable challenge. After reading each listing, decide how you could accurately rate a physician on the specific item and compare him to colleagues. I’ve been a physician for 20 years, and I have no idea how to do this. Perhaps, smarter folks can figure this out, since this is where true medical quality can be found, not in mindless, meaningless and downright dumb data and statistics.

Great physicians have many of the following skills and qualities.

  • They are skilled at palpating abdomens and hearing subtle cardiac and pulmonary abnormalities with a stethoscope.
  • They know when not to prescribe an antibiotic.
  • They know when a symptom can be safely observed and not investigated immediately.
  • They know whether a CAT scan finding should be ignored or pursued.
  • They are expert communicators who sense when a patient harbors an additional concern.
  • They have an adequate and current core of medical knowledge.
  • They can skillfully manage a medical issue on the phone after hours.
  • They understand and counsel that more consultants and tests often mean less care and healing.
  • They tell the truth when a patient asks if the surgeon he has seen is the best choice.
  • They are compassionate.

    Of course, this list could be longer. The point is that what truly defines good and great doctors, can’t be calculated and entered on a spreadsheet. Don’t let the government or the insurance companies fool you on this one. Besides, are these institutions of such high quality that we should trust them to measure medical quality?

    On the next posting, some physicians who might be too good to be true.

Saturday, February 7, 2009

Appraising Art and Medicine

You have reluctantly left the blogosphere bubble for an afternoon to view a special exhibit at an art museum. You join a crowd who is gawking at a towering marble sculpture. Is it a true masterpiece or simply the work of a talented local art student? How do you accurately assess the work’s worth and quality? Even art scholars may not be able to agree on the piece’s value or if the work is counterfeit. If there is no sure way to measure its value, should we resort instead to using the sculpture’s weight as a quality surrogate just because it is easy to measure? This is ludicrous, but this is exactly what’s happening in the medical field. Let’s not resort to misleading and inaccurate methods of measuring medical quality because we haven’t figured out yet how to do it right. Each year, physicians and hospitals are subjected to still more ‘quality’ initiatives which burden the medical community without improving medical performance. After 3 years of participating in Medicare’s PQRI (Physician Quality Reporting Initiative) program, I can state with confidence that it has cost my practice $$$, wasted lots of our time and failed to help a single patient. It’s all a game but I haven’t figured out yet who wins.

The next time you are in your physician’s office, ask about the various government and insurance company quality programs. If any of you find a doctor who supports these programs, contact me STAT and I’ll post your comments.

Next posting, true medical quality which can’t be measured.

Sunday, February 1, 2009

Why Medical Quality Programs Fail

In medicine, there are many facts and figures that can be easily measured. Here are examples of data that is being diligently recorded and scrutinized by medical number-crunchers across the country.

  • Hospital deaths
  • Volume of hospital and individual physician surgeries and medical procedures
  • Average # hospital days for specific illnesses
  • % of a physician’s practice who have undergone preventative medical testing
  • # minutes the gastroenterologist’s colonoscope spends within the colon (This is not a joke!)
  • A physician’s medical malpractice history
  • Automobile the physician drives. (This is a joke!)
  • # and % primary physician referrals to specialists
  • $$ that physician expends per patient per specific medical condition

I could have made this list a lot longer, but you get the idea here. Sure, you can collect and measure all kinds of medical data, but this doesn’t measure medical quality. Since the government and insurance companies have no reliable way to measure quality, they have opted instead to measure what can be easily counted, as if these are actual quality benchmarks. This is the fallacy of these ‘quality’ programs. Consider a hypothetical example. If Physician A has an 80% mammogram rate in his practice while Physician B has a 50% rate, is the former doctor a higher quality practitioner? Not necessarily. What if Physician B’s patients are not health conscious and don’t pursue preventative care? Is this the doctor’s fault? Of course, not, but he may be assigned a lower quality score anyway.

Next posting, what you can learn about medical quality in an art museum!