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The Medical Quality Conundrum

Posted Aug 23 2008 10:37pm
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.
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