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Why Comparing The Performance Of Doctors Is Trouble

Who do you think is likely to be a better doctor: A board certified graduate of one of the top medical schools in America, or a non-certified doctor trained in a foreign country?

If your answer is “I have absolutely no idea,” then you’re probably spending a lot of time looking at the “report cards” that pass for measures of health care quality. And you’re probably confused.

Researchers in Pittsburgh studied 124 process-based quality measures in 30 clinical areas. These process measures are the state-of-the-art ways in which government and private insurers are checking up on the quality of medical care. They include things like making sure patients with heart problems are prescribed aspirin, and that women get Pap smears. The researchers compared these measures against other, simpler measures, like medical education, board certification, malpractice claim payments, and disciplinary actions.

The result? You couldn’t tell the differences among doctors.

From the Archives of Internal Medicine:

For example, the average board-certified, U.S.-trained female physician scored only 5.9% better on performance measures than a noncertified, foreign trained male doctor. There were no statistically significant quality differences when comparing physicians who made malpractice claim payments versus those with no such record. Doctors who graduated from medical schools ranked in the top 10 by U.S. News and World Report scored no better on the quality measures than physicians who did not.

Surprisingly, the Pittsburgh researchers saw this as good news. The problem, in their view, wasn’t that the quality metrics don’t make sense…it’s that things like being highly educated and well-trained don’t actually matter that much. I’m serious. According to the co-author of the study:

You can feel secure in the fact that some of these varied demographic characteristics that are used to judge one physician from another don’t matter much in the end.

Well, okay then.

If it sounds familiar, it’s because the same thing is going on with hospital quality measures. Using the government’s quality measures, you can’t tell the difference between a major academic medical center and a local community hospital.

So what’s going on here?

As well-intentioned as these quality measures may be, they veer so drastically from experience that doctors are starting to ignore — and resent — them. Dr. Danielle Ofri, writing in the New England Journal of Medicine says these measures:

purport[] to make a statement about comparative quality whose objectivity is a fallacy…By and large it serves only to demoralize doctors. It offers patients a seductively scientific metric of doctors’ performance – but can easily lead them astray…Doctors who actually practice medicine – as opposed to those who develop many of these benchmarks – know that these statistics cannot possibly capture the totality of what it means to take good care of your patients. They merely measure what is easy to measure.

And so if the goal of these measures is to improve the quality of care, they’re missing the mark. Doctors will tell you that the biggest challenge they face in delivering quality care is the fact that they have to see 40 patients a day, spending 15 minutes with each one. Checklists and report cards continue the systematic devaluation of the thinking, reflecting and deciding aspects of medicine. So instead, why not start with what really matters: The time doctors spend with their patients. If you ask Dr. Ofri, “What would definitely improve the quality of your patients’ care?,” she will tell you: “An hour-long visit instead of 15 minutes.”

*This blog post was originally published at See First Blog*


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