PERFORMANCE

If you have some free time, read Autl Gawande's new book Better. Gawande's discussion of how to become a better doctor hits very close to home for me as both a patient and a physician.

Contrary to what most physicians would like to think, just graduating from medical school or even going through a well reputed residency/fellowship does not make a good doctor. In fact, medical outcomes for different physicians and hospitals vary widely (The Bell Curve). In one part of his book, Gawande discusses allowing patients to know how doctors perform on various performance criteria. For example, a few states keep public records on the complication rates of all cardiac surgeons. Also, the Cystic Fibrosis Foundation keeps very detailed records detailing how each cystic fibrosis center in the nation performs against the national average on several important criteria.

Many physicians fear that the creation of these criteria (that will be available for everyone to see) will create an incentive to direct care towards the criteria and not towards each individual patient. Physicians might order tests just to check off a box and get a better rating, instead of thinking about whether or not the patient really needs the test/intervention. In addition, physicians argue that no set of measures can truly gauge the competency of a physician. Diagnostic acumen, integrity, and compassion are all important traits in a physician that are hard (if not impossible) to measure. In summary, the main argument against performance measures is that they are incomplete and they force physicians to disregard individual variation.

However, this does not mean that this data is not useful. I'll be the first to acknowledge that medicine is complex enough that no single group of performance measure will truly capture a physician's full ability, or lack thereof. I know plenty of physicians/medical students that might do great on tests, know all the answers on rounds, and be able to spout the latest data from the most recent research, but that I wouldn't trust to treat me or my family. You want your doctor to be compassionate and have integrity. But you also want your doctor to be able to cure you of whatever is ailing you. None of these factors is easy to measure. So, how do we figure out if our doctor is good.

I believe that information about adherence to performance measures and mortality/morbidity data for each physician should be recorded and made public. The combination of both of these pieces of information will allow patients to make a more informed decision. For example, if a physician does not adhere to well established criteria and has below-average morbidity/mortality rates, I think his prospective patients have a right to know this information. Hopefully, as physicians see that they lag in both categories, they will be encouraged to make changes to improve their patient outcomes. This might mean adhering to established criteria or it might mean innovating and finding new ways to improve patient outcome. This database will allow identification of physicians that do not adhere to the performance measures but have great outcomes. The establishment of a database that combines both of these factors will allow both patients and physicians to see what these innovative physicians are doing and hopefully allow for innovation in patient care that is evidence based.

This data will make patients more informed consumers, but in the end patients will still have to judge based on individual experience whether or not the doctor they pick is the right doctor for them. You might go to the physician with the best record of adhering to performance measures and the best outcomes and find that he is a jerk. Or you may go to a physician with a great record and find that he only treats the rich and famous (his patients come to him healthy) and he isn't doing much for them. Currently, patients pick doctors based on word of mouth (either through what their family/friends recommend or what another doctor recommends/refers). Having some solid information to base important health decisions on can make patients more informed consumers and encourage better patient care.