Doctors should embrace feedback and learn from it

In Quality Measures and the Individual Physician, Danielle Ofri, MD, PhD questions the usefulness of feedback report cards for individual providers. She states, “Only 33% of my patients with diabetes have glycated hemoglobin levels that are at goal. Only 44% have cholesterol levels at goal. A measly 26% have blood pressure at goal. All my grades are well below my institution’s targets.”

It would be better for Dr. Ofri’s patients if these numbers were higher. I think even Dr. Ofri would agree with that assessment. And yet Dr. Ofri’s response to these low scores is that “the overwhelming majority of health care workers are in the profession to help patients and doing a decent job.” And more upsetting is Dr. Ofri’s conclusion where “I don’t even bother checking the results anymore. I just quietly push the reports under my pile of unread journals, phone messages, insurance forms, and prior authorizations.”

Dr. Ofri’s defense that doctors are smart and good people who are trying hard to help others does not reassure me as a patient or physician executive. Everything we know about cognitive neuropsychology tells us that humans are not good at judging our own competence in any field of endeavor. One hundred percent of high school students rank themselves as having a higher than average ability to get along with others (a mathematical impossibility), and 93% of college professors rank themselves as above average at their work.

Literature teaches us the same lesson. Martha Nussbaum discusses how Proust has Marcel confident that he does not love Albertine any longer. And then Marcel finds out that she has left; he now knows for certain, without the least room for doubt, that he loves her. Humans are masters at self-deception, and Michael S. Gazzaniga even hints that this quality separates humans from other animals.
Richard Russo makes a similar point in Straight Man about the need for humans to have feedback from others, about our inability to know ourselves without it. “Which is why we have spouses and children and parents and colleagues and friends, because someone has to know us better than we know ourselves. We need them to tell us. We need them to say, ‘I know you, Al. You are not the kind of man who.’” Physicians need report cards to tell us how well we are taking care of our patients, even when we sincerely think we are doing a fine job.

As Chief Medical Officer for a large health system, I never met a clinician who did not think that they did a good job at taking care of diabetic patients. And yet when I did an audit of their care, I found that many had suboptimal results. They were genuinely surprised that patients fall through the cracks and did not receive their required retina exams.

Physicians are always telling me that they have to be the leaders of the health care team. Well, then they need to accept that feedback is necessary for learning and improvement and leadership. Good leaders in my experience only do four things: they examine the environment and decide on a vision that can excite themselves and others. They translate the vision into strategies and tactics; they assign the strategies and tactics to someone to carry out; they then hold the responsible party or parties accountable for the results. In my experience health care does not do a good job at the accountability step.

Who is accountable for the quality of care in Dr. Ofri’s clinic? Do we have examples in medicine where someone has stepped up to the plate and become accountable so that the quality results improve instead of never budging from the results two years ago?
Dr. Kim A. Adcock, the radiology chief at Kaiser Permanente Colorado, created a system that misses one-third fewer cancers on mammograms and “has achieved what experts say is nearly as high a level of accuracy as mammography can offer.” At the heart of the program was his willingness to keep score and confront his doctors with their results. He had to fire three radiologists who missed too many cancers, and he had to reassign 8 doctors who were not reading enough films to stay sharp.

The Kaiser experience mirrors the literature on how to be a best performing organization in a chaotic, rapidly changing environment: one has to focus on sources of error and failure and learn from them to improve the results. The Kaiser leaders worried about negative publicity, malpractice claims, women neglecting the test due to skepticism, but in the end they did what was right for their patients. They tracked down the women who were at risk for having cancer even though the less skilled radiologist had read their films as normal.

I agree with Dr. Ofri that “we need good evidence that the data measure true quality and that providing data is actually helpful.” However we will never get to that point by not “checking the results anymore.” We have to emulate Dr. Adcock and wade into the messy reality of why Americans receive only 55% of indicated care. We can learn how to do better if we embrace feedback and learn from it; we cannot improve by ignoring reality. Trust me I am a doctor just doesn’t cut it. We all deserve better than that.

Kent Bottles provides health care leadership consulting and blogs at Kent Bottles Private Views.

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  • John wyatt

    Physician executives should be required to care for patients routinely to avoid the ethereal sense that they are above reproach. The Kaiser example in no way is comparable to a physician managing a diabetic population.the Kaiser example is a closed system where variables like physician skills can be assessed and monitored. Dr Orif? must
    Measure patient compliance and education routinely on every encounter. What has her hospital done to identify non compliance? What has been done to remotely monitor the at risk patient. In short, my reply to you is rather than take issue with your peers roll up your sleeves and work on new paradigms to help them and their patients improve outcomes

  • Jennifer Warren

    What the author fails to address is that there is a vast difference between a physician misreading an x-ray, and a physician who is unable to force an unwilling patient to follow through with recommendations to have an eye exam, or follow a diet and exercise plan! It is entirely the radiologist’s responsibility to read an x-ray, but it is a SHARED responsibility between the patient and the physician when it comes to problems like diabetic management. As long as it is a “free country,” a physician cannot (and should not) FORCE a patient to do something against his or her will. The physician’s job is to educate the patient, recommend appropriate interventions, encourage the patient to follow them, and followup on results, and give a patient feedback. The physician should not be judged on things that are beyond his or her control – such as the willingness of a patient to “comply” with recommendations – but rather should be judged on the parameters over which he/she DOES have control – such as whether appropriate education, recommendations, and followup were completed.

    Some physicians ARE better motivators than others, I realize this; this is likely related to personality traits, and the support or lack thereof by the parent organization. For example, when I worked in practices owned by other people, with relatively weak staff support for education, my diabetic patients had only average results. Once I opened my own clinic, and had complete control over the quality and quantitiy of staff for patient education, my patients’ numbers improved markedly.

  • bev M.D.

    One may take issue with Dr. Bottles’ examples; however let that not be an excuse for blanket avoidance of accountability for results involving real patients. This attitude reminds me of the hospitals’ excuse “our patients are sicker” for why they have below average outcomes compared to their peers. Certainly, patients are not always compliant, or adherent, or whatever the latest PC term is. But this factor is a relative constant across all practices, at least within given demographics. What is wrong with a system which compares physicians’ performance on these metrics to those of his/her peers? Don’t throw the baby out with the bathwater.

    Also, I believe physicians’ lack of acceptance of these metrics stems from the perception that they are imposed by external ‘authorities’. As I have said before – quality assessment is coming. You can’t stop it. Get on the train and start being the engineer instead of the caboose.

    • Marc Gorayeb, MD

      A recurring metaphor among the statists: better ‘get on board’ or (a) get out of the way, (b) get run over, (c)become the caboose. And they try to convince you by setting up a false choice: lead the way or get left behind. Statists have no intention of letting you lead the way; they just want your quiet acquiescence and cooperation. This threat is a not-so-subtle way of ending the debate, of force-feeding an orthodoxy, of intimidating people from expressing perfectly reasonable dissenting views.

      Just as it is unfair to evaluate a teacher using performance metrics that depend on the cooperation and motivation of his or her students, so is it unfair to start tagging physicians who happen to have patients who don’t adhere to our upper middle class sensibilities. You want to evaluate a physician’s effectiveness as a cheerleader? Fine. Go for it. Just don’t use it to judge him or her as a physician.
      Evaluaitng the performance of physicians who aren’t outliers is a complex undertaking. It’s much easier and more effective to make sure that medical schools only pick the brightest minds for entry into the profession.

  • Muddy Waters

    Like mama always says, “You can’t please everyone!”

  • Justin

    In jest and reality:

    For now doctors will just discharge the patients they cannot motivate. Primary care is hugely understaffed (<3% of med students become family docs or primary care internists). Doctors will not have a hard time filling there offices with patients that follow instructions. This may cause a paradigm shift leading to increase pay so doctors can spend the 30 minutes per patient they need to properly engage and motivate. I don't know how you can motivate someone during a 6 minute office visit, but the economics of outpatient medicine do not allow for anything else.

  • rwatkins

    For the most recent “feedback” report I looked at from a major insurer, I pulled 10 charts at random and found that over 90% of the recommended studies I had supposedly not done were documented in the records. The insurer asked for my feedback, and I responded that all future reports from them would go straight into the circular file.

    Insurers would do better to put their resources into learning how to process clean claims correctly (the error rate is appalling); they are utterly incapable of evaluating the performance of physicians.

    And no, three months later, I haven’t had any response to the feedback I gave them.

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