Measuring quality: What doctors and teachers have in common

Measuring quality: What doctors and teachers have in common

I was watching Jon Stewart recently, and he had Michelle Rhee on.  For anyone who doesn’t know her, she’s the superintendent of schools in Washington D.C. who made a bunch of reforms that caused some controversy and resulted in her being one of the main spokespersons for education reform in this country.  Her conversation with Jon made me realize the similarities between what’s happening in education and what’s happening in health care.

One major emphasis of education reform is the regular testing of students and the evaluation of teachers based on the test results.  There has been a lot of push-back from teachers on this method of evaluation.  One major emphasis of healthcare reform is the regular measurement of “quality indicators” and the evaluation of doctors based on the results.  There has been a lot of push-back from doctors on this method of evaluation.

When things need to be changed the easiest thing to do is to target the people on the front lines.  If our kids aren’t getting educated, it must be the teachers’ fault.  If patients aren’t getting quality health care, it must be the doctors’ fault.  Here’s the problem with that logic in both cases:  most of the real culprits in the lack of good education and good health care have nothing to do with the teachers or the doctors.  Society, parenting, systems, legal considerations, and politics play at least as big a role.

Let’s consider teachers.  I truly believe that teaching is the most important job on earth.  If aliens landed on this planet right now and evaluated our economics they would probably conclude that football players were the most important, based on remuneration per hour.  Or movie stars.  But our future is determined in large part in how well educated our population is going forward.  The problem with the current standard of evaluating teachers is that the social environment surrounding each student is as important as the teacher.  Parents have to step up and emphasize education, do homework with their kids, be pro-active in supplementing children’s education.  You can’t just drop your kid off at school and assume he’ll end up at Harvard.  No kid can study effectively if they don’t have enough to eat, if their parents are on drugs, if the home environment is chaotic, if the parents are not involved.

Consider the doctors. I can’t say I truly believe doctoring is the most important job on earth.  I will say that our future is determined in part on how healthy our population is going forward.  Doctors can do some things.  We can grant access to screening tests, laboratories and imaging facilities, and our own training and advice.  But the responsibility for being healthy, barring unexpected and unpreventable events, belongs with each of us.  It is not the doctor’s responsibility to make you eat right, or exercise,  or not smoke.  The health of our population is heavily influenced by societal pressures including poverty, obesity, lack of education, lack of social supports, and addiction.  Doctors can help with these things, but they cannot be held responsible for them.

This is why teachers are frustrated.  This is why doctors are frustrated.  Both professions are being asked to take accountability for the breakdown of society.  We will continue to do what we can.  We should not be judged for our efforts.

Shirie Leng is an anesthesiologist who blogs at medicine for real.

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  • http://twitter.com/NicoleCherieH Nicole Cherie Hess

    I agree with the premise, but doctors and teachers should be responsible for how they deliver messages and inspire their students and patients to follow their advice. Many doctors are known for writing a prescription and it ends with that.

    However, explaining how that treatment was chosen as the best, what it can mean to take it regularly, the change one can expect and other motivators are equally important. There’s a great book that extends this point titled “Join the Club” and it explains the power of messaging and how its a part of ensuring desired outcomes from campaigns to treatments.

    • http://twitter.com/shihjay2 Michael Chen

      Messaging is certainly important but the root of the problems are much deeper than that. If doctors and teachers were not constrained by the effect of state and federal budgets (for teachers) or other third party payors and the RUC (for primary care doctors), we wouldn’t be talking about dcotors just writing a prescription. And those that are trying to do right are burned for doing so because they cannot survive in such a hostile environment. I know, I’ve tried.
      It’s about priorities by our communities and whether our commons and those that budget and deliver the commons (our government, local, state, and federal) are living by these priorities.
      If I was an alien from outer space looking at the state of our communities for schools and for our health care, I would say that we are not living up to our missions and priorities to provide a safe, healthy enviornment for our children, both from a medical as well as an educational standpoint.
      If money is a value statement of our priorities (which I belive it is at the moment) and looking at what is valued most right now in society, we are certainly not valuing those that are in the front lines (teachers, doctors) which in effect is a statement that we do not value our children and our future. Until we step back and see what our systems are doing in the big picture, we’re just spinning our wheels and pointing fingers.

    • http://www.facebook.com/people/Donna-Rovito/100003242586757 Donna Rovito

      Clearly, you haven’t been to “most doctors” if you think writing prescriptions is all they do.

    • azmd

      The only problem with that statement is that no one seems to want to pay either teachers or doctors for the extra time required for “delivering messages and inspiring students and patients” to do the right thing. Last time I checked there was no CPT code for “messaging” and the average teacher had 30 kids in her classroom.

      Depriving professionals of resources while simultaneously blaming them for poor outcomes will reliably produce only one result: embittered professionals. A burned-out doctor or teacher is hardly going to be able to “inspire” others as I think we can pretty clearly see.

      • Suzi Q 38

        It is hard to expect to get paid for every little thing.
        Many jobs do not get paid like this.
        My husband is a manager of 3 departments at an average sized city. He gets calls at times, not all the time, at nights and on weekends. Once, a city car was hit by a train. The conductor had run a red light. It was all documented on video. He had to go out to the scene during work hours, then deal with the situation for the remainder of the weekend. The employee was 6 months pregnant, and had to be hospitalized.
        She made it through better than we all expected, thank goodness.

        I am a teacher at an adult school. Sometimes students need help before and after class. Sometimes, I have to call them to get them to come in for mandatory testing. I have to send out and answer emails. I have to make lesson plans and correct papers. You get the idea.
        I am not paid extra for this, but I do it because it helps those that I am paid to serve, and I know that it comes with the “territory.”

        My husband and I love our jobs and wouldn’t trade them for now. We take the good with the bad, as no career field is perfect. Far from it.

        I think y ou need a better understanding of what your career choice is, evaluate the good and embrace it. Be thankful for it.
        As for the bad parts of your job, if they are annoyingly minimal,
        live with it. If they are an enormous thorn in your side, change your job!
        Figure out how to tailor your life in the manner to which would work best for all parties involved, including you.

        • Ian

          I spent $40 on phone call with an attorney this afternoon at lunch to review my taxes. Plenty of similarly educated professionals bill for every little thing.

          • Suzi Q 38

            Yes, isn’t that annoying??? I agree. That profession is one that if you screw up, unless it is really, really obvious, you will still get paid.
            Our attorney too.
            I remember that I called her the first time, and she billed me about $50.00 for the call. I was livid, and rarely called her again. She would call me from time to time, asking my advice on this or that, as it was a Power of Attorney case for my FIL who had had multiple strokes. She didn’t know anything about medical.
            I finally had to end each conversation with: “Are you going to bill me for this???? If so, please DO NOT call me unless it is an emergency. Remember, YOU called me. I don’t think I should have to pay you if you are the one seeking MY advice.”

            Also, with attorneys, I always ran any errands needed or mailed them any documents in a timely manner WITH copies of such so they would not me for $1.00 a page copying. I remember that my best friend served my step MIL with divorce papers, under the ruse of a holiday flower arrangement delivery.
            I provided my own expert witnesses (physicians) and called friends who were pharmaceutical reps to give me recommendations. I would call the doctors to see if they would consider being an expert witness. They charged $700.00 or $800.00 cash instead of the usual $1500.00 or $2K that my lawyers doctor charged.

            Anyway, the lawyers know how to get paid…you are right. We (doctors, teachers, managers, accountants, and many, many other profefssions) just haven’t figured it out.

        • azmd

          I think you missed my point, which was that at this point, in order for doctors and teachers to competently execute every single task they are expected to do, at the level of perfection that everyone expects (see the above post on “messaging,” they could literally work 20 hours a day. Or more.

          That’s just not realistic, and we shouldn’t expect anyone to be volunteering their time to meet a deluge of top-down expectations, unless the system wishes to make changes, such as appropriate compensation, for those hours and hours of extra work.

          There is “taking the good with the bad.” and then there is the public having a completely unrealistic idea of what they can expect their doctors and teachers to do. We have, unfortunately, gotten to the latter stage. Professionals have to set limits somewhere, or burnout is inevitable.

          • Suzi Q 38

            Ok, I get it.
            I guess I am spoiled.
            I don’t call my PCP very often, but when I do, he speaks with me. I always ask the nurse to ask him for me in case he doesn’t have the time to talk to me directly, but he ends up on the phone.
            My specialists don’t usually talk unless it is really important, and even then, one didn’t call me back and got a lot of flack for it from his colleagues, as my health declined.

            I guess I would pay for the service of talking to the doctor if it was a reasonable charge. I just would think that it was strange if other doctors offices did not charge me.

          • azmd

            But we weren’t talking about phone calls. No one has ever disagreed that returning phone calls is part of the job. The issue is understanding that each of the myriads of things that people think it would be great for doctors to do, takes extra time, which is uncompensated. As an example, the writer above who is suggesting that doctors need to explain “how that treatment was chosen as the best, what it can mean to take it regularly, the change one can expect and other motivators” appears not to realize (or care) that she is describing an extra 10 minute conversation added on to the patient’s visit. That time is not compensated, and if you multiply it by 20 patients a day, you have an extra 200 minutes EVERY DAY of what is basically volunteer work on the part of the doctor, apparently in the service of trying to secure the cooperation of the patient in complying with a given treatment.

            That is simply not a sustainable expectation. All of us do extra things for our work. That’s a given part of being a professional. But we need to be able to set limits on what it’s realistic for us to do, and what’s not unless the system decides to compensate us. Brief phone calls are fine. Phone calls where we provide counselling or therapy? Probably not so much. Likewise, explaining treatments is part of our job. Spending 10 extra minutes on “messaging” to motivate a patient? Maybe not so much if it starts to be an expectation for yet another unpaid service we have to routinely provide for everyone.

          • Suzi Q 38

            My doctor doesn’t “message”me. You mean in terms of the iphone and the text messaging form of information delivery?
            I guess that would be cool, but not mandatory for me.
            It would not be a “deal breaker,” and wholly unlikely from my 60 something PCP from another country that possibly is not technology oriented. If your boss expects you to do that for us, maybe I would be on a long list of patients, and you would have to type in a short encouraging message to our group. If that is the case, WOW! Your group provider is quite progressive.
            I would not expect any such thing from my doctors.
            Although, Eric Topol, M.D. “gets it.” He uses technology with his patients everyday.

          • azmd

            Again you should not personalize this. My own professional situation is quite sustainable and I am not complaining about it. I am merely pointing out that we cannot take a group of professionals who are trained to work long hours and make many sacrifices for their patients, then exploit those qualities by micromanaging the professional into working more and more hours for less and less money. Eventually the smart, hardworking and caring people will stop going into medicine.

            And the argument “didn’t anyone warn you about the long hours” also completely misses the point. No doctor in his or her right mind is complaining about long hours. What they are complaining about is being asked to work even longer hours for even less money, carrying out tasks that have nothing to do with why they went into medicine in the first place.

      • Suzi Q 38

        I had to call my doctor the other day. It was the late afternoon, maybe 4:30 P.M. I asked the nurse if I could speak to him, and she sent my call through. He didn’t mind, and it was all business and short. Maybe 2 minutes. If they told me I had to come in to see him, I would have, but I had just had my appointment with him on Friday a week ago. I don’t think that he will be billing me for it, and if he did, I would probably give him my copay of $15.00. My insurance wouldn’t pay him anything.

      • Caitlin Peebles

        Both healthcare and education had better outcomes when there was less government involvement.

        • Molly_Rn

          Please cite your proof.

          • N N

            It’s called looking at test scores. You might want to actually look at them.

          • Molly_Rn

            So where is this so-called proof? What I see without government involvement with healthcare is drugs that don’t work, medical devices that are dangerous and people dying without healthcare.

  • Ian

    I agree with the author. Two things that are different that will take them along markedly different paths. 1. Doctors have no unions and as such will be easier to coerce into these top down solutions (About 20% of doctors belong to the AMA which isn’t a union anyway). 2. Physicians can fire their patient’s should they be non-compliant if that is applicable by their state board. One of the repurcussions of this grading physicians is that doctors will have a financial incentive to stop seeing the sickest and poorest patients. The first easy way to do that will be to stop seeing medicaid if they haven’t done so already. Reform is going to turn into a game of who can keep the healthiest panel of patients from deciding who will initially be seen, and who will be kept within the practice. This could change some as penalties for hospital readmissions appear and more physicians begin working in large hospital groups or if state boards start mandating that seeing medicare/medicaid is mandatory for state licensure. The lastter doens’t have much political traction at this time. Teachers can’t change the makeup of their class very readily without physically moving to another school.

  • buzzkillerjsmith

    Oh what a wonderful life it must be to have a job forcing others to do the impossible and then punishing them when they fail! How do I get a job like that? Go to business school?

  • Mika

    “I was watching Jon Stewart recently…”

    Totes awesome that our teacher-preacher-healer class rely on the Comedy Channel for their news & opinions.

    • http://www.facebook.com/shirie.leng Shirie Leng

      Ha! So true. Actually I usually rely on NPR but Stewart is funnier.

      • Molly_Rn

        And most of the time Jon Stewart is more honest about the reality of the situation.

  • Harley Firth

    “Most of the real culprits in the lack of good health care have nothing to do with the doctors.” This may be true, but paying physicians based on the quality of care delivered is better than the status quo of “fee for service”, regardless of the quaity of that service.

  • Suzi Q 38

    I never viewed the education of our two children the total responsibility of a set of teachers. I always viewed their education as my responsibility.
    The teachers were there to teach, but it didn’t mean that my kid was necessarily “getting it.” Also, certain methods of teaching may not match up to your idea of how your child should be taught. For example, for at least a decade, our children’s school district adopted the “whole language” method of teaching children how to read. They did not teach them phonics.
    I was aware of this so I taught them the old fashioned way: at home (late afternoons and weekends). Everyday I asked what they learned in school. I asked them to tell me. If they did not understand, we worked at it together. On the weekends, we worked on what was expected of them for the coming week, before the teacher taught them. This way, they were prepared. Not every teacher is very good. I tried to get what I perceived as the best teacher for both my children. This was not always easy.
    As they became better and better students, I was able to relax on this more.
    I just made sure that they had the most rigorous classes and most challenging teachers.

    Doctors need to help us become better “directors” of their patient’s health.
    They are not responsible for my family medical history, my heath challenges, or my attitude. They are responsible for assisting me, with their vast knowledge of medicine and the human body, to evaluate and treat me to obtain the best optimal outcome for my care regardless of how difficult my medical problems are. They need to realize, that like teachers, they are “teaching” me about how to care for myself when they are not there to observe me. They are also highly skilled “coaches” of sorts. Encourage me, correct me, help me be a better “player” in the game of managing my own health.

    I see this comparison of teachers and doctors as interesting. Of course, the teachers have much to learn from the doctors: How to assess clients, evaluate the family dynamics, etc. My doctor even knows what my insurance plan is and tells me where I can get my tests done. He knows
    my personality and how I am going to get away with asking any question I want to ask, or I follow him out of the room to the door of his next patient.
    He knows that it is just better to answer my questions and get it over with.
    I know that he is the best doctor for me because he is good and understands this about me. When he is truly concerned about something, I get the test I need. I trust his judgement.

    I will say also that the doctors need a new form of representation that the teachers as a group have been successful at getting. why not elect someone like Michelle Rhee to represent you? It has to be a physician that knows first hand about your struggles and concerns and is willing to be vocal about it. Learn from the teacher’s model. For all of a union’s faults, it is sad that that model is what gets things done.
    Maybe you all are too good to have a union, but having a group of physicians more focused on helping your cause should be one of your priorities. Maybe start with the group of doctors that sued for higher medicare payments. They were a brave group that tried their case alone.
    Back them up! They have laid the groundwork, give them the financial help and encouragement they need to appeal and fight again. Maybe some of you know some lawyers that can help out. Maybe some of you have dual degrees and are lawyers as well as doctors. Tell them that you
    want to help with your time and legal knowledge.

    • http://www.facebook.com/shirie.leng Shirie Leng

      The union idea has been suggested in other forums. It has some appeal, for the reasons you suggest: representation. Doctors have put their heads in the sand for so long about cost that the regulation of cost has been taken away from them. The AMA (American Medical Association) has not spoken up and taken a leadership position on this either.

      • Suzi Q 38

        Because maybe they are paid to sit on these boards, they may also get excellent free medical coverage from serving, as well as “perks,” monetary and otherwise. They may be retired and too tired to “ruffle feathers,” or argue emphatically for your cause.
        Try to find out who they are, how long they have served, what their backgrounds (education, specialty, career path, politically, age, gender and community service).
        These attributes may seem trivial, but they are important.
        Maybe someone like that female physician that fought for equal pay. She just one that huge, multimillion dollar settlement.
        When everything is said and done, she may have a few million net and therefore able to forgo working so many hours and devote some time to “your cause.”

        She is tough, brave, and must have “nerves of steel” to go up against her own employer and still work there.

  • http://www.facebook.com/SillyInSuisun Jerry Linnins

    The author had me right up until the last sentence. I think I understand the point being made. However, I might have rephrased it, “We should not ALONE be judged for our effforts.” Each element of the “system” should be judge (i.e. measured, evaluated). However, we do need a 360 degree picture when we make the “final” determination of performance or lack thereof. You have, as Dr. Deming was fond of saying, good people (Dr, nurses, patients, other care team members) working in a bad, bad, bad system. But, who “designs,” reinforces, and supports that system? We should follow Joel Barker’s advice and examine our healthcare paradigms to get us to the “bleeding edge” where innovation, creativity, and insight reside.

    • Ian

      My father was a physician back in the “golden era.” We lived in a rural part of Ohio. He had two solo offices and even the little black bag for home visits. He charged what he felt people could pay. Yes, I realize he wasn’t ordering $2000 MRI scans or prescribing medications that cost as much as a nice new sports car every year. He didn’t have to pay huge sums in malpractice insurance. He also worked six days a week and didn’t share call with anyone unless we went on vacation. It was defintately a different era.

      Regardless, some of his patients paid nothing, some people paid with barter (vegetables, gifts, one guy even did some plumbing in our house), and he charged the well off patients of the community a lot because he felt they could afford it and they thought he was good enough to pay it. If you accept insurance physicians no longer have this ability to control what they charge and how they practice medicine unless they take cash. Physicians take what the third party payer will give them or they don’t see people covered by that third party. You prescribe treatments that are on the insurance formulary or spend hours filling out forms to authorize the use of the medicine you think the patients need.

      The insurance companies and the government dictate what doctors make. This third party isolates the patient from the costs of tests, mandates meaningless paperwork, drives up costs, and generally makes life miserable for all parties involved. Off the cuff, half of doctors don’t know how much the things they do or recommend cost. I’m sure my dad’s poor patients were generally sicker, had worse outcomes, required more of his time, took him longer and cost more money to care for. That being said he didn’t have some giant bureacracy grading him on how well he was doing while simultaneously telling him what he could and could not do for his patients.

      I believe that most if not all physicians want to help people, and many are even willing to care for people on whom they lose money, but when you couple the financial side that with all the BS paperwork, hassles that go with caring from them because of the third party bean counters (which are always worse for the Medicare/medicaid patients) and prior authorizations that they throw in the towel. The system is moving towards telling physicians how to to do their jobs and then grading them on how well they do it. I believe if this pay for performance gains significant traction, then many intelligent, self motivated, independent health care providers will find a new job. I suspect that this will be true of teachers as well.
      Many doctors will try and game the system to keep as many healthy patients in their practice as possible and dismiss those that aren’t healthy (something as I have already posted that teachers can’t readily accomplish). I asked a doctor friend of mine about pay for performance. His reply “I will suffer the aggravation of jumping through all the hoops to care for a patient or lose money on caring for a patient but I won’t do both.”

    • Docbart

      I agree that everyone must be accountable for their work. Evaluation is the hard part. I have had some great teachers, but also some real duds, who should have been remediated or replaced. They continued until retirement, however, and cheated generations of students of the education they deserved. I have seen many fine doctors, but plenty of poor ones, most of whom succeed in practice, nonetheless. We are remiss in policing ourselves, and it costs us dearly.

  • Guest

    “We should not be judged for our efforts.”

    Yes, you should. Just because both teachers and doctors are on the public purse doesn’t mean they should be exempt from performance reviews.

    • Conor Mccartney

      thats fine in theory, but it is dangerous in practice. It has led schools to cancel classes that aren’t on the test (good bye art, good bye recess). And it encourages hospitals to ‘teach to the test’ as well even if that means bad medicine. When CMS decided that part of hospital re-embursement would be tied to how quickly pneumonia patients got anti-biotics a lot of community hospitals gave patients with any symptoms anti-biotics often before even seeing a doctor. The result was those hospitals got better scores then prudent hospitals (and thus more money) even though they gave strong anti-biotics to people with colds

    • http://www.facebook.com/shirie.leng Shirie Leng

      Of course we should be judged. Everybody is taking exception with that last sentence. I’m saying we should not be the only ones.

    • N N

      You won’t have to worry about that for long when doctors will continue to stop accepting Medicare and Medicaid. Then they will no longer be on the “public purse”. My performance should not be judged on your inability to eat right, exercise, etc. = lack of personal responsibility.

      • EmilyAnon

        Giving up on Medicare patients might result in lost privileges in practicing at teaching hospitals which depend on Medicare funding to train new doctors.

  • Doug Capra

    We as a society are beginning to accept that this issue needs to be seen and approached in its totality. It’s a cultural issue as much as anything else. You know “It takes a village…” But we have such an individualist, independent streak in our culture that some want to put total responsibility on individuals. I’m not saying individuals don’t have responsibility for their actions. They do. But we also need to put pressure on the cultural elements that are working against us. We did it with smoking didn’t we? How do we influence behavior change? It’s been done before. We do it all the time. How do you think the big corporations sell us stuff and convince us to eat food that isn’t healthy for us? Influence. Techniques. Knowledge of brain psychology and human behavior. Non-compliant patients? Why don’t some patients comply? What are the reasons? How about a little more narrative medicine — find out the patient’s story of non compliance. Interestingly, if you studied large groups of doctors and nurses as patients, you’d probably find that their non compliance rate as patients would be about the same as non medical professionals. So let’s look at the big picture. Movie stars and athletes really are the most valued occupations in culture of celebrity. Follow the money. What we “say” are our most important to us — our children, our health, etc. — our not in realty our most important values. Follow the money. Follow the media.

    There are many elements to this complex issue and we must look at the whole picture and figure out methods that we know work to influence people and start using them.

  • Molly_Rn

    As long as we have a healthcare system based on sickness instead of preventative care designed to promote having and maintaining health, we are doomed to chase our tail. We spend enormous sums treating things that could have been prevented. We do not pay for preventative care, but we are willing to pay for very expensive “interventions” and “procedures” once people are ill. It makes no sense for anyone. Instead of having an end of life conversation and preventing enormous sums of money spent on prolonging the patients agony we pay to keep them in ICU on every machine available until death finally wins. It takes rethinking the whole concept of healthcare.

    • http://www.facebook.com/shirie.leng Shirie Leng

      Absolutely true.

  • Gisele

    Um, everything sounded good right up until “we should not be judged for our efforts”. That sounds more akin to utopia than reality! I think it is perfectly fair to judge physicians or teachers for that matter. Granted there’s a whole lot of room to discuss what merits a fair assessment of these individuals.

    You can also sometimes see when a provider or teacher means well but is under an institutional/facility obligation to rush and spend limited time on something. In such cases you may be able to separate the individual and their desire to do well with being forced to compromise their standards.