What truly counts in medicine isn’t easy to measure

Obamacare has promised to provide all of us with quality medical care that is affordable and accessible. The very name of the law is the Affordable Care Act, which I have maintained will be short on both affordability and quality care.

Most of the country agrees with me. The postponement for a year of the corporate mandate to provide insurance in businesses with at least 50 full time employees was a great relief to these businesses and to Democrats across the country who were shivering from fear that voters would hold them accountable in 2014 when the country witnessed the debacle. Was this solely a policy decision independent of politics?

How will the Obama and insurance company vanguards of bureaucrats ensure quality? They will measure of bunch of silly stuff that is easy to measure but counts for almost nothing. What really counts can’t be easily counted. But, these guys will count what is easy to count and pretend that it matters.

Let’s have readers try their hand at measuring medical quality. Depending upon your responses, you might gain a position with the Department of Health and Human Services.

Which of the following is the best measurement of quality of an obstetrician?

  1. The percentage of Pap smears done on his patient population
  2. The percentage of mammograms done on his patient population
  3. Judgment of when a Caesarean section is appropriate
  4. Patient satisfaction score

Which of the following is the best measurement of quality of a cardiologist?

  1. The doctor puts heart into his work
  2. The doctor and his staff have a good rhythm
  3. The doctor has a good beat
  4. The doctor knows when chest pain is serious

Which of the following is the best measurement of quality of a pediatrician?

  1. All appropriate vaccines are administered
  2. The physician rates very highly on surveys grading compassion and caring
  3. The practice uses a nurse practitioner available for same day appointments
  4. The pediatrician knows when a sick child should be hospitalized

How can the government and insurance companies use your responses in measuring physician quality? Is it possible that what truly counts in medicine isn’t that easy to measure?

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower

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  • PoliticallyIncorrectMD

    The bureaucrats are not interested in objectively measuring physicians’ performance. The goal is to create obscure unattainable benchmarks to further devalue medical profession.

    • drjoekosterich

      Couldn’t have said it better

  • querywoman

    Duh? For the cardiologist and the pediatrician, the measurements are vague. For the OB/gyn, the measurements are quantitative. The more surgery, mammograms, and Paps that an OB/gyn does reveals just how knife happy the doc is. I’d run from such an OB/gyn.
    Some feminists say that we do not need gynecologists, that they are surgeons. I have mixed feelings.
    My body is more than a potential vessel for cancer. An OB/gyn does not know the meaning of a “complete physical.” What’s wrong with them that they cannot look into the eyes, ears, nose, and throat on an exam?

    • PoliticallyIncorrectMD

      So does OB/GYN who takes on more complex / risky cases others shy away from does not perform as well based on “objective” measures?

      • querywoman

        I put a long post above that responds to you. I agree that some doctors routinely take on more risky cases.
        Still, measuring the number of tests is ridiculous for evaluation! It doesn’t tell us if they were necessary or, for the high risk docs, if they were interpreted properly.

    • DoubtfulGuest

      Your points are all worth considering and have a historical precedent. It’s just really complicated and depends on the individual case. It used to be common for women to have unnecessary surgeries and inadequate follow up care, and there’s somewhat of a backlash in recent years that women have to stay intact because it’s “natural” or something. As if “nature” wants women to suffer with only conservative treatments when sometimes more is medically necessary?

      • querywoman

        Well, I started typing a big post, and then I hit something, and it all got wiped out.
        I see PoliticallyIncorrectMd posted below me about an OB/gyn who takes high risk cases. Sure, I agree with that. That kind of doc needs more tests. Look at Angelina Jolie, who lost a mother and an aunt to breast cancer.
        Doctors who treat sicker patients are more likely to be sued, because the risk is higher. A high malpractice suit rate may or may not reflect on a doctor’s skills. I think surgeons are probably the hardest to evaluate by malpractice suits. Surgery is easy to botch, but also very risky.
        But measuring the number of tests is an awful way to evaluated any doctor. An OB/gyn can do umpteen Paps and mammograms just like any FP or internist can order umpteen and 1000 blood tests. The number done doesn’t tell if they were necessary or how the results were used.
        I never got to have a baby, but I feel confident I would have been coerced into a C-section.
        As for an OB/gyn, it’s hard to evaluate noninvasive techniques. Cas the doctor managed menstrual problems noninvasively well?
        The evaluation system for a pediatrician is ridiculous. I have never understood the purpose of NP’s and PA’s that well. Should a NP being given prompt sick appointments? I always maintain that doctors need to see sick patients themselves.
        It would be nice to evaluate how well a pediatrician keeps his or her patients out of the hospital and in school.
        The evaluation system for a cardiologist is a joke: it’s about bedside manner. We know that bedside manner doesn’t necessarily reflect technical skills.
        Can’t chest pain have other causes?
        I had fast heartbeat Thursday with rising pulse after throwing up. We called the cardiologist at 2 PM. The nurse suggested the fast heartbeat was due to my nausea.

        She suggested a home monitor. She said to monitor myself and they could get me in Friday if necessary.
        I said if I threw up again, I would go to the ER and then I wouldn’t need him immediately. That was fair to us all.
        I went to sleep and woke with serious nausea and a rising fever in about 8 hours, went to the ER, got IV’s for dehydration, and my pulse fell in the ER.
        Then I was released after a few hours.
        I haven’t got back to the cardiologist yet, but I plan on it. It appears we all did the right thing.

        • DoubtfulGuest

          Gosh, you’ve had a rough week! I hope you feel better soon. Your experience with gyn surgery is probably more common, and I didn’t mean to discount it in any way. I’m sorry you didn’t get to have kids, if you wanted to. I just get nervous when people criticize gyn surgeons in general or say that women shouldn’t have hysterectomies at all except for cancer. I think, what if a woman in my situation were not able to have the surgery? It really helped me.

          I see how you were not saying that, with the mixed feelings and all. My surgeon is wonderful, did all the non-invasive stuff that was indicated (but it didn’t do jack for me — my case was weird), and she is very conscientious with follow up care. I trust her completely, and I had a big part in decision making. I’d feel pretty bad if surgeons like her were penalized for doing a lot of procedures, because she’s one who takes on difficult and complex cases.

          • querywoman

            DoubtfulGuest, dear he@rt, I have just read some awful stories about babies who died from forceps injuries because the docs wouldn’t do C-sections.
            As for hysterectomies, etc., I don’t have any problem with them if a woman wants them. I have a problem with coercion.
            I used to work with a lesbian who absolutely hated her periods. She was kind of on the masculine side. She mentioned something about maybe an “operation” once.
            Once she thought about coming to a Halloween party as Prince Charles complete with the “family jewels.”
            She could easily have found a doctor to cut out her uterus, but I don’t think she ever did.

            You can also see how very, very good that male OB/gyn was. I’ll call him Dr. Gyn No. 2. I went to him when I was about 33, which is an interesting story in itself.
            My family practitioner whom I used from ages 17-33 had sent me to Dr. Gyn No. 1 when I was 18. I absolutely hated Dr. Gyn No. 1, but my mother loved him. Dr. Gyn No. 1 was never a knife-happy doctor with her.
            I had asked my FP for another doctor. He had suggested, from when I was very young onward, Gyn No. 2 and Gyn No. 3 who practiced together.
            Over the years, I went to umpteen other OB/gyns. The I went to Gyn No. 2 at age 33, whom I’d known about for years. A very good man and doctor!
            I made my peace with my childlessness years ago.
            There are ways you can tell if doctors are greedy! Good doctors don’t reorder recent blood work, unless it is questionable. Yet, private insurance and government insurance will pay for new blood work at 2nd opinion doctors and specialists on the way up.
            My mother, before she passed away, had doctors who were always phoning each other for records.

          • querywoman

            I just researched the good male ob/gyn. He’s listed as a professor at a medical school now. Perhaps he’s just working part-time.
            When I visited him at first, I had just moved. I bruise easily and I had to convince him that I was not being beaten up.
            He may have seen my legs and tummy first. Then he came up to my breast, and I had a huge bruise and I couldn’t remember bumping it.
            One of my friends prefers doctors to have nice, expensive equipment. I don’t need a lot of test other than blood, and I’m leery of all that stuff.
            I like my doctors to have good skills in their eyes, ears, and head, like him being able to read my temperature charts.
            I like that better than costly hormone tests. It probably takes a long time to learn that skill. Perhaps he is training younger docs to do it now.

  • querywoman

    I blasted OB/gyns hard. I don’t need to elaborate much on my medical past here, but I have had very good luck with nongreedy male ob/gyns who had extra training in fertility.
    Female OB/gyns, no.
    I once had such a male OB/gyn who had me keep temperature charts. He looked at them and wanted my thyroid tests. He ordered my thyroid tests from my long-term family practitioner, whom he knew. I didn’t sign for them, but that was fine with me.
    His nurse called and said they received a test from 20 years ago. I laughed and said I’ll get you a more recent one from an endocrinologist.
    His nurse also called me once off the temp charts and asked me if I had been taking antibiotics. I had been.
    So this is an excellent example of an OB/gyn with good noninvasive skills. He’d be retired and/or dead by now.

  • querywoman

    Patient satisfaction score? Don’t ER docs who freely dish out pain meds get high scores?

  • querywoman

    Dr. Kirsch is a gastroenterologist. He put out some discussion. about how to evaluate other specialists.
    He does colonoscopies, lots of ‘em. He writes like he is a kind, sensitive, bright, competent doctor. I like him; he has a sense of humor.
    The number of colonoscopies he does tell us nothing about his skills! That’s what a gastroenterologist does all day!

    So, Dr. Kirsch, how do you evaluate another doctor for yourself or your family?

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