Can we measure what it takes to be a good doctor?

I recently spoke to a quality measures development organization and it got me thinking — what makes a good doctor, and how do we measure it?

In thinking about this, I reflected on how far we have come on quality measurement.  A decade or so ago, many physicians didn’t think the quality of their care could be measured and any attempt to do so was “bean counting” folly at best or destructive and dangerous at worse.  Yet, in the last decade, we have seen a sea change.  We have developed hundreds of quality measures and physicians are grumblingly accepting that quality measurement is here to stay.

But the unease with quality measurement has not gone away and here’s why.  If you ask “quality experts” what good care looks like for a patient with diabetes, they might apply the following criteria:  good hemoglobin A1C control, regular checking of cholesterol, effective LDL control, smoking cessation counseling, and use of an ACE inhibitor or ARB in subsets of patients with diabetes.  Yet, when I think about great clinicians that I know — do I ask myself who achieves the best hemoglobin A1C control? No. Those measures — all evidence-based, all closely tied to better patient outcomes — don’t really feel like they measure the quality of the physician.

So where’s the disconnect?  What does make a good doctor?  Unsure, I asked Twitter:

Can we measure what it takes to be a good doctor?

Over 200 answers came rolling in.  Listed below are the top 10.  Top answer? Having empathy. #2? Being a good listener.  It wasn’t until we get to #5 that we see “competent/effective.”

Can we measure what it takes to be a good doctor?

Even though the survey results above come from those I interact with on Twitter, I suspect the results reflect what most Americans would want. As I read the discussions that followed, I came to conclude one thing:  Most people assume that physicians meet a threshold of intelligence, knowledge, and judgment and therefore, what differentiates good doctors from mediocre ones is the “soft” stuff.

It’s an interesting set of assumptions, but is it true?  It is, at least somewhat.  Most American physicians meet a basic threshold of competence — our system of licensure, board exams, etc. ensure that a vast majority of physicians have at least a basic level of knowledge.  What most people don’t appreciate, however, is that even among this group, there are large, meaningful variations in capability and clinical judgment.

And, of course, a small minority of people are able to get licensed without meeting the threshold at all.  We all know these physicians — a small number to be sure — that are dangerously ineffective.  We, the medical community, have been terrible about singling these physicians out and asking them to get better — or leave the profession.

In the Twitter discussion, there was a second point raised by John Birkmeyer and that was likely on the minds of many respondents.  He said “I’d want different things from my PCP and heart surgeon. Humility. Overrated for the latter.” John was raising a key distinction between what we want out of a physician (an internist or a family practitioner) versus a surgeon.  Yes, in order to be “good,” humility and empathy are important, even for cardiac surgeons. But when they are cutting into your sternum?  You want them to be technically proficient and that trait trumps their ability (or lack thereof) to be empathic. Surgeons’ empathy and kindness matter — but it may not be as critical to their being an effective surgeon as their technical and team management skills. For internists, effectiveness is much more dependent on their ability to listen, be empathic, and take patients’ values into consideration.

A final point.  My favorite tweet came from Farzad Mostashari, who asked, “If your doctor doesn’t use the best data available to them to take care of you, do they really care about you?” In all the discussions about being a good doctor, we heard little about effective use of beta-blockers for heart disease, or good management of diabetes care.  That’s the stuff we measure, and it’s important. We use them as part of the Physician Quality Reporting System (PQRS).  But I’m not sure they really measure the quality of the physician.  They measure quality of the system in which the physician practices.  You can have a mediocre physician, but on a good team with excellent clinical support staff, those things get done.  Even the smartest physician who knows the evidence perfectly can’t deliver consistently reliable care if there isn’t a system built around him or her to do so.

So, when it comes to thinking about ambulatory care quality — we should think about two sets of metrics: What it means to be a good doctor and what it means to work in a good system.  In measuring doctor quality, we might focus on “soft” skills like empathy, which we can measure through patient experience surveys.  But we also have to focus on intellectual skills, such as ability to make difficult diagnoses and emotional intelligence, such as the ability to collaborate and effectively lead teams — and we don’t really measure these things at all, erroneously assuming that all clinicians have them.

For measuring good systems, we could use our current metrics such as whether they achieve good hypertension and diabetes control.  We need to keep these two sets of metrics separate and not confuse one for the other. And, alas, for surgeons, we need a different approach yet.  Yes, I still believe that humility and empathy go a long way — but these qualities are no substitute for sound judgment and a steady hand.

Ashish Jha is an associate professor of health policy and management, Harvard School of Public Health, Boston, MA.  He blogs at An Ounce of Evidence and can be found on Twitter @ashishkjha.

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  • http://www.davisliumd.blogspot.com Davis Liu, MD

    Great discussion. What we often measure is the effectiveness of the
    system more than the physician. Even within good systems, there is
    variation among doctors. The public is unable to discern this because
    they use bedside manner as a proxy for quality. They don’t see variation
    in physician ability and clinical judgment. Yet we must continue to
    have quality measures on elements of medical care in areas which are not
    as dependent on physician judgment.

    Isn’t it possible that we are talking about precision medicine and
    intuitive medicine? This is a framework used by Professor Clayton
    Christensen from HBS and his book the Innovator’s Prescription.

    For example, diagnoses and subsequent treatments for hypertension and
    diabetes, for the most part, are well-defined, optimal outcomes are
    recognized, and in an ideal world, does not need a doctor’s day to day
    involvement except for perhaps initial diagnoses or oversight. Some of
    the work can be delegated to less expensive resources like pharmacists
    and others. This is precision medicine where protocols and workflows can
    be developed for best practices and work moved to others.

    However, intuitive medicine, which is what we and the public equate
    as a good doctors, is the realm of a primary care doctor, emergency
    medicine doctor, and surgical specialist, who sees patients with a
    constellation of symptoms. The diagnosis isn’t clear initially on
    presentation. Sometimes it still isn’t clear with a physical exam, lab
    work, and imaging studies. This part is far more difficult to measure.
    This ability to make diagnoses in uncertainty what separates good
    doctors from truly exceptional ones.

    Even in these two areas of precision medicine and intuitive medicine,
    we need to have technically competent and empathetic doctors. In the
    case of immunizations, precision medicine, we know scientifically the
    recommended age groups for influenza vaccination. A doctor could be
    graded on the outcomes of this which is more a reflection of the system
    she works in. Whether she is also able empathize, address a patient’s
    fears or concerns, and build on the doctor-patient relationship, to help
    a patient get recommended treatments or interventions, can make the
    extra difference which may or may not be reflected in the measure.

    Finally, why do we need to choose between either or instead of and?
    Why don’t we want doctors who are empathetic, good listener, compassion / caring / kind, humble AND competent / effective? Is it possible when we label empathy as a “soft” skill that that somehow it is interpreted with a connotation of being less important than technical skills?

    As doctors, we often denigrate things we don’t understand or are
    trained to do. As an example in the case of physician leadership, an
    excellent article, “Challenges of Physicians in Formal Leadership Roles:
    Silos in the Mind” by Thomas N. Gilmore noted:

    Because [doctor] training inculcates values of autonomy,
    learning from experience, and professional distance, physicians see a
    team (managerial) approach as ‘other’ and distance themselves from those
    colleagues who take up formal leadership roles.

    The consequences are ambivalence and splits, both among leaders
    and within individuals who accept such leadership roles. A maladaptive
    strategy is often silos in the mind, in which the different bodies of
    knowledge (clinical and business) are kept too separate, with the latter
    denigrated. Yet, many of the current challenges require closer linking
    of substantive medical knowledge with sophisticated organizational and
    managerial knowledge to invent and implement new systems…

    …No talented surgeon would enter the operating room without
    scrubbing, reviewing all the available diagnostic information, and
    checking the infrastructure and the team’s readiness. Yet, that same
    surgeon, as a chair going into a meeting, will grab a folder from his
    secretary and skim it en route to the conference room three doors down
    from his office and begin a meeting with no acknowledgement of absent
    members, and differentiating between those who, respectful of community
    life, informed the leader and those who simply did not turn up. The
    leadership of the meeting often ignores the interdependency of the
    various items to one another and to the overall well-being of the
    institution.

    What Langer (1989) calls ‘mindfulness’, when brought to the
    adaptive challenge facing academic medicine, will go a long way to
    bringing the inherent intelligence and aggression in physicians core
    training to the leadership task.

    As we go forward, I hope as a profession we continue to mindful of
    what patients really want and measure what we can both at a system level
    while ensuring we do everything possible to ensure a trusting doctor
    patient relationship that provides great clinical care.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Yes, excellent discussion. I would offer the opinion that quality measurement in its current form it is still considered “destructive”, but for several reasons, not least of which is Prof. Christensen’s theory, destructiveness is now viewed in a positive light as being the prerequisite to some innovative creativity to be defined later.

    I believe this way of thinking is peculiar to those considering themselves experts, leaders or thought leaders in health care. The public, I think, understands perfectly well that physicians must be competent (and particularly the, no doubt, eclectic public that interacts with the author on Twitter). I also believe that the public is very aware of the existence of physicians that are not qualified to practice medicine, as well as of the existence of systems that provide sub-par care. As a reminder, one of the main reasons cited by surveyed poor for choosing the ED was perceived inadequacy of other venues available to them.

    The answers to this little Twitter survey are most likely in reference to what else should a physician have in addition to stellar competency. Otherwise, one could safely seek medical care at church. And we don’t.

    As for Dr. Liu’s suggestion that medical care could benefit from increased division of labor, I see how it can be done (it is done), but I don’t see how you do that without compromising all the things people say they want in their doctor. I guess this is where the destruction part comes in. The problem I have is that even if we follow Prof. Christensen’s thoughts, what replaces the destroyed product/service is a cheaper version of much lower quality that is being accepted by poorer people as “good enough” because they can’t afford the better versions, which employ people that are paid more and consequently cost more. This is the race to the bottom in a nutshell.

    And this is completely supported by observing markets that developed by “creatively” destroying what preceded them. This is why our food is junk, air travel is unpleasant, air is polluted, water is contaminated by chemicals, climate is changing, education is education mostly in name only, etc.etc.etc.
    How certain are our physicians that this is the correct prescription for health care? Or are we engaging in this exercise because health care has no choice now, but to follow the rest of the “economy” into “creatively” transforming itself into a service that is “good enough” for the impoverished? Shouldn’t our doctors have a different mission statement?

    • http://www.davisliumd.blogspot.com Davis Liu, MD

      Prof. Christensen’s framework is a good one. However, to your point, if it is used to its extreme, we have issues with food, air travel, air and water quality. I worry about this kind of mindset when it comes to health care particularly around those who shun doctor’s perspective or insight in healing health care (ie. Silicon Valley – http://thehealthcareblog.com/blog/2012/08/31/vinod-khosla-technology-will-replace-80-percent-of-docs/). Creative destruction could happen if this tool isn’t thoughtfully used.

      What will stop the creative destruction of health care to the point it is completely unrecognizable? It will be the doctors’ voice and perspective of doing no harm and doing what is best for the patient. However, in the current state our health care system must be better and adopting a framework like Christensen’s and using it mindfully is one way of getting there.

  • http://www.davisliumd.blogspot.com Davis Liu, MD

    As a primary care doctor, I agree that there are many challenges you point out. Many of them can be overcome. Why should we have doctors to routine algorithmic care in areas well defined, like diabetes? Yes we are very well trained. However, there is a primary care doctor shortage Certainly if a doctor disagrees with treatment, a doctor should override the suggestion; we are experts in our specialty whether primary care or endocrinology. I don’t know whether doctors want to only do harder cases. What I do know is that patients are being offered options to provide convenient care in areas where algorithms provide clarity on diagnosis and treatment. This is now beginning to occur in areas like diabetes – http://www.kaiserhealthnews.org/stories/2013/april/04/walgreens-primary-care-services.aspx
    There is a shortage of endocrinologists to help with the obesity and diabetes epidemic, so why not have others who are well trained complement, not replace doctors, in areas they can do? http://www.diabetes24-7.com/2013/01/30/new-diabetes-guidelines-to-buffer-shortage-of-endocrinologists-poor-healthcare/
    Completely agree that the doctor-patient relationship is vital. We can continue having a trusting relationship while also having others complement our work and as doctors have the ultimate authority to change treatments if needed.

    • Dr. Drake Ramoray

      =================================

      “Why should we have doctors to routine algorithmic care in areas well defined, like diabetes?”

      =================================

      So that there is an existing relationship with the provider and sense of trust established before things get complicated. One of the biggest challenges I face taking care of diabetes is suggesting someone start insulin or multiple injections of insulin on the first visit that I see them. This is challenging in large part because I have not seen the patient before and have no existing relationship or rapport with them. Your proposed system makes that writ large for diabetes and lots other conditions for even primary care physicians. Ie. your system destroys the personalized physicain patient relationship.

      =============================

      Certainly if a doctor disagrees with treatment, a doctor should override the suggestion; we are experts in our specialty whether primary care or endocrinology.

      =============================

      What you are suggesting in the change of implementing care is that I am required to police the actions of people with lesser training than myself. So you have basically turned my job into reading board questions provided by other providers (not even mentioning the reimbursement aspect of this idea). In addition particulary in the pharmacist example you provided, unless they plan on taking out their own malpratice insurance you would be assuming that I am also willing to take on the risk of their medical decisions (umm…. no thank you).

      I am well versed on Kaiser and the issues I have with that system would take up a whole book and go beyond the scope of this post. I will link the salary of the head of Kaiser and other healthcare “systems” for all of your readers though. It’s part way down. He’s the one whose pay approximates the number 8 with six zeroes after it.

      http://www.kaiserhealthnews.org/stories/2013/june/06/hospital-ceo-compensation-chart.aspx

      I am also well versed on the dearth of both primary care doctors and endocrinologists. I also don’t dispute the movement for NP’s and PA’s, but the part you are missing in all of this is that they don’t want supervision. Since the care has been desribed as so algorithmic and don’t need to be seen by physicians these providers then protest that they don’t need supervision and already don’t in many states.

      There wouldn’t be a primary care shortage or even an endocrinology shortage if they weren’t some of the most high overhead, most red-tape, lowest reimbursed specialties given the training of being a doctor. The solution would be to make the practicing of primary care better, endocrinology especially diabetes too, by correcting those problems. The correct solution is not to outsource it to other providers who you are naive enough to think are going to be happy being supervised by physicians. When they are independent on a wide scale you as the doctor are going to be left with complicated after complicated patient which does pay less both under this system or even a pay for performance system per time spent, and is much less rewarding when you have no relationships with any simiple patients and only get to know them after they are sick (At least I’m pretty sure that isn’t what you had in mind when you chose family practice, an intensivist sure).
      You are playing into the hands of the insurance companies, CMS, and corp med, who plan to replace you with lower cost labor.

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