We have performance measures based on rather weak evidence

Recently, we had a wonderful reception at the American College of Physician’s Internal Medicine 2014. Sitting with leadership colleagues we had a wonderful conversation about how medicine changes. One colleague gave the example of ulcer disease. Those who trained in the 1960s and 1970s know most of this history, but it actually goes back to the early part of the 20th century.

Consider the Sippy diet, the Bilroth II, highly selective vagotomy, the introduction of H2 blockers, the introduction of PPIs, and then the crazy idea that a bacteria causes ulcer disease.

At many points in time, one could now imagine a performance measure that would now create laughter.

In the early 80s, we castigated students and residents for using beta blockers in patients with heart failure, now with systolic dysfunction we would castigate those who did not use beta blockers.

I think we are making progress in our understanding of disease and the management of disease. But what will we say 20 years from now.

We have performance measures based on rather weak evidence. Expert opinion does not substitute for strong evidence.

The naïve believe that we can measure physician quality. We cannot. Quality has too many legitimate dimensions. Not all those dimensions are measurable.

In another discussion, several physicians discussed how history taking (the first, and perhaps most important step to correct diagnosis) requires a variety of skills. We must learn how to ask each patient the proper question. That question changes according to the patient’s background, education, and personality. We must become comfortable reading body language and facial expressions. We must have the patience to wait for the patient. We must convince the patient that we really are non-judgmental so that whatever they tell us is just information and does not induce a harsh reaction.

We are complex beings and we react to disease or diseases in various ways. We have different goals once we have a disease. The best physicians really do treat the patient rather than the disease.

Yet our performance measures focus primarily on the disease, not the patient. Our performance measures rarely measure our diagnostic ability. Our performance measures do not consider the patient’s disease burden and how we prioritize treatment.

Knowledge will continue evolving. We will continue our quest to improve patient care. But will performance measures based on weak evidence help?

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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  • Dr. Drake Ramoray

    They will help insurance companies increase profits by reducing physician payment, which is exactly their unstated goal. Performance measures will accomplish exactly what they are intended to do. The most important factor in pay for performance will new patient demographics of which I have little control unless I move or stop taking insurance, or both.

  • John C. Key MD

    I love this post because I have had the same thoughts so many times. Further, I am quite confident that in my lifetime we will see yet another theory on the cause and treatment of “acid peptic” disease.

  • Venkatramana Srinivasan

    Very good post. But we all know when we see a good physician, nurse. They are attentive, spend time and underlying passion. Internists h ave to excel. At diagnosis, surgeons at technical ability.

    But overall we have to use the best judgement and keep changing with the dynamic scenarios that evolve right in front of us.
    Doctors also have to patiently teach nurses in how they see and react to a problem. This will help us navigate through this tumultuous times

  • Dr. Drake Ramoray

    True but the MBA business people are being just what they are. You can’t truly fault them for that. The million dollar question is why I the AMA, AAFP, ACP, as most physician societies who are supposed to represent physician unable or unwilling to see what you are describing?

  • buzzkillerjsmith

    I try to between maybe 30th to 50th percentile in whatever bogus performance measure comes along.

    If you’re 10th percentile, you risk being punished. If you’re above 50th you’re punishing yourself by doing well at something that is not worth doing well at.

    If the bar gets higher you have to work a bit more. If it gets lower you can let things slide a bit.

    It is also reasonable to see how far you can push things on the downside before you get taken to task. No use being 30th percentile if you can get away with 20th.

    This same reasoning applies to all the dumb@#%@& who study and take prep courses and suchlike for the family med boards. The IM boards are much harder but you can take the fam med boards completely cold and pass.

  • Eric W Thompson

    I have thought the same. What is ‘known’ now will be ridiculed 20 years from now. It would be nice if there were a way to measure provider quality. There are some who are not that great and should transition to doing something else. No way to know.

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