Quality or Conformity?

Yesterday I received something in the mail about how I might be judged by certain “Quality Indicators”, such as my patients’ mammography rate. This struck me as very odd, since just a few weeks ago the U.S. Public Health Service Taskforce reversed their longstanding recommendation that all women should have annual mammograms from age 40.

This is a striking example of how yesterday’s truths are tomorrow’s fallacies in modern medicine. A doctor who orders annual mammograms this month could be viewed as practicing poor quality medicine, even though the same behavior might have earned him or her bonus payments and honorable mentions last month.  

I think it is time we speak honestly about what the agenda really is here. If we, or those who pay us or regulate us, choose quality indicators that are not based on solid scientific principles, but instead on expert opinions that could – and do – change at any moment, we are not measuring quality at all. What we are measuring and rewarding in that case is conformity. How fast and how consistently today’s physicians can implement new guidelines is certainly easier to measure than how well their patients are feeling.

We aren’t measuring how often doctors make the correct diagnosis on the first visit or how well they handle difficult clinical situations. We aren’t measuring how often we are able to reassure or comfort another human being who would otherwise keep circling within the health care system at great expense in search of peace of mind.

No, the things we measure are only the underpinnings of quality in health care. It is fine to measure doctors’ compliance with official guidelines, but we need to look well beyond such low hanging fruit if we want to be serious about quality. 

Frankly, there are ways we can let our office staff, our disease registries or Electronic Medical Records handle a lot of the housekeeping items people think of as quality indicators. The quality measures of physicians’ work would then reflect how we practice the art and science of medicine. We need to look more to clinical results (outcomes) and appropriateness of care.

Just like in school, we can strive to master the subject or just pass the test. If we just want to pass the test, we can change the subject when our patients bare their souls to us, fumble with the chart or peer into the EMR and start talking about tetanus shots and cholesterol and mammograms (or perhaps why we won’t order a mammogram), or we can push the paper chart or computer screen aside, look them straight in the eyes and say:

“We’ll let the system catch up with you about those things. Tell me what’s bothering you…”

Saying No

I said no when Nora Williams asked me to order a CA 125 blood test the other day. She is worried about ovarian cancer, not because of any family history, but because she, in her own words, just has the worst luck. She is an anxious woman, and I would have loved to help relieve her anxiety, but I couldn’t.

I said no when Mark Michaud asked for an antibiotic, even though he was miserable after several days of cold symptoms which had by now turned into a severe and productive cough with thick, yellow sputum.

I even said no when Jim Westerdahl asked for an MRI of his back after his sciatica attack cleared on prednisone. “I just want to know what’s going on in there”, he said, “so I know what to expect.”

I seem to be saying no a lot lately. More and more often, patients present with requests for specific tests or treatments, sometimes as a direct result of searching online for ways to screen for, diagnose or treat disease.

Nora Williams’ fears of ovarian cancer cannot be allayed by a CA 125 test. Women often ask for it, but the sad truth is that for an average risk woman without a family history of the disease, a positive test means ovarian cancer only 20% of the time, and only 50% of early ovarian cancers cause a rise in this particular tumor marker. The real usefulness of this test is to follow an already advanced ovarian cancer for recurrence after treatment.

Mark Michaud, like many other people, wishes antibiotics would work on viral infections, but they don’t. Twenty years ago I might have treated his type of bronchitis with an antibiotic, but now we know that colored phlegm does not necessarily mean an infection is bacterial.

Poor Jim Westerdahl. Whether an MRI showed a herniated disc or not, that would not help predict his risk of recurrence. It has been said that 10% of healthy people have MRI evidence of significant disc disease, but no symptoms. His symptoms were already gone, so he didn’t need any treatment, and a $1500 MRI would not help predict future symptoms any more than flipping a coin.

Sometimes I say no when patients want disability parking placards, electric scooters or narcotic pain medications when it really is in their best interest to push themselves a little harder.

I say no when patients ask me to write prescriptions in their name for an uninsured family member, and I say no when patients ask for expensive, new medications they have seen advertised on TV when there are effective, tried-and-true generics that work just as well.

I also say no when patients call in with a request for a prescription when they have self-diagnosed something I haven’t seen them for many times in the past.

Saying yes is often faster in the moment, since a no requires a thoughtful explanation, but my job is to consider the long-term consequences of every clinical decision. As a physician I have the freedom to ignore the guidelines and the scientific evidence that’s out there when I think my patient doesn’t fit the usual pattern. We need to be careful with that power if we want to keep it.

Thanksgiving Potpourri

Several patients Wednesday made me reflect on how fortunate I am to be doing what I do for a living.

There was the young man with chest pain, skin problems and unusually long fingers. Could it be that he had a syndrome I have never diagnosed before?

There was the woman with a platelet disorder and new onset atrial fibrillation. The cardiologist had recommended against using blood thinners because of the woman’s low risk for stroke based on her CHADS score, but had deferred to her hematologist and me because of her thrombocytosis. The hematologist couldn’t be sure that her hydroxyurea treatment completely neutralized her risk for blood clots, and wanted to defer to the cardiologist and me. I was able to pull it all together for her by showing her the NNT, or number needed to treat, for patients with her CHADS score. She chose to go with aspirin alone and left the office visibly relieved that nobody was trying to make her take warfarin.

There was also the young mother who wept about the loss of her grandmother a few days earlier. “Gram was my best friend”, she said, adding “I need to keep it together for my two-year-old daughter”. The woman’s presenting complaint of cough and shortness of breath didn’t seem to be a sign of anything dangerous. At the end of our visit I pointed out how fortunate she was to have been that close to her grandmother while growing up. I encouraged her to help her little girl know the importance of family the way she did.

My last two patients were a husband and wife, both around eighty years old. He had almost crushed his lower leg in a farming accident, and came in for a wound check and some pain pills, which he had declined on his first visit.

“I’m too stoved up to wrestle with my cows now. The shape I’m in, I couldn’t even wrestle the rooster”, he muttered in his thick local accent.

His wife’s blood pressure checked out okay, and I asked her to come back in the spring for a recheck. She looked me square in the eye and said:

“I’ll call you if I need you”.

There was enough time left to take care of all the incoming laboratory and x-ray reports, prescription refills and other chores well before five o’clock.

I wished my nurse, Autumn, “Happy Thanksgiving” before calling my wife to tell her I was on my way. I turned out the office lights and locked the clinic door behind me. My Thanksgiving was already well under way.