One of the articles talked about this being an era of medicine by the numbers. The editorialist commented that there are at least 50 scales of measurement now being used to generate report cards on physicians. Many of these are percentages: such as what percentage of the doctor's female patient base has had their yearly mammograms; what percentage has their LDL (bad) cholesterol under 100; percentage of smokers counseled on quitting smoking, percentage of people screened for depression, percentage of flu shots given, etc etc. Then sometimes a group of these measures are computed together to come up with a general score rating how good the doctor is. Such report cards that supposedly demonstrate how well a physician is performing his job, are starting to be used to determine a doctor's salary. Without any personal contact with the doctor, and without a complete understanding of his practice, the type of patient he sees, and his style of practice, would such a numerical calculation standing alone really represent the quality of this physician's work?
Insurance companies are keeping track of cost effective measures, such as how many generic prescriptions are written, which blood pressure medicine is most often prescribed and its cost, what is the average cost of an office visit, and how many times are patients being called back for example for blood pressure follow up. All of these numbers determine whether a physician is "cost-effective" or not and sometimes are used to determine if that doctor is hired or retained on a provider panel. This strong emphasis on saving money while still being sure to meet all of the above performance parameters essentially creates a vice and the practicing physician is right in the middle of that vice.
As I was readying to retire one of the most frustrating things I that came up every year was the patient satisfaction survey. There were about 5 questions that the patient had to answer -- questions such as Were you satisfied with you last appointment with this doctor?, did this doctor listen and answer your questions satisfactorily, chances you would return to this professional if needed, and chances you would recommend this physician to one of your relatives or friends? After the questions came 5 check boxes: excellent, very good, good, poor, very poor. Now we as physicians were told that very good doesn't count. Your rating must be excellent. Indeed, my husband and I recently bought a new car and were asked to fill out a very similar survey about our car salesman and the dealership. The salesman told us that if we could not check "excellent" on the survey, then we should not fill it out and we should call him back and tell him why we couldn't check excellent. "Very Good" is not worth anything on these surveys. I recall that when we first had these patient survey questionnaires being handed out about 10 years ago, I gave the survey to one elderly lady whom I had taken care of for many years. I knew that she thought a lot of me as her doctor, so I told her to please fill out the survey and rate me very highly. She filled it out and handed it back to me as she was leaving without putting it in the envelope. I glanced at the ratings and realized that this sweet little lady who loved me as her doctor had marked "Very Good" for everything. With this knowledge, I wondered how we could possibly increase our ratings. To add to my frustration about 5 years ago, our clinic decided to use only one of these questions as a representative and to use the percentage answers to that single question as the individual doctor's rating score. That question was "What are the chances that you would recommend this doctor to your friends and relatives?" A colleague of mine and I scored quite low on that question and we couldn't understand why? Our scores on the other questions were around 80% excellent, but this question was about 30% excellent. Why? Well both of us were planning to retire within a year or two and our patients knew this. In the other doctor's case, he had already began talking to his patients about what doctor they would choose to replace him. So the patients would be unlikely to answer that question in the positive. They knew we would not be around for their friends or relatives to see us as their doctor. I argued with my clinic that they should not use only this question as the true rating of a doctor, but got nowhere. Their quality consultants had told them this single question was the most likely to be a good measure of the quality of the doctor, and they were not going to change their mind.
Now patients can log on to the Internet and find their doctor in one of several databases and enter a rating of that doctor. Sometimes these are again a numerical rating scale. But sometimes these entries include a narrative critique of the doctor. A negative critique of a doctor when entered is there to stay and the doctor has no way to counter that narrative. Patients can be dissatisfied with a doctor for many reasons that have nothing to do with the quality of that doctor's care. Perhaps the doctor thought the patient had a viral upper respiratory infection and refused to prescribe antibiotics because he felt they were not indicated even though the patient expected this prescription. The patient can enter a negative report based on this encounter and this rating is forever on the Internet. A doctor is a human being and the patient is a human being and hence there are going to be differences of opinion and there are going to be misunderstandings. But are narratives and ratings that are entered on an Internet survey without understanding the underlying controversies between these two individuals really reflective of this doctor's quality or care? I don't think so.
The other day at the coffee clutch following my water aerobics class, one of the members of the class said, "A doctor almost killed my husband 4 days ago." She went on to explain that she had taken her husband who had a respiratory infection to see a doctor in the Urgent Care Center. That doctor examined him, didn't order an Xray and gave him some medications. They were told that the husband had a viral infection. The next day the man felt much worse and that evening they went to an emergency room. An Xray showed that he had pneumonia, and he was sick enough to be hospitalized for it. The wife felt that clearly that first doctor had made a huge diagnostic mistake. Clearly if he had pneumonia 36 hours later, he had pneumonia when he went to the Urgent Care Center and that doctor missed the diagnosis. How many of you would agree with this statement? Well, if you agree, you are medically wrong. Pneumonia can develop within 24 hours or less. Many cases of pneumonia start as viral colds or viral bronchitis which does not require hospitalization or maybe not even antibiotic pills. But some of these cases can move on to pneumonia and the individual gets much sicker. Then indeed hospitalization can be required, though sometimes pneumonia can be treated as an outpatient also. This doesn't mean that a misdiagnosis was made; it means that the natural progression of the disease has occurred and the person now needs further care. The wife and the husband did exactly what was required. He became sicker or did not respond to the first treatment, so he needed to be reevaluated to see what that progression of illness was. But in addition, the lay person often, not understanding medicine, how illnesses present, and how illnesses progress, jumps to the conclusion that the doctor has made a huge mistake either in diagnosis or in treatment. The wife says she called the doctor at the Urgent Care Center and told him what had happened. She said, "The doctor said, "Oh yes, pneumonia can develop quite quickly." The wife said, "Humphs! Well, then they should have told me what to watch for and that he could get pneumonia from this illness." This is an example of the unmeetable expectations that our society now has of the medical profession. I am sorry to report to society in general, that the doctor does not have a crystal ball. He can not predict what way an illness is going to go. He cannot possibly outline all the possibilities and enumerate them for a patient or his family. In this case the possible list of complications of a simple viral upper respiratory infection presenting in an Urgent Care Center includes but is not limited to: conjunctivitis, tonsillitis, tonsillar abscess, ear infection, loss of hearing, vertigo, sinus infection, feverish convulsions, epiglotytis, bronchitis, lobar pneumonia, bilateral pneumonia, both viral and or caused by one of several bacteria, empyema, lung absecss, bacterial endocarditis, allergic reaction to antibiotics, shock, sepsis, and the list goes on. How could an urgent care physician possibly prepare a couple for all these possible eventualities? And think about this -- if you were the patient or the family member, if indeed a doctor did give you possible symptoms to look for for all of these eventualities, some just natural progressions of the disease, could you keep track of them all, could you watch for all of these symptoms in the patient, could you even deal with these possibilities? You would likely want the person hospitalized because you wouldn't be able to deal with all of these descriptions. So what is the answer? The answer is that you seek medical attention. If the first treatment doesn't work or the person gets worse, you go back to the doctor or you go to an emergency room, or you at least call your doctor. You don't immediately as a lay person jump to the conclusion that "That awful DOCTOR has made a mistake!"
Recently I took my mother to see her primary care doctor, a young DO practicing in a small town in northern Illinois. My mother is 94 years old and is on some blood pressure pills and is blind from macular degeneration, and is also very hard of hearing. Most recently she had developed pain in her leg and in her back which to me, her internist daughter, seems to be a pinched nerve probably due to a herniated disc or spinal stenosis from severe arthritis. I took her to her primary doctor, the DO, and went into the exam room with her. This young doctor briefly greeted her, asked two questions about where her pain was, looked down at her leg and felt around the lower thigh where Mom had pointed to. She then turned to her computer and flipped through a screen or two and began asking Mom questions about depressions: "Are you feeling depressed? Do you feel sad when you wake up in the morning? Do you enjoy doing the things you used to enjoy doing? Do you find yourself crying frequently?" She was clicking things on her computer screen. I couldn't see the screen but I think she had gone into some screening questionnaire for depression. One of the performance measurements that I described in the first paragraph above is a screening for depression in all patients that the doctor sees, in order to make the diagnosis more appropriately and to start treatment. Now in this case, you have a 94 year old woman who has only seen this doctor for blood pressure control, who has never been depressed in her life, who is now sitting in a wheelchair in this office in acute back and leg pain and this doctor is screening for depression. She didn't even examine my mother's back, never got her out of the wheelchair. But someone somewhere in the clinic she worked for, or higher up in her medical society somewhere had convinced this young doctor that she needed to run this depression questionnaire on patients. She might have been trying to get her performance score up in this area. I finally spoke up, which I don't usually do, and said, "Mom is not depressed.She is 94 and she has never been depressed in her life. She is in pain and she is trying to deal with it the best she can. She needs you to pay attention to the cause of the pain and not screen for depression. OK?" The young DO clicked out of the screen about depression. This is an example of what happens when the government, when administrative and analytic bodies in medicine decide to emphasize performance measurements and thus enter into the relationship between a doctor and her patient. I am afraid that the office visit becomes even more unsatisfying for both the patient and the doctor. Now you might say that this doctor should have realized that this was not the time for a depression questionnaire and indeed that is true. But the pressures being placed on the doctor to accomplish more and more in less and less time in the office visit can skew the ability to decide what is the most important thing to accomplish during those 8 1/2 minutes. ----I believe that is the most recent measurement of time allotted for a routine medium intensity office visit. Exactly 8 1/2 minutes. That time then allows another 5 minutes or so to document what has taken place, the history, what was examined and found, what tests were ordered, and the working diagnosis, and treatment.
One quote from a primary care doctor, presented in the April Medical Economics Magazine sums up the major problem. Speaking to physicians, Nancy Falk, MD, internist from Washington, D.C., says "A negative online review can begin in your parking lot, swell up during a bad waiting-room experience, and end with a billing error. You could be left out of the equation altogether, yet the Web ensures that postings that cut like a knife remain long-associated with your practice. The crux of the issue is that physicians today don't have the time to develop personal relationships with patients, which allows small problems to fester and leaves patients feeling as though they have nowhere else to turn to air their complaints. So often, patients are angry because they didn't get what they want, and that's an open-ended question."
The issues and the pressures intruding themselves on the relationship between a patient and his doctor have truly reached a point where I think the system is truly broken. More and more performance measurements, more and more documentation, more and more pressure to meet society's expectations which are basically unmeetable, a litigious climate in the background and an ever widening and complex medical knowledge base makes me very glad I am now a retired physician. I now regard my only medical job is to serve as an advocate, liaison, and interpreter of this complex medical world for my friends and relatives. It may be in the future that every patient will need such an interpreter to even begin to navigate their medical care. What do you think? Are my complaints above well founded or am I just a curmudgeon on the issue?
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