Giving Doctors Grades - The New York Times

Kelly Blair's illustration of health care grades

Kelly Blair's illustration of health care grades

I write a lot about well-intentioned tests and treatments for patients leading to (unintended but very real) negative consequences.

For example: high cholesterol is linked to heart attacks and heart attacks kill. We have a kind of drug that lowers cholesterol (statins). Give the drug, lower the cholesterol, lower the number of heart attacks. So, we put everyone on statin drugs, yay! 

Except, no. Physiology is not logic; lowering cholesterol with statins may NOT lower the number of heart attacks or it may not do so in most people. And statins don't actually save lives in people who don't already have heart disease. But many people (~1/10) given this statin drug will experience unpleasant side effects, like daily muscle cramps. (theNNT.com)

Good intentions, bad results. Surrogate markers are not meaningful.

 

That understood, it should not be surprising to see this thinking error applies not only to physiology but also to the health care system, a system (like the human body) that does not follow the simple rules of logic.

Well-intentioned quality or performence measures can lead to unintended and very negative consequences. This NY Times article, Giving Doctors Grades, illustrates this problem perfectly.

While trying to ensure high quality care, some metrics are set. These metrics are meant to be measured repeatedly to ensure that whatever changes are made result in better and better patient outcomes, lower costs, etc. Unfortunately, the choice of metrics can drive physicians to behave badly, in order to score higher on their report cards. To get the best outcomes, surgeons stop helping the sickest people and surgerize the healthy instead.

Bad things happen to patients that did not need things done to them.

My own provincial medical association, Doctors of BC, and many other organizations in Canada have discussed measuring physician performance. We as physicians want to be accountable to our patients, and the public wants this too. Our common goal: that dangerous, unsafe practices be weeded out and high quality care be supported and applauded.

We must proceed very very carefully when we put measurements in place lest we incentivize the wrong thing and do more harm than good.

Read more in the NY Times.

Source: http://www.nytimes.com/2015/07/22/opinion/...

What Can Patients Do In The Face Of Physician Conflict Of Interest?

I had the pleasure of meeting Dr James Rickert, an orthopedic surgeon and a patient, at the Road to Right Care conference put on by the Lown Institute in March. Dr Rickert works with the The Society for Patient Centered Orthopedic Surgery, advocating for health care reform and patient care that puts the patient in the centre.

One of the topics that he writes and speaks about frequently is conflict of interest in medicine and the financial incentiviazation of care which may be unnecessary or harmful to patients. 

To that end, his most recent contribution to the Health Affairs blog, What Can Patients Do In The Face Of Physician Conflict Of Interest?, describes some the major issues that emerge when caring becomes a business. There are also suggested Action Steps for patients to take when confronting these concerns.

Strong relationships between patients and providers are the heart of healthcare; we must work together to improve our culture and hold providers to a high ethical standard to stop the erosion of trust.

Source: http://healthaffairs.org/blog/2015/04/10/w...

Corruption: A devastating factor driving inappropriate health care in India

The Canberra Times highlights the challenges facing Indian citizens who seek medical attention in "Indian doctors shed light on massive medical procedure scandal."

Usually when I think about factors that drive inappropriate health care, I imagine it's a case of "good intentions and bad results." When doctors are trying their best for patients, sometime we go too far trying to fix a disease or result and lose sight of the person (the patient). Some negative pressures, like pharmaceutical marketing, fear of lawsuits, fear of being disliked, or a misunderstanding of the latest evidence can drive providers to do thinks that are not the "best care" though these choices may have seemed like good ideas at the time.

I never thought to put BAD INTENTIONS at the top of the list of things that drive health care providers to provide 'too much medicine' or to choose unwisely. It certainly happens (eg. Mount Sinai catheterization scandal, where people are told to lie in order to get in for unnecessary cardiac catetherizations paid by the public system), but – perhaps just by my wishful thinking – it's not as prevalent as bad acts driven by good intentions.

In India, maximizing profit appears to be the number one priority of some hospitals. Extra scans, surgeries, and avoidable deaths are all the result of doctors striving to meet "revenue targets" and taking bribes.

This is a devastating state of affairs.

One solution comes in the form of  Mission SLIM: the Society for Less Investigative Medicine. Hopefully they find success advocating against unnecessary tests and treatments, though they have their work cut out for them.

Source: http://www.canberratimes.com.au/world/indi...