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/...

Doctors' grade: C- on #ChoosingWisely Test Your Knowledge Questions in CMAJ

Fascinating results emerge from a small online poll of Canadian Medical Association Journal (CMAJ) readers. Web polls on the CMAJ site were done over the span of 7 months and the following 12 True or False questions were asked.

Although not scientific, the results tell us that (at least mildly-) engaged physicians (those going to the CMAJ website) like to provide a lot of unnecessary and harmful care, particularly in the area of diagnostic imaging.

Not only do we need more research on why physicians think this way, we also need research on what methods are effective at changing behaviours. We don't know yet if Choosing Wisely-type outreach to patients and providers can improve practice. We think and hope so . . .

See the Choosing Wisely Canada update for more.

EDIT:

*NB: Dr S.P. Landry has a keen eye and noticed an error; for the item pertaining to "All children with head trauma require imaging to rule our fracture and brain injuries" the answer should be FALSE. So, the correct response rate would be 70% on that question, making the overall score of respondents a little less terrible, but still remarkably bad ;)


Source: http://www.choosingwiselycanada.org/news/2...

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...

Perspective: Want to learn the value of healthcare? Try to diagnose your own mother

Dr Ranjana Srivastava is a specialist. Specifically, she is an oncologist (cancer doctor).

Naturally, she thought the worst when her mother became ill and started thinking up a series of diagnoses, implications, tests, and treatments. She struggled a little to decide how much would be important and good advocacy for her mom, and how much was "too much" and might do more harm than good.

Her husband, a GP, interrupted and helped Dr. Srivastava's mother decide what to do next - and in doing so, also answered Dr. Srivastava's bigger question:

Why is it so hard to see the value of experienced GPs?

Read the full article in the Guardian to understand her answer.

Source: http://www.theguardian.com/commentisfree/2...