Measuring the quality of care and improving it over time is a fundamental obligation of healthcare providers. Increasingly, quality is also tied to reimbursement and is reported publicly. While I strongly agree with both trends, three recent articles point out some of the challenges ahead.
The common theme among them is that “risk-adjustment” is a hard thing to do. A brief diversion to provide some context.
There are two main ways to measure and compare quality. One is to assess processes of care, such as adherence to established best practices and evidence-based treatment guidelines. This is relatively easy to do, but is by definition highly reductionist. Clinicians understand that “good care” is more than the sum of a handful of isolated activities. Does anyone really think that good diabetes care is equivalent to measuring the HgbA1c level annually and making sure that everyone is screened for diabetic retinopathy? The other way to me is to assess patient outcomes, or how patients actually fare at the hands of different providers. This allows for comparison of endpoints that providers and patients find important, and frees providers to innovate. The challenge is that it is very difficult to separate the relative impacts of patients’ baseline characteristics from the care received in determining the outcomes.
Continue reading Adjusting the Adjustment
We held a retreat last week for the Board of Governors of Northwell Health Physician Partners. Because we have matured as an organization, the agenda was different from recent years. Instead of asking “big questions” about what the group is and should be, we focused on providing information to the Board, and on addressing ways in which we could reduce physician burnout.
Given the imminent inauguration of the new president, and his party’s pledge to repeal the Affordable Care Act, one of the informational sessions was devoted to how the changeover in Washington may affect health care policy. We heard from Northwell Health’s head of government affairs, and from a former senate staffer who now works for a firm that provides our organization with insight into what is going on inside the beltway.
The speakers were knowledgeable and engaging, and I am confident that their description of the incoming administration and of the plans being laid by the new congress was accurate and insightful. It is no criticism of them to also say that I found their description appalling, frightening, and depressing.
Here are a few “highlights”:
Continue reading Repeal and… Then What?
Every clinician knows that “framing” – how we present information to patients – has a big impact on decisions they make about their care. Even something as simple and apparently transparent as talking about “survival” versus “mortality” is important, with “a 90% chance of living” sounding a lot better than “a 10% chance of dying” even if both phrases convey the same estimate of risk.
Things get even more dicey when doctors start talking to patients about more subtle concepts like risk-reduction or number needed to treat. The clinical impact of a big relative risk reduction operating on a low absolute risk can be hard for doctors to explain and patients to understand.
The impact of that complexity was the subject of a recent editorial in Circulation. In it, Diprose and Verster speculate that doing a better job of explaining these things to patients, which certainly seems like a good idea, may paradoxically lead to worse population health outcomes. Here’s how it could happen.
Continue reading Prevention Paradox
A recent story in Crain’s New York Business cited the difficulty small independent medical practices face coping “with declining reimbursement rates from insurers, rising overhead costs and a torrent of new regulations that have come into play in recent years.” According to the article, only 26% of NY State physicians now own their own practice, compared with national rates of physician ownership of 76% thirty years ago. Honestly, I was not surprised by the numbers. Consolidation of independent medical practices into larger organizations is old news, and it is no secret that the drivers include those mentioned.
I was, however, struck by the subsequent letter to the editor by Malcolm Reid, the president of the Medical Society of the State of New York. In it, Dr. Reid states: “Physicians should have a fair choice of practice setting to deliver care to patients, whether that is in a large health system, large medical group or within a smaller medical practice,” and goes on to say that “Many physicians enjoy independent practice because of the personal attention that can be directed to their patients without external interference.”
I am sure they do, but honestly, why should we expect the government or the public to assure that physicians have a “fair” choice? To put it bluntly, Reid (and the rest of us) should get over the idea that the organization of care should revolve around what’s good for doctors. He makes it quite clear that he is not advocating that “fair choice of practice setting” is about patients, since he concedes that effective patient-physician relationships can be maintained in a variety of practice and employment arrangements. Rather, he is saying that doctors should have the right to practice in independent practices because, well, that’s how they like to practice.
To be clear – and before the pitchforks come out – I am NOT saying that independent practice is bad, and I am NOT saying that I don’t care about how physicians feel about their practice arrangements. What I am saying is that if an independent practice is worth preserving, then the case for it has to be made on the basis of what it provides to the patients we serve, and not on the basis of what it provides to the doctors who care for them.
What do you think? Continue reading Is this about Doctors or Patients?
Physician burnout has received a lot of well-deserved attention lately. Characterized by emotional exhaustion and professional frustration, it has been tied to array of bad outcomes, from physician suicide to poor patient outcomes. Organizations are waking up to the need to measure its prevalence and ameliorate its impact.
There seem to be two broad schools of thought about the causes – and by extension, the fixes – of physician burnout.
The first is focused on the inner life of the physician. Yes, the demands of medical practice are high, but if doctors were a little more “zen” about things, then life would be better for them and the people around them, including their patients. There is now a substantial cottage industry peddling retreats, wellness classes, yoga and more to help physicians find inner peace in our tumultuous times.
The second school of thought focuses on the externalities of physician practice. Increasing demands for productivity, economic stress, loss of control over scheduling, and higher “hassle-factors” associated with EMRs and regulations have made medical practice harder and less rewarding. Burnout is just the natural reaction of sane, well-adjusted, intelligent people put into an insane environment.
Continue reading Burnout
In my prior post, I made the case that physicians in leadership roles should maintain a clinical practice. Doing so informs their administrative actions, affords them greater credibility with their peers and strengthens a vital link between the bedside and organizational activities. All of those benefits would accrue to nursing leaders who did the same.
In many organizations, as soon as a nurse takes on a defined managerial role (beyond being the “charge” for a shift) he or she leaves the bedside, never to return. They start to dress differently, with the whites or scrubs replaced with business attire and (often) a white coat. In fact, when I was a resident, we referred to the managerial, non-clinical nursing leaders collectively as “plain clothed nurses.” More importantly, I believe they also start to think and act differently.
Some of that difference is important and appropriate. As they advance organizationally, all leaders – not just nurses — must adjust to new responsibilities, acquire and develop new skills and broaden their perspective. Unfortunately, it also often seems as though clinical leaders lose an important attachment to patient care and to their staff when they are no longer “in the trenches” with them. In fact, it seems that much of what nursing leaders are now asked to do by “rounding” on their staff or regularly visiting nursing units is an attempt to replace what they have lost by leaving the bedside – credibility, first-hand knowledge of organizational effectiveness, and connection to purpose.
I think it would be better if they worked a shift now and again instead.
What do you think?
A recent opinion piece in the Annals of Internal Medicine really resonated with me. It is entitled “Why Physician Leaders of Health Care Organizations Should Participate in Direct Patient Care” and made many of the same points I cite for my own ongoing clinical practice, and which I often point out to maturing or aspiring physician leaders.
The authors lay out 4 reasons for physician leaders to remain clinically active:
- Access to information about how the organization really works. I can tell you from personal experience that this is absolutely true. When I was a hospital chief medical officer, I used to joke (but truly meant) that I learned more about how the hospital really worked by being on call on a Sunday than by going to hours of meetings during the week.
- Credibility. This also rang true for me personally. I have had physicians’ attitudes toward me turn on a dime when they learned that I was still seeing patients and had not become a full-time “suit.” Despite the fact that effective organizational leadership requires a distinct skill set from clinical expertise, it is exceedingly difficult to be a physician leader without having genuine clinical bona fides.
- Personal fulfillment. Amen to that too. I refer to this as having an opportunity to “connect to purpose” by getting back to the reason why we became physicians in the first place – to forge intimate bonds with others, and to make a positive difference in their lives.
- Job security. OK, so they didn’t call it that, but they did say that physician leaders should maintain their clinical skills so that they can go back to being clinicians when their leadership roles expire. This reason fell a little flat for me. Most leaders I have seen do not go back to full-time (or predominantly) clinical practice, and it seemed like a hedge against failing rather than a positive game plan.
Here’s a big reason for physician leaders to continue to practice that the authors didn’t discuss. For me, physician leadership is an extension of clinical practice. Clinicians have the sacred and honorable ability (and responsibility) to make a positive difference for each patient that they see. I have always embraced the idea that physician leadership is about extending that ability and responsibility from one patient at a time to many patients at a time. I think that maintaining the one-on-one connection that can only be had through clinical practice is an important reminder of that higher calling.
What do you think?
I believe in the principle behind practice guidelines. That is, I believe there is value in compiling the best available evidence related to treatment options for a particular condition and synthesizing it into a series of recommendations for clinicians. There are certainly potential pitfalls in developing guidelines, but I still think that a high quality guideline, applied critically and with respect for patient preferences, can improve care.
One objection that clinicians often raise about guidelines is really not about the guidelines themselves, but rather about being judged on the extent to which their management matches guideline recommendations. The argument is pretty straightforward: management depends both on the physician’s recommendations and the patient’s adherence, and physicians can’t control the latter. I have argued that physicians have more influence on adherence than they may care to be accountable for, but the point is well taken. There are limits to how much physicians can influence patients’ behavior. Are there other means for improving adherence?
A novel collaboration between the American College of Cardiology (ACC) and Google is based on the assumption that patients can be engaged and activated if they have easier access to high quality information.
Continue reading Patient Engagement
My mother died last week. This is about her.
She was born in New York City, raised as an only child on the Lower East Side, and was the proud product of city public schools and City College. She was an accomplished student and, as was common in those days, was accelerated through grade school, so that she graduated high school at the top of her class at age 16 and college at age 20. As was also common in those days, she married my father of blessed memory the same year she graduated from college, in August of 1949.
She and my father lived with her parents for a bit, with her teaching in the NYC public schools and then went off to Boston, where my father went to graduate school, and she taught 2nd grade in the Brookline public schools. When her father – a grandfather I never met, and for whom I am named – became ill, they moved back to NY, eventually becoming part of the great migration from the LES to Kew Gardens, Queens, and then, in 1960 with 2 little boys to Merrick, Long Island. She used to like to tell the story that she voted for JFK in the morning, and moved in that afternoon.
Continue reading Charlotte Nash
Perhaps you have heard the rather grim joke about how doctors don’t know when to stop treating patients who no longer benefit. It goes something like this: The oncologist goes to the cemetery to find (and treat) Mrs. Jones, since she hasn’t “seen” the latest chemo-cocktail for her recently fatal malignancy. When he asks the grave-digger why she isn’t in her assigned plot, he is told that she is off getting dialysis. Bah dum bump. OK, so it is crude, but everybody “gets” it, because it is just an exaggeration of the kind of aggressive, low-utility care that we often see (or “provide”) at the end of life.
Readers of this blog know that I believe that we, as physicians, often fail our patients by doing more than we would want done for ourselves. I have generally considered this a distinctly “American” issue, fueled in part by unreasonable expectations of the utility of medical interventions, the entrepreneurial nature of a lot of US health care, and the prevalent American sentiment that death is somehow “optional,” or at least to be opposed vigorously at all times regardless of the circumstances.
A recent paper in Heart provided a little international – and, alas, cardiology — flavor.
In it, researchers from the UK, Israel, and France reported on their experience performing primary percutaneous coronary interventions (PCI) for acute ST-segment elevation myocardial infarctions (STEMI) in nonagenarians. It was a retrospective analysis of a series of 145 patients with no control group, which almost certainly means that there was a strong selection bias toward treating only “the best” nonagenarians. The principal finding was a 24% in-hospital mortality, with a 6 month mortality of 39% and 1 year mortality of 47%. Here is what the survival curve looked like:
Continue reading No Way Out