“Quality.” It’s one of those words that used to mean something: actual quality you could trust. Nowadays in hospital hallways, quality is a charged word that is more corporate-speak than actual English, eliciting stomach churning and eye rolling in equal measures.
Quality. Who can argue with such a noble goal? Of course we all want quality medical care. Doctors want to provide quality care, patients want to receive quality care, and administrators want to demonstrate quality care in their institutions. All parties aligned in agreement.
The problem, of course, is that no one can agree on how to measure quality. This might be an intriguing question to untangle, if it weren’t for the fact that the quality measurement field has long since left the starting gate. Despite a lack of agreement on how best to measure quality, metrics are being applied broadly, with concrete consequences for doctors, nurses, hospitals and patients.
My own experience in being evaluated for “quality” left me with decidedly mixed feelings. Our hospital had undertaken a laudable and herculean effort to improve the care of patients with diabetes. There was no disagreement that diabetes is one of the most complicated diseases we face, and that these patients would benefit from the best medical care possible.
In that light, each doctor was given a report card citing the percentages of his or her patients whose glucose, blood pressure and cholesterol were “at goal.” These seemed like reasonable data points to evaluate how good a job we were doing.
My report card was dismal, way below the targets our institution had set. It made me feel awful, because I was already working hard. But I felt guilty about the bad numbers, so I worked harder, staying later in the office and calling patients from home. Still, my numbers didn’t seem to budge; it was downright dispiriting.
I wrote about this experience in an essay in The New England Journal of Medicine. In it, I tried to point out that these sorts of metrics don’t give a full measure of quality; they simply measure what is easy for administrators to measure. Like the blind men touching the elephant, they can describe only isolated parts of a medical encounter. Each metric might be important, but they do not add up to the totality of good medical care.
Most people, when they need a doctor, ask for personal recommendations about someone who is smart, caring, thorough, thoughtful and trustworthy. Rarely do they ask for a physician with the best stats.
The responses were swift and vehement. “Dr. Ofri, are you afraid to be measured by hard data?” was a common refrain. My suggestions that most doctors are genuinely doing their best to help their patients and that these report cards might not be accurate reflections of their care were considered evidence of arrogance.
Many of these opinions came from doctors — but mostly doctors who were not involved in direct patient care (medical administrators, pathologists, radiologists). None were in the trenches of primary care.
In contrast to these comments, I was flooded with personal letters from nurses and doctors who felt demoralized by the quality measurement system. These were clinicians who were trying their best in a dysfunctional system, but were constantly being told how they weren’t measuring up. Many said that they were ready to quit, but couldn’t countenance abandoning their patients.
I thought about these nurses and doctors when I came across a recent study that found that patient outcomes (in this case, preventing readmission to the hospital after being discharged) were correlated more strongly to the “fuzzy” measure of patient satisfaction than to the standard “objective” measures of quality.
Patient satisfaction can be an amorphous thing to quantify. But typically, when someone expresses satisfaction with a doctor’s care and would recommend him or her to someone else, it usually includes those “soft” attributes like attentiveness, curiosity, compassion, diligence, connection and communication.
There certainly are some bad doctors out there — incompetents, loafers — and they should be weeded out. But they are a minority.
This is not to say that there isn’t room for every doctor to improve. I don’t view my poor scores as a free pass to blame the system for everything. I have to take responsibility for the things that I have control over, and do my best to stay current and improve my skills.
We need to remind ourselves and the public, though, that these quality measures miss much of what makes a good doctor good. If you want every blood pressure below 130/80, hire a computer to dose the drinking water with antihypertensives. The quality measures will be perfect, and every hospital will be No. 1 in the U.S. News & World Report rankings.
But if you are facing illness — critical, chronic or terminal — you might seek other qualities.
