Sunday, May 4, 2014

How Well Do Doctors Listen and Care? – Measuring Quality that Matters to the Patient

For many years, health care systems, government and insurers have attempted to measure the quality of care delivered by individual physicians.  In health systems, the main methods used to evaluate doctors rely on the mining of the medical record and patient surveys.  The article by Weiner and Schwartz published in the April issue of the Journal of General Internal Medicine, points out the challenges of these current methods and suggest another option of directly observing the encounter between a doctor and a patient.  The current methods, the authors rightly point out, are flawed.  In the article they state:

“Neither captures an array of performance characteristics including clinical attention to symptoms and signs while taking a history or conducting a physical examination, accurate recording in the medical record of information obtained during the encounter, evidence based communication strategies for preventive care counseling, and effective communication behavior.”

They do not comment on two other modalities used to measure physician quality and that is mining medical claims data and standardized patient forms used mainly to document activities for insurers and regulators, such as informed consent forms before surgeries and forms meant to inform about privacy and confidentiality laws.  These two are even more flawed than the use of medical records and surveys and yet many millions of dollars are spent each year just to manage the use of these claims databases and the flow of the attestation forms.  These two, admittedly inferior techniques are the main ones used by payers and regulators who turn to medical records and survey tools only rarely as the costs of these types of reviews tend to be high
Therefore we have four data sets, all of them admittedly flawed which we currently use to measure physician quality.  The direct observation, in this article accomplished by unannounced standardized patients and in other articles by this team by the use of audio recordings of patient visits, is a tremendous step forward as this fifth type of dataset can potentially be the most powerful of all.  When the work of Wiener and Schwartz and others who are pursuing this more direct evaluation methodology is reviewed in total, it points to a few truths so obvious that they rise to the point of being profound.  The following truths are my interpretation alone and are not part of the work cited.

  • Just because patients sign a form, that does not mean they understand what they signed and that the communication of the contents of the form actually occurred.  More often than not, for example,   HIPAA forms are given to patients as they first register at a practice or a facility by a clerk who does not explain the form of even understand it him or herself. 
  • A claims data base, which is a financial record used for billing and reimbursement purposes, is often not an accurate measure of what really occurred during a patient visit.  While useful for macro purposes, it is much less useful for assessment of individual practitioners.
  • Big data clarifies big trends and hides small differences.  It is often the small differences that matter to the individual patient. 
  • Patients don’t know what they don’t know so surveys devolve into popularity tools rather than true assessment tools of good clinical skills, listening and assessment quality, and abilities to truly understand the context of a patient’s life that is critical to their ability to carry out recommendations, follow advice, and change destructive behaviors. 
  • To assess listening, you have to listen.  Weiner and Schwartz, in their numerous studies over a decade demonstrate this repeatedly.

Only focusing on evidence based algorithms and value as measured by cost benefit analysis devalues the professional art, which may arguably be the most important part of medical practice.  Ultimately, the quality of a physician, and of any health professional, is dependent upon their ability to see and understand their patient as a unique individual, and then apply the appropriate best practices in the context of that person’s life and values.  The truly gifted practitioners do this as an art form, applying science at a very high level while always testing to ensure that they are bringing value to the patient, in the physical, social, emotional and even financial realms.   We have to measure that professional ability and develop the right methods to do that effectively and consistently.