Popular debate concerning the recent health reform legislation has focused heavily on costs, access to care and the powers of government. That debate has neglected a crucial component of the legislation, which is the quality of health care.
The proposition that patients, employers or the government can actively shop for health care quality in a competitive market has been accepted by all sides of the health care debate. The Affordable Care Act itself extends existing policies that attempt to reward physicians for quality. Starting in 2014, there will be financial penalties for physicians who perform poorly.
It sounds good, right? But what if we are measuring the wrong thing? And what if we are teaching doctors to do the wrong things for their patients?
That's precisely the message of a landmark paper published recently in the Annals of Internal Medicine.
The study author, Dr. Saul Weiner, started with a perfect description of what we want a good doctor to do. He or she has to decide "what is the best next thing for this patient at this time?"
If a doctor doesn't make the right decision, it's an error.
Dr Weiner's study devised an ingenious way to highlight the kinds of errors doctors make all the time. He sent undercover patients into doctor's offices with regular complaints: a diabetic with blood sugar out of control. Raging asthma. Need for a hip replacement. They functioned as the "secret shoppers" of health care.)
In each case the actors could present a standard version of the problem, or versions where they offered a clue to an extra fact, something all physicians would agree should change the plan of care, if it were known. For the patient with raging asthma, one clue was "it's been worse since I lost my job."
A smart doctor would ask if new financial problems meant the patient could not pay for medicines. With that information in hand, the doctor could readily change to cheaper medications or identify a source of support. If a doctor fails to pick up on that clue, however, then they are likely to add new prescriptions. That would be the wrong decision.
Physicians only asked follow-up questions about those clues to good care about half the time. When there was a problem in the patient's life situation, like inability to afford medicines, doctors only came up with an appropriate plan of care one time in five. Four times out of five, the patient left the office without receiving good care.
That error rate is unacceptable. What's worse is that the most popular methods for measuring and rewarding quality don't encourage doctors to listen for aspects of the patient's life situation that should, if known, completely change the plan of care.
A quick look at quality measures used by the federal government, and disseminated by major health care organizations, reflects a sadly mechanical vision for quality of care.
The measures focus narrowly on whether physicians prescribe certain drugs, run certain tests, or get certain health problems under control using strict numerical measures. The measures reflect the algorithmic, rule-bound view of care promulgated by conventional health care guidelines. In this view, every problem can be met with a new prescription, an increased dose of the old prescription, or a new test. In recent years a new body of research has emerged to explain why doctors don't raise the doses on medications fast enough. Failure to do so is called "clinical inertia."
The medical residents I train have learned these lessons all too well. They tick through checklists of tests and medications faster than I ever could. But when I ask them why the care is not working, very few have the slightest clue. They rarely even know what questions to ask.
As this recent study shows clearly, new doctors are not well trained to listen with an openness to the kind of information that nearly every doctor agrees totally change the plan of care. And sadly, our system of medical education has been, in the main, passive in response to this challenge. We try to teach students to listen, but we don't show them how to listen for what matters.
And that challenge eats at the heart of today's health care quality industry, and its laudable objective of "value-based health care." It's also the source of a great deal of patient frustration.
A blizzard of mechanical quality measures, promulgated by insurers and the federal government, is actually distracting us from making good clinical decisions. The promise that we'll all be able to shop for "value" in health care will be undermined unless all of us who work in health care change the way physicians think about quality, and measure it. And that won't happen until patients demand it.
Observe how contextual errors were identified for yourself.