Several years ago, when I was a very junior faculty member at a well-regarded medical school, I was asked to give a lecture to first-year students about, among other things, medical licensure and specialty board certification. I considered this task to be unenviable because these processes 1) are boring; and 2) don't happen until after medical school graduation, and thus are probably the last things on the minds of first-years who are spending most of their waking hours memorizing anatomical and biochemical trivia.
So, to get them interested, I began the lecture with a question: how does society assure that medical schools like their own produce "good" doctors who are worthy of the trust that patients have traditionally placed in them? More to the point, how do processes such as licensure and board certification assure the quality of practicing physicians? As it turns out, not well at all. Only the worst offenders (doctors who abuse or divert prescription painkillers, for example) are typically disciplined by state medical boards, and there was no publicly available information then or now that would allow an average citizen to determine how his or her doctor measured up against others.
More recently, in an attempt to provide feedback about their performance, some institutions have started giving primary care (and other) physicians "report cards" that summarize their performance on objective measures of care quality; for example, what percentage of patients with a hypertension diagnosis met blood pressure goals at their most recent visits. In theory, this type of reporting should motivate physicians who receive lower scores than their peers to improve their practices, and, therefore, the quality of care they provide their patients.
A few weeks ago, general internist Danielle Ofri, MD, PhD (a frequent guest contributor to Common Sense Family Doctor) wrote a commentary in the New England Journal of Medicine that portrayed current methods for assessing quality in individual primary care physicians as inadequate and potentially misleading. Ofri writes:
Quantitative analysts ... will see it as a sign of medical arrogance that physicians insist that everyone simply trust us to do the right thing because we are such smart and noble people. I've always wanted to ask these analysts how they choose a physician for their sick child or ailing parent. Do they go online and look up doctors' glycated hemoglobin stats? Do they consult a magazine's Best Doctor listing? Or do they ask friends and family to recommend a doctor they trust? That trust relies on a host of variables - experience, judgment, thoughtfulness, ethics, intelligence, diligence, compassion, perspective - that are entirely lost in current quality measures. These difficult-to-measure traits generally turn out to be the critical components in patient care.
Notwithstanding the firestorm of blog responses that Dr. Ofri's editorial provoked (most of whom misunderstood her as arguing for discarding quality measurement in general, rather than the crude tools being used to measure it in primary care), she has a point. Quality measurement in primary care needs to move beyond what is easy to measure. For example, current metrics target underuse of health services (e.g. not ordering enough recommended screening tests) rather than overuse (e.g. ordering tests too often or for no good reason). They have a myopic focus on individual chronic conditions rather than assessing overall quality of care for a patient with multiple diseases, where some disease-oriented goals might be inappropriate. They provide retrospective information rather than real-time feedback. And they fail to measure at all many of the personal qualities that most patients would agree are essential to a good primary care physician.
This doesn't mean that we should throw up our hands and stop trying. Not at all - in fact, I think it's critical for family physicians to be open to novel methods of quality measurement to in order to support our role in the changes that will be taking place in the U.S. health system over the coming years and decades. As I've said in this blog again and again, there will be no real health reform without meaningful investment in good primary care. To that statement I now add this corollary: there will be no meaningful investment in good primary care until we develop much better tools to measure what, exactly, good primary care is.