Friday, December 05, 2008

Relentless determination

I recently saw a note from a person I respect very much that set forth an important and interesting point of view:

Measuring quality in health care is an imperfect process. We can collect and measure such factors as compliance rates, trends, outcomes, complications and adherence to protocols, all of which are important in helping us improve care and safety of patients. And our tools and our understanding of what constitutes meaningful quality and safety measures are constantly improving. But at the same time, there are very important aspects of quality that cannot currently be quantified. For example, we have no yardsticks for technical expertise, critical thinking, fund of knowledge, keen judgment, passion, compassion, talent, profound curiosity or relentless determination to do best by each patient.

This is beautifully written and it is hard to disagree with. It reminds us that all is not measurable and that we must cherish and respect the humanity of doctors, nurses, and others who have devoted their lives to eliminating human suffering caused by disease. It captures, too, the discontent felt by many in the medical profession, particularly those who were trained years ago and who practiced for many years in a very different environment.

I believe that the discontent arises from the fact that those served by the health care establishment, those paying for it, and those supervising it are now demanding more accountability from the professions engaged in it. Those groups, too, have figured out that, for decades, those in the medical professions have ignored many important aspects of the science of care delivery. The subject gets short shrift in medical schools, in residency training programs, in academic journals, and in the administration of hospitals.

We have learned from studying other industries that have engaged in and achieved process improvement that such improvement requires an approach to the organization of work that is very different from that seen in most hospitals. But it also requires measurement and transparency. While even the best calculations and data don't tell all, they do tell a lot, and they are the only way we have for an organization to hold itself accountable.

But those in the medical profession sometimes fall into the trap of believing that because measurement is an inherently reductionist and mechanistic act, it can never be sufficiently accurate to reflect the overall realities of patient care. The paradox is that without it, we can inadvertently fall into the trap of self-congratulatory statements about our good intentions. Only with it can we demonstrate that we actually have a "relentless determination to do best by each patient."

I have spent innumerable pages on this blog discussing these points and giving examples from BIDMC in the hope of sharing our experiences for the benefit of all. As you have seen, I gratefully borrow from concepts that Berwick, Batalden, Spear, Conway, James and many others have been espousing for many years. We at BIDMC have devoted ourselves to implementation of these concepts, and yet we consider ourselves infants along the path of learning to walk. But we believe that this is an essential part of the mission of an academic medical center during an era in which the public is demanding greater accountability from the medical profession.

11 comments:

Anonymous said...

It strikes me that the examples given by the writer for which we have no yardstick, are all qualities that an employer would look for if he/she were making a hire for any professional job. Since physicians are not usually "hired", they largely escape such evaluations. Medical schools and post graduate training facilities are beginning to understand that these qualities need to be measured and "graded", somehow, during medical training, in order to select the types of physicians which we would all like to have caring for us in the future. There has been a series of articles about this issue under the "bcoming a physician" series in the NEJM.

nonlocal

nasov said...

One of my favorite topics -- art vs. training. The art of medicine is something granted to doctors who seem to have almost a calling for medicine. At the root of it, I think, is curiosity, because that leads to experience, which is what can seem like art. So it shouldn't be in conflict with the systems you're implementing, unless there is something in the environment that does not foster curiosity.

It's when I see a driven young person choosing a specialty based on money that I feel "please put systems in place to protect me from her." Or the intern secretly checking his blackberry instead of listening to one of the best surgeons in the world ask questions.

Great doctors, great people, always start with an unquenchable curiosity. That's what grows into the art. Just make sure nobody stifles that.

mdspencer said...

It might help doctors to remember that we ALL grew up in a different environment, patients too. Our doctor came to the house because there would be eight of us with strep or something. That's a little different from a ten minute appointment with someone who doesn't know your name.

What remains the same? Doctors have been given one of the most meaningful professions we know. Can't beat that, no matter how icky the working conditions.

e-Patient Dave said...

Well said.

I remember at the Oct 2007 board meeting, when I was on a panel with Monique Spencer, and she related how her primary physician had, on a hunch, sent her for an MRI that early-detected the onset of spine mets. Lord only knows what benefit accrued from catching them early when there was no real "evidence." She asked why he did it, and he said "You just didn't seem like yourself."

And she said, "That's the *art* of medicine."

I have the most profound gratitude and appreciation for people who can do that. Same for the extraordinary people who care for me during my in-patient weeks.

enrico said...

I agree 100%, Paul and thank you for posting on a topic of this delicate balance from someone at the top. Metrics are needed but metrics can not govern everything because not everything, as you mentioned, can be quantified. I feel similarly on the fence about "ratings" and surveys and the like--there is much data to be gleaned from these and are useful instruments with which to obtain them, but reducing a statistcally calcualted result into real-life decisions in the absence of common sense or other "soft" factors is where I fear too many organizations have already crossed.

@nasov: I hear what you're saying but that resident checking his/her Blackberry could be checking any number of things. "Unquenchable curiosity" is a state of mind, but people need to reset, especially overworked clinicians/house staff.

Finances too are a legitimate consideration in choosing a specialty; that's why we have a choice. At $300,000 of scholastic debt (and then working for a teacher's salary while the interest is capitalized over 3+ years) would you be so idealistic and trust that it will be paid off "somehow" while still trying to plan for family and a retirement? Having said that, I don't think anyone chooses a specialty solely for money; it's just a reality which can not be overlooked.

Don't judge a book by its cover, just as you'd want the same in return.

Anonymous said...

how can you talk of patient care when all you do is cover up all your hospital's stupid mistakes. You care nothing for real patient care, only how much money you can get. Your hospital is full of coverups and doctor caused patient deaths It is time you resigned and get rid of your drug addicted and drunk doctors

Albert Maruggi said...

People are many times fearful of measuring not because of the accountability, but retribution.

An environment that rewards process improvement, training, individual education would fear a bit less being measured across a wide spectrum of metrics. Measurement in a "Gotcha" environment will be manipulated, measurement in a "road to perfection through learning" environment will be embraced.

All the best to those at BIDMC

Anonymous said...

Anon 8:16:

Methinks thou dost protest too much.

nonlocal MD

e-Patient Dave said...

Yes, anon 8:16, look how feverishly he refused to publish your comment. Lo, a massive cover-up, before our very eyes.

Speaking of transparency, you wouldn't happen to be affiliated with SEIU, would you? You sound a lot like Rand Wilson when he signed a comment here some months back.

Anonymous said...

Actually, in the interests of scientific truth and transparency, I misquoted Shakespeare:

"The lady doth protest too much, methinks."

But you get the idea.

nonlocal

Marilyn Mann said...

"there are very important aspects of quality that cannot currently be quantified. For example, we have no yardsticks for technical expertise, critical thinking, fund of knowledge, keen judgment, passion, compassion, talent, profound curiosity or relentless determination to do best by each patient."

Yes, this is hard to disagree with. Unfortunately, many physicians lack these qualities.

Marilyn