HOW GOOD IS YOUR DOCTOR??

Time has been ever-changing. And it’s time it changes again. In the past, medical care was more sporadic than it is now, diabetes affected mostly older patients, who didn’t live long enough with the disease to develop complications, there were no blockbuster drugs for many diseases, and doctors did not manage nearly as many patients on multiple medications as they do now.

In those times, there wasn’t much doctor-patient interaction between visits. Today, doctors manage more chronic conditions; use more medications and laboratory monitoring, more patient education, and more administrative work for the patients than before.

What makes a good doctor, and how to measure it? Should doctors be judged on the basis of the outcome of treatment? Real outcomes of treatment are not values of blood pressure or blood sugar; they are the number of deaths due to negligence, strokes, heart attacks, hospital-acquired infections and the like.

In today’s scenario, such events are seen as preventable and punishable. Ironically, even the insurance industry has no trouble recognizing “Acts of God” as events beyond human control in all spheres other than healthcare.

There is too little discussion about responsibility of the patient. Both in medical malpractice cases and in the healthcare debate, it appears that it is the doctor’s fault if the patient doesn’t get well. If a diabetic patient doesn’t follow his doctor’s advice, then the concerned doctor must not have tried hard enough. And as the logic goes, the doctor should be penalized with a smaller paycheck or huge penalties.

A few comparisons illustrate the dilemma of judging the outcomes. Are firefighters ever penalized if the house they’re dousing to the best of their ability still burns down? Do the police investigating a murder case not get a paycheck if the crime remains unsolved? Is the military shamed in full public view if it loses a war? Even if we were to accept and embrace outcomes-based judgments in health care, the main question remains how to and who would we measure outcomes? We already know that an episode of hospitalization for a given life threatening disease can seem successful, but any readmission due to the same disease can cast doubt on that. First, of course, not all of that “outcome” is dependent on a single provider or even a group of providers, but involves ancillary staff, hospital resources and much more.

There can be a mediocre doctor, but with a good team and excellent support staff, he might be able to work wonders. On the other hand, even the smartest doctor who knows the science perfectly might not be able to deliver consistently reliable care if there a lack of proper system built around him to do so.

In measuring doctor quality, skills like empathy towards patients should be also taken into account, which can be measured through patient experience surveys. Likewise, focus must also be on intellectual skills, such as ability to make difficult diagnoses and emotional intelligence, ability to collaborate and effectively lead teams. People don’t really bring these things into consideration, erroneously assuming that all doctors have them.  For measuring good systems, the current metrics are prevalent such as whether the doctor is able to achieve good blood pressure and diabetes control.

In addition to the qualities of humility and empathy, a doctor also needs to be technically proficient. For example, a surgeon’s empathy and kindness matter, but it may not be as critical to his being an effective surgeon as his technical and team management skills. For physicians, their effectiveness is much more dependent on their ability to listen, be empathic, and take the patient’s values into consideration.

Also, much of what happens in sickness and in health is not dependent at all on the doctor. For example, a miserable weather pattern can make the rate of relapse of common cold and flu higher for one month than the next. What kind of bureaucracy would it take to create a judgmental scale that factored in such things?

Other than short term outcomes for specific diseases like some surgery, hospitalizations and such discrete episodes of care, how can the outcome be measured in primary care and disease prevention? When patients switch doctors, who gets the credit or blame for future outcomes?

Defining outcomes is fraught with scientific and ethical problems, since quality targets really aren’t, or shouldn’t be, the same for all the patients. For example, the elderly diabetics with “ideal” blood sugars are more likely to suffer harm or die than those with sugars that are a little higher (due to a higher incidence of attacks of low blood sugar).

In almost every area of medicine, every case is a different one, and that must be considered if doctors are to best serve each of their patients. It is ironic and very sad that those who used to consider the doctors next to God are the ones who look for crude, universally applicable target outcomes. Up until now, the gold standard of scientific research has been to prove which standardized interventions work best for large groups of patients, even if there are subgroups that aren’t helped at all by them.

The central question for who should judge the outcome of the treatment hinges on the priorities of whoever holds the purse strings. Health insurance companies, if the profit motives are overlooked, prioritize population management. They pay for what works for most people, knowing full well that some patients will not get the best care for their individual situations, for example when certain medications or procedures are not covered. Politicians also favor the population view of health care. If a patient is paying the doctor directly, he expects the doctor to deliver the care that works for them. If the government or an insurance company is paying, they expect doctors to deliver care that meets their standards, because they don’t trust the patients to know what is best for them, with their main focus being to have the doctor do what helps most of the patients, even if some are not helped or are not happy with what they are getting.

With all the political talk about “Patient Centeredness” during the current scenario, patients and the relatives need to be given every option about the ways how their health can be taken care of. With limited choice and no responsibility, patients tend to feel entitled and deprived at the same time. This creates a toxic environment for delivering health care.

In order to maintain what partnership is left today between doctors and patients, there needs to be a sense of trust, shared by patients and providers. And there must be, after all, some ways to achieve this.