Confronting the Quality Paradox - Part 5
In previous articles I have been examining the notion that current quality improvement efforts marginalize the patient-provider encounter, because it is inherently subjective and difficult to measure. While managers may choose to ignore this problem, physicians (and other clinicians) cannot. In thinking about quality in this context, we are forced to fall back on the notion of professionalism. But what do we mean by this?
DeAngelis notes that the “Charter on Medical Professionalism,” perhaps the best statement made recently on the subject, lists three aims and 10 qualities that define professional behavior.
However, the 10 professional responsibilities are very general and open to individual interpretation of what exactly is meant by each one. According to Harris, “the essence of professionalism in the practice of medicine is intensely personal,” and therein lies the problem of exactly defining medical professionalism…[Patients] recognized physicians as professionals by good behavior, high values, and positive attitudes as clinicians, workers, and citizens.
Cohen undertook the issue of self-governance as part of being a professional. He notes the social compact underlying the practice of medicine.
Medicine’s social contract with society is the implicit, mutual understanding of the obligations physicians individually and collectively agree to on the one hand, and the privileges they are accorded by the public in return on the other hand. “Society grants physicians status, respect, autonomy in practice, the privilege of self-regulation, and financial rewards on the expectation that physicians would be competent, altruistic, moral, and would address the health care needs of individual patients and society.”
He then reviews the myriad structures that govern the practice of medicine, and concludes by predicting further governmental intrusion on the regulation of medical practice.
Is the medical profession fighting a losing battle? Do physicians have the fortitude as individuals to sustain their professionalism and abjure the lure of self-interest? The best and arguably the only hope of doing so is to recognize and strengthen the well-spring of personal motivation for adhering to professionalism’s ethical principles. That well spring is what has come to be called humanism in medicine. In this context, humanism denotes an intrinsic, deep-seated conviction about one’s obligations toward others. It is the passion that motivates true professionalism. It is the passion that motivates many, if not most, young people when they choose a career in medicine. It is the passion that is all too often dampened by the rigors of medical education and by the hassles of medical practice.
He concludes by noting that sustaining public trust depends upon individual physicians behaving in a trustworthy fashion, and that trust is the basis for the social contract that underlies all of medical practice.
Fuchs and Cullen examined the changes in medical practice as they may impact on sustaining public trust. They note that medicine in the twentieth century evolved from a craft to a profession, albeit not particularly lucrative, and then into a business that rewarded physicians well. In pondering these changes, they note:
The causes of the substantial shifts in medical practice in recent years is reasonably clear, but the consequences for the medical profession less so. Most physicians and many thoughtful non-physicians wonder whether the change from self-employed practitioners to salaried employees will adversely affect the professionalism of physicians. Preservation of the long-term societal trust of physicians and the special role physicians have in society may be at stake.
They propose that the outcome is determined by whether we end up with an “exchange” or an “integrative” system. They describe the former as an impersonal commercial relationship, or what I have called a transactional relationship. The latter relationships are based on expectations that are socially defined, similar to in a family or a religious community. Fuchs and Cullen point out that medical education must change, and rather quickly, if we intend to promote the latter sort of thinking.
Certainly, transactional relationships are being actively promoted by various forces, which view physician services at some level as interchangeable. One thesis in this series is that quality of care depends upon the intangible, but real, interpersonal relationships that develop between care providers and recipients. Loss of this relationship will inevitably damage satisfaction with care, regardless of how it is measured, both for patients and for their physicians.
Madara and Burkhart capture this notion in their editorial. The cite studies showing that intrinsic rewards such as realistic feedback on clinical performance, has more impact that extrinsic rewards, such as money. They also cite a survey showing that current “dashboards” are not seen as providing useful feedback. In pondering what might be done to enhance intrinsic motivation, which is the basis of professionalism, however it is defined, they note:
Physicians appear motivated intrinsically to provide the best care for patients. When tools are applied that assist this aspiration (timely data feedback, measures that truly matter,) motivation occurs. The current incentive system for physicians, however, largely relies on extrinsic motivators, (financial rewards and penalties,) and thereby creates misalignment…Physicians have a high degree of intrinsic motivation to engage their patients, use tools that work effectively for clinical care, and improve patient care using real-time measures of meaningful data highly relevant to their patient population. However, physicians often find themselves embedded in systems that diminish time with patients…provide tools that are far from optimized for clinical care…and rely on extensive sets of measures, many of which fail to relate to either practice type on one hand, or an actual outcome on the other.
In my years in leadership positions I have formulated these notions rather more simply. First, all physicians got into and out of medical school being graded on the curve, so they understand Gaussian distribution in their core, even if they can’t write the mathematical description. If you show physicians meaningful data that show they are an outlier compared to their peers, they will respond appropriately and fix the problem, usually without being told what to do. (Failure to respond appropriately is evidence of a personality disorder, and these are not treatable.)
Second, the data have to be both meaningful and actionable. Most of the so-called performance indicators being used today are not all that actionable, which promotes gaming. Coming up with actionable indicators is quite difficult, and outcomes are often embedded in complex systems of care such as dialysis units. Changing outcomes may be difficult if there is no means to change the system.
Thirdly, physicians are accustomed to getting “A”s on the test, and will generally try to keep doing this. Unfortunately, when dealing with systems such as Medicare’s current Hospital and Dialysis Facility Compare, the goal is to be average. You will not be rewarded for being good, and since the comparison is statistical, your goal has to be keeping up with the neighbors so you won’t be subject to penalties. The psychic discomfort produced by this discordance is one reason for the general unhappiness with “public reporting” in the name of “accountability.”
I will conclude this review by considering a paper by Ezekiel Emanuel which may be the most provocative. After reviewing a definition of professionalism which is consistent with that outlined by others, he notes that pursuing professionalism in the practice of medicine is not simple, as patient needs evolve and change over time, and many factors outside the clinical encounter impact both needs and responses to medical interventions. But, as he notes:
The real concern about professionalism is that money is corrupting the practice of medicine—that the pursuit of monetary gain for the physician is distorting judgments about what is best for the well-being of patients. All other threats to professionalism pale in comparison.
The threat of money to the ideals of medicine is not new. But what is perplexing is that as the money in medicine has increased—as physicians, hospitals, and other health care institutions have become richer—the threat to professionalism has not decreased but increased. With more resources available, physicians should not need to compromise their judgments about their patients’ well-being to live well. However, it appears that more financial resources have only increased the desire for even more, and the commitment of physicians to the moral ideal at the heart of the medical profession may have been corrupted as a result.
To deal with this, Emanuel proposes incorporating some elements of business education into medical education, specifically those that deal with organizational management. As he notes, improving quality usually means changing the systems of care, which requires some expertise in those aspects of business education that are needed to impact those systems.
Physicians can learn how to form and motivate cohesive teams, how to lead change in their organizations, and how to establish and execute on strategic goals. Most importantly, physicians can learn to create cultures of excellence that aspire to the medical ideal of putting patient well-being before all else. These are taught skills that are essential and will become even more essential as the delivery of care becomes more organized.
This website is designed to help promote the learning that underlies these activities. I hope the articles in this series have/will stimulate you to think about the lessons you can apply in your own practice setting. Your patients need you to do this just as much as they need you to be emotionally present and professional in your clinical encounters with them.
9 August 2015
 DeAngelis CD. Medical Professionalism. JAMA 2015(May 12);313(18):1837-38.
 Cohen JJ. Tasking the “Self” in the Self-Governance of Medicine. JAMA 2015(May 12);313(18):1839-40.
 Fuchs VR, Cullen MR. The Transformation of US Physicians. JAMA 2015(May 12);313(18):1821-22.
 Madara JL, Burkhart J. Professionalism, Self-Regulation, and Motivation: How Did Health Care Get This So Wrong? JAMA 2015(May 12);313(18):1793-94.
 Emanuel EJ. Enhancing Professionalism Through Management. JAMA 2015(May 12);313(18):1799-1800.
Confronting The Quality Paradox - Part 1
Confronting The Quality Paradox - Part 2
Accounting is not simply a matter of recording reality objectively, it makes things up and changes the definition of what really matters.
Confronting The Quality Paradox - Part 3
Confronting The Quality Paradox - Part 4
There will never be authentic quality within healthcare unless the word explicitly accommodates the truth that a human being is simultaneously both a subject and an object.
The Center Effect
Some dialysis units have consistently better performance than others, even after adjusting for individual patient variables, which is termed the center effect. This has important implications for hospitals and health care organizations as they respond to public reporting of data.