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Medical Practice
I’m sure you are a good doctor, but how do you know? You might say—my patients come to see me and my appointment book is full, so that proves I’m good. But we know the truth of the matter is expressed in a formula I give to young doctors. For 5% of our patients, we are the only person who can take care of them, because their idiosyncrasies and ours line up perfectly. Another 5% will take an immediate dislike to us and the sooner they find someone else to be their doctor, the better off both of us will be. For the remaining 90%, they tolerate us as long as we are reasonably polite and reasonably kind, but almost anyone else could do what we do. So how do you know you are a good doctor? The question has become more than an ego-building question in a time when the people who pay for medical care are questioning the value of what they receive from us. The usual way to do this is to use the methods of continuous quality improvement as originally popularized by Deming. (CQI—Wave of the Future.) The AHRQ maintains an excellent website that covers the nuts and bolts of how to do CQI in healthcare, as well as links to evidence base databases. Here, I want to emphasize a couple of points that you need to keep in mind. First, most of the indicators available measure processes of care, but what patients care about are outcomes. Most of our process indicators bear little, if any, direct relationship to outcome. The choice of indicators may be mandated, as in the hospital core measures project, but if you get to choose, spend a lot of time and thought in defining your indicators. The better the processes you measure determine the clinical outcome, the more valuable the indicator becomes. If you are going to use process measures of individual physician performance, you need to be aware of some other issues. You must choose the appropriate time interval for your measurement. Some measures should NOT be calculated every month, or even every quarter. You must be aware of the distinction between common cause and special cause variation. If you pick an appropriate measurement interval, you are more likely to be able to tell the difference, but, of course, it may take longer to do than you think reasonable. You must be aware of the problem of attribution. Rarely is a process under the direction of a single physician. Perhaps the appropriate level of attribution is the unit or team, rather than the individual. You must also be aware that statistical probability becomes stable only after 30 or more observations are in the data set. For most physicians, only a few problems will be sufficiently common that they will have 30 patients at risk in a given year. Lastly you must be aware of the misuses and abuses of CQI (Culture Matters). Too often, I fear, CQI becomes divorced from decision-making in medical organizations. In 1999 I presented my notions about how using CQI for data-driven decision making can close the loop, improving both patient outcomes and nurse and physician satisfaction. (Building Resilient Dialysis Units). Fifteen years later, I remain convinced that wider application of these ideas is critical for medical organizations of all types as they navigate the changing waters of healthcare. |
Medical Practice Articles
A Good Place To Work Is your organization a just one? How do you know? A Season for Everything Maybe it is time to rediscover the art of medicine. A Way Forward on Public Safety? Recently, a group of thought-leaders in the field of patient safety have considered the rather alarming slippage in patient safety results related, in part, to the pandemic stress test. Actionable Data Medical organizations have a lot of data, much of which is not "actionable." However, if taken as a vital sign, such data can lead to important actions that indirectly improve "the numbers." Activating Patients - The Achilles Heel of Healthcare Reform? Studies show 25% of the population is not involved in their healthcare, but reform efforts assume wider application of evidence-based medicine is the key to better value. Perhaps it is the Achilles' Heel? Adding Versus Subtracting A recent study suggests people favor additive rather than subtractive solutions to problems. Addressing Health Care Culture A contrary view of the culture changes needed in healthcare. Advisory Report on Burnout, part 1 Health care worker burnout has become so prevalent, the US Surgeon General has issued an Advisory Report on immediate steps needed. Advisory Report on Burnout, part 2 We are in a time of “bowling alone,” “working from home,” and other trends that result in a general stretching of the social bonds that hold our communities together. This means organizations must be intentional about creating healthy communities within the walls if they want to create healthy communities outside the walls. Agility "Agile managment" is a business term akin to what I have called resilience. Are we at the point of a conversion experience? Alignment Alignment is another buzzword that means different things to different people. Another Case Study An effort to redefine corporate purpose offers a parallel to efforts to reform healthcare. Answering Strategic Questions Answering strategic questions is hard work and also uncertain, but these are not reasons to avoid asking them. Answering Strategic Questions Part 2 What happens if hospitals think of themselves as cost centers, not revenue centers? Are We Too Task Oriented? The number of tasks doctors must complete grows exponentially. Have we become too task oriented at the expense of our patients? Asking the Right Questions Solutions for problems in health care abound, but are we asking the right questions? Attribution Attribution is a buzz word for deciding which individual provider is accountable for the cost of a patient's care. On paper the definition seems straight-forward, but in practice it is not really possible to define it. Balancing Money and Mission The expose in USA TODAY March 11th of the excess COVID 19 mortality in Trilogy nursing homes is yet another example of the need to address the imbalance between money and mission in healthcare. Bandwidth Bandwidth, the mental and emotional capacity to handle information flow, is routinely ignored in healthcare. We need to rethink when, and for what, we really need the overloaded clinician's attention. Barriers to Innovation Innovation is critical for organizational survival, but internal and external forces make it difficult. Beyond Toxic Organizations Are medical organizations toxic environments or is the problem one of changing generational expectations? Big Medicine Big medicine may be financially necessary, but it poses risks unless care is taken to become a real system, which requires putting the clinical enterprise at the center. Building Team Effectiveness Buzz Words Buzz words are verbal shorthand phrases that often conceal complex underlying realities. Care Management Transitional care management seems likely to be good for patients, but costly to hospital-based organizations. A recent study illuminates the challenge. Care Redesign Care Redesign is one step needed to deal with clinician burnout. Changing Nature of Work Recent news articles raise issues about the changing nature of work with implications for medical organizations Changing Physician Behavior Choosing Wisely Clinical Microsystems Clinical microsystems are composed of front-line clinicians engaged in direct patient care. Despite a lack of formal authority, they are the key to successful healthcare reform. Clinical Reasoning A new computer program has been developed to help trainees learn clinical reasoning, but the challenges remain large. Coaching and Process Improvement Can individual coaching be a key to process improvement? Communications Messaging is replacing dialogue in clinical practice to the detriment of all. Concordat The pandemic is a time of disruption. Can it be chance to "push the reset button? 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. Confronting The Quality Paradox - Part 5 Continuity and Fragmentation in Health Care Dr. Linda Rourke has written a thoughtful piece about the challenge of maintaining continuity in patient care Costs and Wasteful Care Thinking about aggregate cost won't help doctors reduce unnecessary testing, but understanding Bayesian analysis might. CQI - The Good, the Bad, and the Ugly Are the uses and misuses of the continuous quality improvement method emblematic of our times? Crisis To paraphrase Donald Rumsfeld, you fight coronavirus with the healthcare system you have, not the one you might wish you had. Déjà vu All Over Again Yogi Berra reportedly said "It seems like déjà vu all over again," which is apt for describing private equity investment in medical practices. Dunbar's Number Dunbar's research suggests a practical limit to our human capacity for emotional connection with others. This has important implications for dialysis unit function. Empathy Is empathy the value we have tossed out as part of "improving" health care? Encouraging Signs How do we deal with the shortcomings of industrial medicine? Engaging Burned Out Physicians Ensuring Resilience Unintentional injuries during hospitalization have reverted during the pandemic to levels not seen in years. Authors from CMS and CDC opine about what should be done about it. Experimentation Experimentation may seem risky, but is essential for progress. How do we do it safely in challenging times? Eye of the Tiger KKR has described structural workforce changes that bode ill for health care organizations. If the challenges are not viewed with the "eye of the tiger," organizations are likely to be eaten by that tiger. Financing Healthcare Fusion Cells Fusion cells aren't a new form of fuel, but a method designed to break down institutional rigidity. Getting Excited Watching people think constructively is exciting, but rare. Getting the Tempo Right Effective doctor and patient communication requires getting the tempo of the conversation, not speed, but the current production system makes this a rare event. High-Cost High-Need Patients A small number of patients use a disproportionate share of medical resources—the high-need, high-cost patient. If you can identify such patients prospectively, care management resources might be deployed cost-effectively, as most studies of care management methods yield disappointing results. Can this approach work? History Lessons If the public response to an epidemic is a play in three parts, we are currently in Act 2 and Act 3. "Hotspotting" "Hotspotting" is a new term for an old idea, but it usually means identifying and intervening on patients who are, or at risk for becoming, superutilizers. But are we asking the right questions? Humility A new paper found literature supporting a pivotal role for physician humility in five domains: learning and professional growth, preventing and managing error, tolerating uncertainty, trust, and teamwork and communication. Three other studies from the same journal show how this might work in practice. Individual and Organizational Stress During the Pandemic Individual Resilience Fear is a normal response to threat, but how do some people develop resilience in the face of it? Is My Hospital Going Broke? I was visiting with a friend the other day who said “60% of hospitals in this country are losing money.” I decided to see if I could find some of the data underlying his statement. Linking Guidelines and Process Improvement I fear working on the difficult issues of improving health care delivery and linking guidelines and process improvement won’t stop us from ramming the iceberg created by current economic realities of high inflation, low unemployment, wage growth, lack of qualified applicants for positions requiring credentials, and pent-up patient demand that was deferred by the pandemic. Managers or Operators Physicians often blame the "suits" for their problems. Maybe medical organizations need more operators and fewer managers. Measuring Social Determinants of Health We can define poverty and discrimination in medical terms and in terms of impact on individual health, but does it help or distract from our historic task of trying to improve physical and mental health in ill or injured patients? I don’t know, but I fear it only serves to make a difficult task impossible. Medical Care as a Commodity Are big data and machine learning likely to solve the problem of uncertainty in medical practice? More Encouraging News Are we on the verge of Clinical Guidelines 2.0? More on Money in Healthcare Hospitals account for the largest fraction of the healthcare dollar, but are usually hegemonic if not monopolies in their communities. Can Trustees call them back to their mission of patient care? More on the Quality Paradox The quality paradox is the number may improve while the experience of care worsens. What's new? More on Variation - Part 1 Variation is not peculiar to healthcare, but is a general issue with the way the people think, and occurs whenever judgment is needed and the data are fuzzy. More on Variation, Part 2 Malpractice and restriction of hospital privileges represent extreme variation, but remain thorny problems. Necessary Conversations Conversation is an essential step if we are to overcome the problems with our current dysfunctional health care system. New Ideas About Electronic Health Records The data entry burdens of electronic health records contribute to physician burnout and may harm patients. Two recent articles give hope that people are beginning to search for ways to turn EHR's into aids for patient care instead." Pandemic Psychology The psychological stress test posed by the pandemic has ramifications for the future of population health efforts. Physician Leadership 2020 Lee and Cosgrove identify six challenges in the decade ahead for physician leaders, but many organizations currently lack meaningful physician participation. Playing it Safe? Many health care organizations have become frightened—so much change is being forced upon them it seems insane to voluntarily try something different. But what it it is essential? Post-Pandemic Leadership Challenges I see four lessons and challenges for medical leaders post-pandemic. Preventable Spending A new study suggests only 5% of Medicare spending in 2012 was preventable, much of it in frail, elderly patients. Is this good news or bad? Primary Care Like Mom and apple pie, primary care medicine is more honored in principle than in practice. Putting Patients At The Center Of Healthcare Putting patients at the center is crucial for healthcare organizations, but how can it be done? Quality Metrics Rationing Rationing is a dirty word, but a necessary part of healthcare reform. A consideration of the implication of this for practicing physicians. Redesigning Medical Care in Hospitals Implementing changes designed to improve teamwork are hard and resource-intensive, and may not be as complete as desired. Supporting the effort must be, and must be seen to be, a top priority in these difficult financial times or staffing problems will get worse. Reducing Hospitalizations A recent report by Vazquez and associates failed to show an impact of two population health processes on hospitalization rates at one year. What can we learn from this study. Regret Regret is a universal emotion. Although we try, avoiding regret is not possible, and our desire to do so creates costs to everyone. Reliability or Dependability Is reliability too narrow a goal? Shouldn't we strive to be dependable, with its connotation of both reliability and trustworthiness? Replacement Theory AI is not going to replace medical clinicians, but used properly, it can free them to do the tasks only people can do. Risk As Michael Tackett put it, we are experiencing a historic referendum on risk. How should we think about it? Risk, Reward, and Other Reasons Patients Don't Follow Medical Advice Patients often don't do what their doctors recommend. The problem is important and contributes to "bad" outcomes, yet we have little insight into the problem. Scenario Planning How do physicians deal with complex, uncertain health care situations? Scenario planning is better than quoting statistics. Shared Decision Making A consideration about decision making at the person, group and organizational levels. Short Term Risk For Long Term Reward Health care executives are faced with taking major short-term risks to their organization's survival in hopes of long-term benefit. This is new territory for them, but is a common problem for physicians. Simple Ideas Making simple ideas work turns out to be complicated and hard. Spending Wisely Are we spending our health care dollars wisely? Staff Shortages When there is no room at the inn due to staff shortages, the standard of practice will have to change. We need to think about what this might mean. Staff Shortages and Health Care Reform Persistent staff shortages may force care re-design in ways healthcare organizations have previously resisted. Standardization Versus Innovation Two recent articles present starkly different approaches for healthcare organizations dealing with the stresses of the pandemic and healthcare reform. Strategic Questions for Physicians Part 1 Several trends are making it imperative for physicians to re-examine their idea of what effective practice of medicine entails. Strategic Questions for Physicians Part 2 Specialist physicians also face strategic choices and no matte which is made, the future will bring major changes. Stupid Stuff Wouldn't it be wonderful if we got rid of stupid stuff? Swimming Upstream Our current cultural norms make following traditional medical advice, like eating less and exercising more, difficult for most people to do. Improving health may have more to do with modifying these forces, which is beyond the competence of health care providers and organizations. System Failure Medicine has adopted the language of manufacturing with terms such as efficiency, reliability, and “lean processes.” An unintended consequence may be increased risk of system failure. Team Building Building good teams is hard work. What does it take to be successful? Team Building II Team building is hard work--getting the right people and bring them in right are important processes. Team Building III Addressing why teams are formed requires considering mental models, transactive memory, and team learning. Team Building IV Since people aren't like Mr. Spock, team building must consider emotional factors to be successful. Team Building V Successful medical organizations are intentional about developing and maintaining robust small unit leadership. The 1% Solution Efforts to constrain health care costs have not been very effective. Maybe instead of grand solutions we need a series of "1% solutions." The Anchoring Heuristic Businessmen and health policy experts fail to recognize the limits imposed by the experiential nature of medical practice, both of which impact achieving the "triple aim." 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. The Doctor-Patient Relationship The doctor-patient relationship is central, but is threatened by excessive focus on productivity. But is the productivity-driven payment system corrupt? The Doctor Patient Relationship 2022 Today in the United States, the physician—patient relationship may be more fraught than ever, challenged as it is by greater emphasis on patient autonomy in the context of widespread misinformation and by external forces, constraints, and incentives not aimed at patient benefit. The Future of Health Insurance The impact of U. S. Supreme Court decisions on healthcare has rightly focused on the reversal of Roe v. Wade, but another decision may be an omen of future developments. The Hospitalist Dilemma Is the hospital medicine model a boon, a bane, or a response to an unresolved underlying problem? The Limits of the Medical Model The Primary Care Dilemma When people are well they want convenient care, but when they are sick they want "the best." Is that possible? The Practicing Physician and Medicare The Profit Motive The American College of Physicians has published a new position paper on financial profit in health care. The Repair Shop Sinsky and Panzer argue for rebalancing medical practice between solution shop (repair shop) work and production work. The Stress Continuum The stress continuum was developed by the military, but is applicable to all healthcare organizations. The Work-Around A work-around get past a problem with addressing either the root cause or a solution. Health care abounds with work-arounds. Toxic Institutions Healthcare institutions have unintentionally become toxic places to work. What can be done to address this? Turnover From the Perspective of the Departing Uncertainty Dealing with uncertainty is at the core of practicing medicine. Have we tried to escape this reality? Understanding the Patient Experience Perhaps it is the ability to see an individual, not a group that counts. Unit Culture and the Leader Creating and maintaining a positive, patient-oriented culture that supports doing the right thing the right way is the central task of medical leadership today. Vaccine Hesitancy Vaccine hesitancy is a case study with implications for what we can expect from current efforts to create "good healthcare". Virtual Integration Platforming is a new buzzword for an old idea--successful organizations put the customer at the center of the business. What does that mean for healthcare organizations? Waste and the Cost of Care There is no doubt individual health care expenditures have grown faster than the economy. Is this due to increased intensity of service (waste)? What Business Are We In? All healthcare organizations have both a clinical and a business function. The proper balance is crucial for success. What Do I Owe? A discussion of unexamined assumptions about what physicians owe their hospitals. What Makes a Successful Physician? What skills are required to be a successful practicing physician? What Matters What really matters to practicing physicians? |