Physician Decision Making
Even though physician income accounts for a decreasing share of the healthcare dollar, physician decision-making drives a lot of other peoples’ costs. This has led to increasing emphasis on “controlling” physician decision-making, otherwise known as pay for performance. Recently, Tsugawa and Mafi have argued that “Getting Doctors to Make Better Decisions Will Take More than Money and Nudges.” They begin their analysis looking at financial incentives for adhering to guidelines or achieving desired clinical outcomes considering both upside and downside risk.
“A large number of studies have found that P4P is effective in improving process of care…but ineffective in improving patient outcomes such as patient mortality rate. (Evidence has shown that better process of care does not always translate into improved patient outcomes, in the same way that “teaching to the test” does not always lead to more successful students.)”
Are the current incentives too small? “Even in the UK’s national health system, where up to 30% of clinicians’ income is paid through a P4P system, patients’ health has not markedly improved since 2004, when the system was introduced.” They also note that too much reliance on metrics can lead to gaming the system, sometimes with adverse impact on patients, for which the British coined the term “quality paradox.”
“Financial incentives may also unintentionally undermine clinicians’ intrinsic motivation or serve as a distraction and hurt performance. Clinicians already have so many increasing and competing demands on their time that adding another initiative (even one that offers financial rewards) may not be well received.”
What about behavioral approaches? Reviewing the available data about tactics such as “academic detailing” suggest little impact on group behavior. “Leaders and clinicians should also understand these frameworks are no panacea and be open to other approaches for driving change.” The approach they favor, which is supported by some data, is to focus on organizational culture. Organizations that encourage front-line clinicians to work on problems and processes, to report problems and mistakes, and still have the support of senior leadership are often able to make substantial progress in important areas such as reducing inpatient mortality.
“A closer look at the hospitals that succeeded in changing their culture and improving patient outcomes reveal that the best outcomes were linked with senior management endorsing decisions made by clinical teams, creating a learning environment, and making people feel psychologically safe to speak up about things going wrong.”
These authors conclude that culture matters and some cultures are more conducive to good results than others, points I have argued before in these articles. My thinking on the Tusgawa and Mafi paper was influenced by a recent paper by Cook and associates, who make a distinction between diagnostic reasoning and management reasoning.
“Clinical reasoning—the integration of clinical information, medical knowledge, and contextual (situational) factors to make decisions about patient care—is fundamental to medical practice…Most research in clinical reasoning has focused on decision related to diagnosis, i.e., diagnostic reasoning. By contrast, management reasoning—which we define as the process of making decisions about patient management, including choices about treatment, follow-up visits, further testing, and allocation of limited resources—remains less well understood. Paradoxically, management actually may be more important.”
They note diagnoses can usually be established as correct or incorrect, but in management the answer is often “it depends.”
“Management plans are influenced by…the preferences, values, resources, and constraints of the patient, clinician, other healthcare professionals, the institution and payers…Management decisions usually require communication and shared decision making with the patient and often with others including nurses, social workers, hospital administrators, insurance agencies, and public policy makers, each of whom could have an interest in how a condition is managed…Management plans are inherently fluid and require ongoing monitoring and frequent adjustments…By contrast [with diagnostic reasoning] management resoning involves a dynamic interplay among people, systems, settings, and competing priorities, and is thus inherently complex and contextually “situated.” Moreover, management often entails more uncertainties, (e.g., unpredictable response to treatment) and these uncertainties often require a more detailed plan (i.e., broader-based treatments, more contingencies, more frequent monitoring.”
Current efforts to constrain spending by controlling physician behavior are doomed to failure. As the physician struggles to balance the competing priorities, the needs of the patient and the clinician are always going to be perceived more clearly and have greater priority than needs that are more abstract and distant. But we keep looking for the “silver bullet” that will make healthcare manageable. Complex problems require multiple partial solutions. Process improvements to make dialysis treatments more predictable and safer are both feasible and can be successful. But doing so requires a stable workforce and a culture focused on doing this. I also think it possible to set boundary conditions—some treatments of potentially benefit won’t be offered for systemic reasons. Cultures that emphasize diagnostic and therapeutic restraint can be created but are vulnerable to the drumbeat of economic pressures. What will not save money, and will cost patient lives, is continued efforts to micromanage clinicians. We are in a time where expertise is derided—anybody can do a Google search and obtain “facts.” We need to recognize physicians spend years and society spends hundreds of thousands of dollars to train them to deal with this complexity. Does it make sense to throw this away?
24 June 2018
 Tsugawa Y, Mafi JN. Getting Doctors to Make Better Decisions Will Take More than Money and Nudges. Harvard Business Review, 18 June 2018. Accessed at https://hbr.org/2018/06/getting-doctors-to-make-better-decisons-will-take-more-than-money.html.
 Cook DA, Sherbino J, Durning SJ. Management Reasoning: Beyond the Diagnosis. JAMA 2018(June 12):319(22):2267-2268. doi: 10.1001/jama.208.4385.
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