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Rebuilding the Social Contract, Part 4
The third “A” of traditional practice is ability, which is the one that we physicians tend to care about the most. After all, we put our academic degree after our name and we are called “Doctor” in polite society. But the older practitioners knew it was not as important to the patient as it was to us. Patients tend to think everyone with a license has an adequate fund of knowledge, so to them reputation and bedside manner are more important. But for our purposes, I want to look at the question of ability more closely. To do this, we first need to disentangle ability from quality measures. Quality these days is equated to attainment of various metrics, with the metrics varying, depending on who is doing the measuring and why. We have discussed this extensively in the series of articles on “The Quality Paradox.” These metrics have become ubiquitous, and I find some younger physicians think the scores identify ability. But patients really don’t care about those scores, even when they have access to the data. We also need to disentangle ability from medical credentials. This is a bit trickier, as credentials do certify a certain level of specialized knowledge and performance. Both doctors and patients place value in initial board certification, which is based on a combination of medical knowledge as determined by a test, and direct observation by senior physicians in the training program. So, a surgeon, for example, who is board- certified, can be assumed to have demonstrated competence in the art and craft of surgery. Unfortunately, we have succumbed to what might be called credentialism, in that we now have insurance systems and hospital systems that place undue emphasis on periodic re-testing rather than actual performance. But physicians and patients find these inadequate. To continue with the surgical example, suppose the patient has a suspected pancreatic cancer and has been recommended for a Whipple procedure? Most general surgeons have been exposed to this extensive GI procedure, but the patient wants the “best,” usually meaning the most experienced, surgeon available. But few institutions list procedures they don’t do. And neither hospitals nor insurance companies publish their numbers of cases and/or specific procedures, even though there are many studies showing the importance of the volume effect on outcomes, both at the individual and the institutional level. All hospitals certified by the Joint Commission on Accreditation of Hospitals must have peer-review processes and must re-credential all staff physicians every two years. The aim of this standard, of course, is to identify those whose practice deviates from the norm and allow for corrective interventions. But does it work? And is two years the right interval? Perhaps for common surgical procedures where a normally busy surgeon might expect to perform the operation 30 times in two years, it may be about right. But for most medical diagnoses, the heterogeneity of patients, or case-mix as it is called, is such that few physicians have enough similar cases to determine anything about competence. So, I suggest peer-review works only in extreme cases or, perhaps in cases where the staff is closed, meaning all physicians are also part of a practice group. Hospital credentials are legally considered as a property right of the practicing physician, not just a license from the hospital board, so attempts to curtail privileges requires extensive time, effort, expense, and litigation. If the staff is closed, the group can fire the physician, thereby terminating his hospital privileges, without the need to go through this process. Don’t misunderstand—credentials and peer review are not going away any more than quality metrics, but they clearly don’t meet the need of patients to identify ability, and we should be clear that none of them really define ability. So, what do patients actually do when trying to determine ability? The old-timers used to say you wanted to be sure the women talked about you well while they were at the beauty parlor. Nowadays, you want to be talked about well on social media. But the old- timers also used to say that a happy patient would tell one person, but an unhappy patient would tell nine. I don’t have data, but think social media is perfectly designed to amplify the unhappy voice more than nine times. For specialists, the key is usually being talked about well by the people who work at your hospital. Untold numbers of patients would start their first encounter with me by telling me their niece, or some other relative or friend, worked at the hospital and had given me the “OK.” Somewhere along the way we seem to have lost the notion that whether people want to see me, as opposed to someone else, was up to me and how I treated the patient, both as a person and as a patient. We seem to have bought into the notion that referral comes from the insurance company or the practice organization, and the role of the doctor is to provide the service requested without much regard for anything other than the “patient” aspects of the case. Perhaps this newer perception is reality-based. After all, the majority of physicians practice in large groups, and the group’s managers are focused on productivity. Since demand exceeds the supply of MD time, these other aspects are “superfluous to requirements” and need not be accounted for. But this is not necessarily just a function of size. I rather suspect it is a function of the productivity mindset. The problem with this mindset, of course, is that it ultimately damages the practitioner as much as it fails the patient’s need to be seen as a human being, not just a patient. To summarize, education, training, credentials and technical competence are all part of ability, but despite all the efforts on testing and inspection, all of this is “inside baseball” stuff, not things patients really want to know. And the insiders know that outcomes are a function of all the care processes involved at a particular institution, the “how we do things” here, not just the ability of the physician. Unfortunately, with all of the bandwith required to keep up with all these processes, we have forgotten that what gets measured gets improved, but what isn’t measured gets lost. So, I think we need to focus more attention on both the human and technical sides instead of trying so hard to “attribute” (blame?) care on individual practitioners. Yes, treating the patient as a person is a soft skill, and difficult to assess, but it is what patients really want. 21 June 2026 |
Further Reading
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. 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 Empathy Is empathy the value we have tossed out as part of "improving" health care? 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. Productivity in Healthcare Part 1 Many are focused on efficiency and productivity in healthcare without a clear understanding that the two are not interchangeable. This article introduces the two concepts as they are commonly used. Productivity in Healthcare Part 2 The conflict between productivity and efficiency is examined from three perspectives using the care of dialysis patients as the case study. Productivity in Healthcare Part 3 The conflict between productivity and efficiency is contributing to widespread physician malaise, which has negative implications for health care improvement. 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. |