Abstract
After decades of resistance, doctors must get over their reluctance to have their performance measured, finds Jerome Kassirer
Americans were proud to claim that our healthcare system was the best in the world—until we discovered that it wasn't. Reports in the early 1990s that patient care was riddled with medical errors served as an important wake-up call, and within a few years we were scrambling to figure out what to do about it. The revelations that our life expectancy and child mortality were worse than in dozens of other countries added insult to injury, and the enormous variations in practice patterns across the country disclosed that medical practice was more like a lone cowboy mentality (“I do it my way, don't bother me with rules or requirements”) than scientific practice. For years the only brakes on poor performance were malpractice suits, and they were heavy handed, inadequate governors of practice. But the error mongers spawned evidence based medicine, which in turn begat clinical practice guidelines, a spate of “best practices,” and a focus on team and individual clinical performance as never before.
What has emerged from the angst of embarrassment and genuine concern is the “quality movement,” and its reverberations are experienced by healthcare workers at all levels. Today we wrestle with what to measure, how to measure it, how to report it, and who should be responsible for collecting and analysing the results. Reporting the quality of our performance and attempting to improve it is a form of accountability to which we have been unaccustomed. For many doctors, it represents still another drain on their time, to others an insult to their professionalism, or an intrusion into longstanding modes of practice that have served them and their patients well. Some complain that focusing on specific measures ignores the complexity of a patient's illness and makes us complacent that our patients are doing fine when their serious needs are being ignored. Almost everybody agrees that it isn't easy to design measures that accurately reflect performance. Do we measure process or outcomes? Must we use clinical databases or will billing data suffice?
The demand to assess, report, and improve performance is driving some hospital and group practice managers to distraction. Given that the quality movement is still relatively young, opinion varies about which organisations should set the standards. Many, including government agencies, insurers, and not for profit organisations have not only assigned themselves a key role but demand measures so varied that compliance managers find it difficult, burdensome, and expensive to provide them all. One executive of a large hospital network told me that her institution sends reports to seven to 10 different national, state, and local organisations, and she estimated that her organisation is required to report 60 or more unique individual data points. Even such a magnitude might seem workable, especially if most of the information is automated, but negotiating contracts based on such measures puts a further burden on both administrators and doctors when reimbursement depends on achieving highly specific contractual goals. Unfortunately, improving and optimising the quality of care is complicated and difficult. Despite these complexities, aggravations, and added expenses, however, there is little doubt that we have been lax in our attention to the quality of our work.
This backdrop is the setting in which Atul Gawande practises, ruminates about his experiences, and writes. He is an introspective, thoughtful, enthusiastic, and gifted storyteller, one of a tiny cadre of doctors who can explain medicine effectively to the public. This book, a collection of short essays on performance and efforts to better it, covers exceptionally diverse kinds of doctors' activities: from the mundane task of washing hands to avoid hospital infections, to complicity of physicians in executions of prisoners, to efforts to reduce deaths on the battlefield. In each essay the reader is drawn “up front and personal” into Gawande's world and given a vision of what he sees and a sense of what he feels. The stories are a reflection of the soul of medicine.
I am a big fan of Gawande and his writing, but I smiled at the advice he gives to medical students—namely, count something and write something. Good advice, but surely incomplete. I'm sure he would add the next logical imperative—namely, improve something: once you see an obvious defect, join the effort to make medicine more effective, safer, and more humane.
Gawande's stories disclose how hard we try to care for the sick, and how difficult it is to get it right every time. His essays are a brilliant diagnosis of medicine's ills, and they illustrate that it's high time for our profession to take responsibility for the cure. After decades of resistance, we must get over our reluctance to have our performance measured. If the analytical measures of quality aren't perfect, we must stop complaining about them and help to fix them. We must get over our unwillingness to display our results publicly. We must be accountable for what we do well and for what we do wrong; only then can we move towards optimal performance.
There is little doubt that we have been lax in our attention to the quality of our work