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I was taught that being an asymptomatic carrier of strep in the throat was not associated with either illness or risk of complications. That’s not always true.
Teaching to the test is controversial. It helps students pass tests and makes educational programs look successful, but everyone knows it does not guarantee improved education. It can be beneficial if it helps focus teaching on the core curriculum, and if the results are used to evaluate and improve the teaching process. It can also be abused. In its most extreme form, teaching to the test consists of skipping the educational process entirely and simply providing the correct answers to test questions. There is universal agreement that this is fraudulent. In many cases it is illegal.
Why are we taking this approach to quality improvement in medicine?
It is ironic that evidence-based medicine was introduced, not to eliminate variability, but to ensure that variability was both present and appropriate. The intent was to ensure that physicians varied what they did based on the nuances of the evidence and incorporating patient values and preferences.
After reading this excellent study in the BMJ showing no benefit and some risk of harm from annual mammographic screening for breast cancer (see also this discussion in the NY Times) I suggested to a local institution that they should reconsider their Pay for Performance (P4P) initiative which penalizes their clinicians (by lowering their pay) if their female patients over 40 do not have regular mammograms.
Quality in the EHR is a zero-sum game, involving a balancing act among three key but competing needs: scope, resources and usability.
It seems I come across an article like this at least once a week. There is a sad sameness to these articles: it takes years of sacrifice and lost earning years to become a doctor, after which our lives are stressful, frustratingly full of administrative garbage, and not rewarding in the way we had hoped. We aren’t as independent as we thought we would be, don’t have enough time with patients, don’t get the respect we deserve, and don’t earn enough money.
He had called and asked for medication for his cholesterol because he had been told by his wellness program at work that he needed to be on medication for his cholesterol to prevent a heart attack. He didn’t understand why he needed to take time off work to come in and discuss the risks, benefits, and options before I would prescribe anything. And he was irritated that his wife was making a big deal about it.
It’s about the patient. All about the patient. Only about the patient.
“If we are following any mandate from any business, hospital, insurer, electronic health record purveyor, or special interest group that truncates our ability to inform a patient and to offer care “with” them in their splendid variability, we are, in our view, abandoning our oath of practice.”
An awesome article by Drs. McNutt and Hadler. Read the whole thing.
I just don’t understand the way we order radiologic tests and procedures.
Doctors often complain that patients indulge in maladaptive magical thinking and talk about how hard it is to get them to face reality. Sometimes, it is easier to join patients in their magical thinking.
Three years and 254 posts I started doing this, wondering if I would be able to find things to write about. As it turns out, that was the wrong question. A better question would have been, would I care enough to keep writing. So far, the answer is a resounding yes. My plan for the next year is to keep questioning so I can keep learning and growing. The future has a way of sneaking up on us like a windshield on a bug.
I hope you all have a wonder-full New Year, and that all your answers lead to better questions.
Anne came in for her annual health maintenance visit with great news. Her irritable bowel syndrome was no longer a problem. “I hope you aren’t upset with me, but I’m cured.”
I miss the relative simplicity and patient-centeredness that characterized the early years of my medical career.
Decades of behavioral economics research and management science predict that framing quality of medical care as something that can be captured effectively by a simple metric, and then incentivized by financial rewards or punishment based on that metric, would misfire. The experience of a colleague suggests that this is not a theoretical concern. Here’s what she told me.
I find it disheartening that those who push for QI and P4P programs based on evidence do not understand the most basic principles of the scientific method. For example, they fail to distinguish between dependent and independent variables. Perhaps they should read this site for children.
Patient-centered shared decision-making is one of the toughest tasks in clinical medicine. It involves a collaborative effort to collect and assess evidence, leavened with clinician experience, and framed within the context and values of the individual patient.
The world of medicine is quite properly focused on finding and applying the best available evidence to processes of care. Unfortunately, too often this results in the use of inappropriate hard targets and mis-applied guidelines. National quality groups, payors, government agencies, professional societies and medical care organizations (including my own) are eagerly looking for ways to improve care by standardizing care around evidence-based best practices. While I celebrate the replacement of eminence with evidence, I wish I saw more humility. The evidence is imperfect and provisional, and the resulting targets and guidelines should be understood as a place to start discussing appropriate care, not a way to end discussion of what is appropriate for a given patient in a given setting. I call this Practicing Safe Guidelines.
The deluge of clinical information I face every day is littered with clinical junk mail.