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 patien

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 a pessimistic article like this at least once a week.

It’s about the patient. All about the patient. Only about the patient.

I just don’t understand the way we order radiologic tests and procedures. 

If I discover skin cancer during an office visit, I refer the patient to the dermatologist or surgeon for evaluation and treatment. I don’t have to order the specific procedure they will do, or fill out a prior authorization form for their biopsy or excision.

If I diagnose symptomatic gall stones or an incarcerated hernia, I refer the patient to the surgeon. I don’t pick the procedure the surgeon will do. My office and I don’t schedule the operating room time and notify the patient.

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.

I remember an incident from an Emergency Medicine clerkship during my fourth year of medical school. I was asked to see an agitated young man whose ED chart said: “Chest pain, agitation, hallucinations.”

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.

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.