Physician Quality Report Cards, Part II

I am frankly surprised by the number of comments, emails, and telephone calls I have received about my doctor report card blog post. (http://ow.ly/2wcvd) Some were charged with emotion and even anger. The number and tone of the responses indicate that Dr. Danielle Ofri (http://danielleofri.com/?p=1169) and I hit a nerve that resonates differently with different audiences, and we should all try to better understand the several sides to this important, complex, and relevant issue

In this post, I would like to explore how we can equip physicians with the humility, courage, and existential strength needed to want to receive the kind of timely, blunt feedback on performance that is necessary for continuous improvement of clinical care. There are models in professional football, innovative teacher training programs, and public school teacher report card initiatives that might inform us. I would also like to revisit my interest in replacing the current pessimistic model of error and failure with a more optimistic model. (http://ow.ly/2wsPq) While we are all too familiar with the shame and embarrassment associated with being told we are wrong, an optimistic model of error and failure guides us to being more receptive to feedback because the focus is not on us, but rather on the “other” that needs to be taught or cared for. In an optimistic model of error, Kathryn Schulz believes we can respond to feedback about failure with bafflement, fascination, amusement, excitement, curiosity and delight. (http://ow.ly/2wsTn).

Why is it so hard for us to admit error and receive blunt feedback? Why is it so important for all of us to always be right? Chris Argyris wrote about why it is difficult for the successful to learn; success really does not teach as much as failure, and when the usually successful fail or need to improve they become defensive. (http://ow.ly/2wsYy) Argyris believes there is a universal tendency for humans to respond to feedback by trying to achieve four goals: stay in control, win and not lose, feel positive, and behave rationally (http://ow.ly/2wt0P). Harville Hendrix, a marriage therapy expert, believes being wrong is so threatening and unwelcome because of concentric consciousness, having our internal cohesive sense of self disrupted resulting in chaos, and experiencing shame and guilt which is painful. We become rigid in our beliefs and defensive because we do not like feeling insecure. (http://ow.ly/2wt5Y)

Primary care providers are dispirited, angry, and upset by the status quo. Their level of frustration is reflected by some of the over the top comments to my blog such as wanting to “projectile vomit over” those with whom they disagree and calling administrators “idiots.” (http://ow.ly/2wcvd) We should all take this low morale problem seriously. However, I hardly see how such an attitude does anything but drive physicians and patients and administrators farther apart. It also reinforces an unfortunate impression that physicians will only learn from other practicing physicians; they will not listen to or learn from patients or other professionals who just might have something to contribute to improving care.

There is wisdom and perspective to be had from non-physicians (sometimes even those wearing suits) who have tackled similar problems in other fields of endeavor. I have long been depressed by how parochial and slow we in medicine have been to adopt knowledge from other fields. Medicine has lagged behind in adopting information technology; hospitals have been much slower to use social media than other industries; health systems have been reluctant to learn from the lean movement; medical schools have been tardy in the use of computer simulation to teach clinical skills.

My daughter Reva spent three years in the media relations department of the Philadelphia Eagles, and one of the take home messages was the level of individual feedback involved in pro football. After every game, the position coaches grade every player on every play based on the film record. It can be a difficult exercise for one’s ego, but because the feedback is timely, it also does promote learning and improvement. Those who cannot master the plays or techniques are cut from the team.

My son Colin tells me that the MATCH Teacher Residency training program in Boston utilizes similar extensive timely feedback to develop recent college graduates into teachers capable of effectively teaching in high poverty charter schools. These students get graded on a 1 to 10 scale after every class, review videotapes with coaches, and even receive via an earpiece real-time coaching while conducting classes.

Public education is faced with a teacher evaluation system that most agree is broken. Traditionally teachers have been evaluated on the basis of brief, pre-announced visits by principals who offer a confidential and highly subjective assessment of their teaching. More than 90% of teachers receive a passing grade according to a four state study by the New Teacher Project. (http://ow.ly/2wcGk)

An evaluation tool that is increasingly gaining popularity with educational reformers is called value added analysis. Value added analysis uses students past performance on tests to project his or her future test results. The difference between the prediction and the student’s actual performance after a year is the value that the student’s teacher added or subtracted. (http://ow.ly/2wcGk) This method has been used for years by educational researchers who claim it is good at identifying star performers and the weakest teachers; it is not particularly good at differentiating between the middle group of teachers.

Value added analysis, developed by economists in the 1970s, has recently been used by some school districts to determine which teachers should be rewarded and which instructors need help. District of Columbia Chancellor Michelle Rhee recently fired 26 teachers based in part on their poor performance on a value added analysis. (http://ow.ly/2wcGk)

The Los Angeles Times hired a Rand Corporation researcher to run value added analysis on more than 6,000 third through fifth grade teachers in LA, using data that had been largely ignored by the school district. In the first article published this month, superior and inferior teachers are identified by name and interviewed. (http://ow.ly/2wcGk)

After a single year with teachers who ranked in the top 10% in effectiveness, students scored an average of 17 percentile points higher in English and 25 points higher in math than students whose teachers ranked in the bottom 10%. Students often backslid significantly in the classrooms of ineffective teachers, and thousands of students in the study had two or more ineffective teachers in a row. (http://ow.ly/2wcIJ)

The newspaper plans to run a series of articles revealing individual teachers’ effectiveness. The union president of United Teachers Los Angeles has called for a boycott of the newspaper. (http://ow.ly/2wcIJ)

Teacher report cards are not perfect. Some teachers who rank highly one year fall to the bottom of the scores the next year, according to a Florida study in the journal Education Finance and Policy. (http://ow.ly/2sNdj) Small class size makes it important to use several years’ worth of data; the LA Times study used multiple years’ worth of data for each teacher. Arne Duncan, the Secretary of Education in the Obama Administration, advocates using report cards as part of the evaluation of teacher performance and considers it an improvement over the current subjective process. Daniel Willingham, a cognitive psychologist at the University of Virginia states, “Damn near anything is going to be an improvement on the status quo.” (http://ow.ly/2sNdj) The question is are report cards better than what we use now; the question is not are report cards perfect.

Several of those who commented on my original blog thought that report cards are better issued at the large hospital or physician network level, rather than to individual physicians. Dr. Anne Marie Cunningham of Wales provides the most complete argument for this tactic in a long and thoughtful blog post, but she also admits in a comment that there are “no published studies of the effect of publicly reporting performance data on quality improvement activity among physicians or physician groups.” (http://ow.ly/2wcyG) So we really do not know if either the system or individual approach will be useful. Dr. Cunningham also posts a video that contends that doctors have autonomy and that team based care is just a myth. I find it interesting that nobody contested the Colorado Kaiser mammogram study where individual report cards identified and removed substandard radiologists who missed suspicious lesions.

Gilles Friedman and e-Patient Dave, both advocates of participatory medicine, make the point that patients need a direct conduit into the medical record without being filtered by the physician’s interpretation. (http://ow.ly/2wcvd) The experience of social media sites like PatientsLikeMe and CureTogether to involve patients in meaningful clinical research is something that I enthusiastically support. However not all practicing clinicians have come around to Don Berwick’s recommendation that the patient control and own his own medical record and that physicians behave as guests and not hosts in the care of their patients. (http://healthaffairs.org/blog/author/berwick/)

The comment by bev MD (http://ow.ly/2wcvd) provides us, I think, with a way forward:

The thing that frustrates me in this whole debate is docs' idea that this entire concept is invalid and should not be applied to them. Then, when it is (and get real guys; this is going to happen, period), they quibble with the metrics and behave as victims….

As Paul Levy repeatedly has commented on his blog, Running a Hospital, we need to get busy and do this ourselves - or it will be imposed externally by those who do not know how to do it. This is happening right now - wake up and get control, or be controlled!

Practicing clinicians, patients, administrators, measurement experts, and others need to work together to create standards that can be measured and that can eventually improve the health status and overall well being of a population. We need to figure out accountability that works, whether at the system or individual level. We need to provide individual clinicians who score low with the tools, time, and institutional support that can help them improve the care they deliver. We need to continually improve the report cards so that they are meaningful and do help improve care.

The fact is we spend so much money on education and on medical care in the United States that we need to develop ways to ensure that we are getting our money’s worth.

US Education Secretary Arne Duncan was talking about teacher report cards when he said: “The truth is always hard to swallow, but it can only make us better, stronger and smarter. That’s what accountability is all about – facing the truth and taking responsibility.” (http://ow.ly/2wcQN) But, he could just as well have been talking about doctor report cards.

I hope all of us in medicine can react as gracefully as Karen Caruso who was identified in the LA Times analysis as in the bottom 10% of elementary school teachers in boosting students’ test scores.

“For better or worse testing and teacher effectiveness are going to be linked….If my student test scores show I’m an ineffective teacher, I’d like to know what contributes to it. What do I need to do to bring my average up?” (http://ow.ly/2wcGk)

Trust Me I'm A Doctor vs. Physician Quality Report Cards

In Quality Measures and the Individual Physician Danielle Ofri, MD, PhD questions the usefulness of feedback report cards for individual providers. She states, “Only 33% of my patients with diabetes have glycated hemoglobin levels that are at goal. Only 44% have cholesterol levels at goal. A measly 26% have blood pressure at goal. All my grades are well below my institution’s targets.” (http://danielleofri.com/?p=1169)

It would be better for Dr. Ofri’s patients if these numbers were higher. I think even Dr. Ofri would agree with that assessment. And yet Dr. Ofri’s response to these low scores is that “the overwhelming majority of health care workers are in the profession to help patients and doing a decent job.” And more upsetting is Dr. Ofri’s conclusion where “I don’t even bother checking the results anymore. I just quietly push the reports under my pile of unread journals, phone messages, insurance forms, and prior authorizations.” (http://danielleofri.com/?p=1169)

Dr. Ofri’s defense that doctors are smart and good people who are trying hard to help others does not reassure me as a patient or physician executive. Everything we know about cognitive neuropsychology tells us that humans are not good at judging our own competence in any field of endeavor. One hundred percent of high school students rank themselves as having a higher than average ability to get along with others (a mathematical impossibility), and 93% of college professors rank themselves as above average at their work. (http://ow.ly/2sCLw)

Literature teaches us the same lesson. Martha Nussbaum discusses how Proust has Marcel confident that he does not love Albertine any longer. And then Marcel finds out that she has left; he now knows for certain, without the least room for doubt, that he loves her. (http://ow.ly/2sCOI) Humans are masters at self-deception, and Michael S. Gazzaniga even hints that this quality separates humans from other animals. (http://ow.ly/2sCLw)

Richard Russo makes a similar point in Straight Man about the need for humans to have feedback from others, about our inability to know ourselves without it. "Which is why we have spouses and children and parents and colleagues and friends, because someone has to know us better than we know ourselves. We need them to tell us. We need them to say, ‘I know you, Al. You are not the kind of man who.’” (http://ow.ly/2sCzk) Physicians need report cards to tell us how well we are taking care of our patients, even when we sincerely think we are doing a fine job.

As Chief Medical Officer for a large health system, I never met a clinician who did not think that they did a good job at taking care of diabetic patients. And yet when I did an audit of their care, I found that many had suboptimal results. They were genuinely surprised that patients fall through the cracks and did not receive their required retina exams.

Physicians are always telling me that they have to be the leaders of the health care team. Well, then they need to accept that feedback is necessary for learning and improvement and leadership. Good leaders in my experience only do four things: they examine the environment and decide on a vision that can excite themselves and others. They translate the vision into strategies and tactics; they assign the strategies and tactics to someone to carry out; they then hold the responsible party or parties accountable for the results. In my experience health care does not do a good job at the accountability step.

Who is accountable for the quality of care in Dr. Ofri’s clinic? Do we have examples in medicine where someone has stepped up to the plate and become accountable so that the quality results improve instead of never budging from the results two years ago?

Dr. Kim A. Adcock, the radiology chief at Kaiser Permanente Colorado, created a system that misses one-third fewer cancers on mammograms and “has achieved what experts say is nearly as high a level of accuracy as mammography can offer.” At the heart of the program was his willingness to keep score and confront his doctors with their results. He had to fire three radiologists who missed too many cancers, and he had to reassign 8 doctors who were not reading enough films to stay sharp. (http://ow.ly/2sCGD)

The Kaiser experience mirrors the literature on how to be a best performing organization in a chaotic, rapidly changing environment: one has to focus on sources of error and failure and learn from them to improve the results. The Kaiser leaders worried about negative publicity, malpractice claims, women neglecting the test due to skepticism, but in the end they did what was right for their patients. They tracked down the women who were at risk for having cancer even though the less skilled radiologist had read their films as normal. (http://ow.ly/2sCGD)

I agree with Dr. Ofri that “we need good evidence that the data measure true quality and that providing data is actually helpful.” However we will never get to that point by not “checking the results anymore.” (http://danielleofri.com/?p=1169) We have to emulate Dr. Adcock and wade into the messy reality of why Americans receive only 55% of indicated care. We can learn how to do better if we embrace feedback and learn from it; we cannot improve by ignoring reality. Trust me I am a doctor just doesn’t cut it. We all deserve better than that.

Randomness and Katie Ladany

This morning after tweeting the newspapers and checking my email, I went to the Wissahickon to take a long walk along the river. Since I do not have to leave for the airport until 2:00 PM, I just walked right on by Valley Green where I usually turn around to head back to the car. It looks they are setting up for a wedding by the river. Or maybe, the wedding was yesterday. This time I kept on walking.

After a while, I came upon a brand new park bench covered with wilted flowers and pictures of a young woman. The plaque stated "Katie Ladany, August 5, 2009." I stopped and tried to understand who she was. How did she die? Was she dead? A handwritten poem made it pretty clear to me that this person was no longer with us.

Who was she?

I kept repeating her name for the hour or so it took me to get back to my car. I wanted to make sure I remembered it so I could google her and figure out the mystery. On the way home from the park, I went to the post office to buy Abstract Expressionist stamps for the 170 letters I needed to mail to prospective medical keynote customers. During the entire time I was putting the stamps on the envelopes, I was wondering about the Katie mystery.

Finally I got home and googled her. She was a 23 year old jogger who was killed by a 30 foot tulip tree branch that fell more than 50 feet. She was a high school teacher, and her iPod was still playing when they found her body.

This is a random world we inhabit. I love the Wissahickon, and I love walking there. Why do I find peace and satisfaction there and Katie found death? This is a random world we inhabit. That is for sure.

KBT2FOE: The Blog & YouTube Project

I may be retired now, so it seems like a good idea to figure things out. A few weeks ago, I got fired from my position as president of a healthcare 501 3c; at the age of 58 it may not be so easy to obtain another physician executive position. And to be honest I am not sure I really want to get another job.

And so I embark on a blog and YouTube adventure I am calling “KBT2FOE” pronounced KB Tsquared foe. The title stands for “Kent Bottles tries to figure out everything.” I am sure the topics will include health care, wellness, wisdom, books, work, behavioral economics, neuroscience, happiness, accountable care organizations, medical student education, and why pay for performance will never work.

But this first installment will try to give an overview of the project; Since both my parents died at age 83, I assume I have about 20 or 30 years left on this earth. What should I do with them?

Aristotle begins Metaphysics with the statement that “all human beings by nature desire to know.” And this is certainly true of me. I am curious, and I want to understand everything. And yet I have read enough to know that all humans suffer from an everyday illusion that Christopher Chabris and Daniel Simons label the “illusion of knowledge” (The Invisible Gorilla, 2010). Advertisers prey on this illusion to make us think we understand how expensive cables with superior shielding, gold-plated connectors, and greater dynamic range will improve the sound of one’s high-end stereo. And yet audiophiles in a blind test could not distinguish such an expensive set of cables from wire coat hangers used as speaker cables.

I first tumbled to this problem of trying to understand myself and my place in the world when I learned about split-brain experiments from Michael S. Gazzaniga. Only ten patients who underwent cutting the corpus callosum (the nerves that connect the left brain to the right brain) for treatment of severe seizures have been well studied. Such a patient was shown a chicken claw to his left hemisphere and a snow storm to his right hemisphere. He was then asked to pick out one image from a group of pictures; he chose a shovel with one hand and a chicken with the other hand.

When asked why he chose the shovel, the left brain, which did not know anything about the snow storm and why one hand picked a shovel, responded: “Oh, that’s simple. The chicken claw goes with the chicken, and you need a shovel to clean out the chicken shed.” We do not say we don’t know because you cut my corpus callosum; we make up a reason to make sense of a world we do not really understand. Gazzaniga calls this function the left brain interpreter and we all have one. This interpreter must find an explanation. “Lack of knowledge is of no importance, the left brain will find a solution! Order must be made. The first makes-sense explanation will do.” (Human: The Science Behind What Makes Us Unique, 2008)

Now as far as I know my corpus callosum is intact, but the above does give me pause about how successful my project to figure out everything will be. Am I about to embark on a task that will in reality be just as frustrating and meaningless as much of my work life? And yet I have to do something, don’t I? Is being Sisyphus satisfied all we can hope for in this life?

I am not a particularly wise person, but I can read about wisdom and that seems like a lofty, but unattainable goal for someone who is retired. Confucius was a wise man, and China is taking over the world so maybe I should see what he did at my age:

At fifteen, I set my heart upon learning.
At thirty, I had planted my feet firm upon the ground.
At forty, I no longer suffered from perplexities.
At fifty, I knew what were the biddings of Heaven.
At sixty, I hear them with a docile ear.
At seventy, I could follow the dictates of my own heart; for what I desired no longer overstepped the boundaries of right.
(Roger Walsh, Essential Spirituality, 1999)

So, I have two years in which to develop a docile ear to hear the biddings of Heaven. Heaven, not so sure about that one.

Erik H. Erikson must have been influenced by Confucius when he identified wisdom as a likely, but not inevitable byproduct of growing old. His final stage of psychosocial development was labeled “ego integrity versus despair,” and if you have a lot of the former you can face death wisely.

Ken Wilber likes the Spiral Dynamics theory of Don Beck and Christopher Cowan with its eight major waves of consciousness. The first six levels deal with subsistence and are marked by “first- tier thinking.” Who wants that? Give me “second-tier thinking” where “a chasm of unbelievable depth of meaning is crossed.” If you are one of the less than 2% of the world’s population that gets it, you can think both vertically and horizontally by using hierarchies (ranking) and heterarchies (linking). I think if you are at level seven (yellow, integrative) or level eight (turquoise, holistic) you really get it. (Ken Wilber, A Theory of Everything)

I kept getting the colors and levels mixed up, and I worry that I am stuck in “first-tier thinking.” And I really do not like the color turquoise, never have. So I was relieved to find that Robert Kegan and Lisa Laskow Lahey use only three levels of adult mental complexity: the socialized mind, the self-authoring mind, and the self-transforming mind. No way am I stuck at the socialized mind because I am not a faithful follower who seeks direction. It looks like I am somewhere between a self-authoring mind (agenda driven guy with own compass and frame; solves problems and is independent) and a self-transforming mind (problem finding guy who likes contradictions and paradoxes). (Immunity To Change, 2009)

So maybe I should spend the next 20 years trying to progress along one or all of these theories of psychosocial development. Since I don’t have a job, I might as well work on something. And near as I can tell from all the jargon, to get higher up on the scales you got to get as far away from yourself as you possibly can.

When I read David Foster Wallace’s commencement speech to the 2005 graduating class at Kenyon College, I realized this guy understands the left brain interpreter and the split brain conclusions.


A huge percentage of the stuff I tend to be automatically certain of is, it turns out, totally wrong and deluded. Here’s one example of the utter wrongness of something I tend to be automatically sure of. Everything in my own immediate experience supports my deep belief that I am the absolute center of the universe, the realest, most vivid and important person in existence.

This guy thinks just like me, but I hear he was a lot smarter than me. I wish I had met him before he killed himself. But the following advice makes sense if you want to develop yourself further.

It’s a matter of my choosing to do the work of somehow altering or getting free of my natural, hard-wired default setting, which is to be deeply and literally self-centered, and to see and interpret everything through this lens of self

The really important kind of freedom involves attention, and awareness, and discipline, and effort, and being able truly to care about other people and to sacrifice for them, over and over, in myriad petty little unsexy ways, every day.

Sounds like a plan, but how do you do it? And why did he commit suicide? I think I need to be careful here. And the next advisor may have died by starving herself to death. The coroner's report said that "the deceased did kill and slay herself by refusing to eat whilst the balance of her mind was disturbed." I love to eat. Bummer.

Simone Weil died at age 34, some say because she refused to eat more than those suffering under the German occupation of France in World War II. Weil believed that beauty requires us “to give up our imaginary position as the center….A transformation then takes place at the very roots of our sensibility, in our immediate reception of sense impressions and psychological impressions.” Elaine Scarry who turned me on to Weil writes, “It is not that we cease to stand at the center of the world, for we never stood there. It is that we cease to stand even at the center of our own world. We willingly cede our ground to the thing that stands before us.” Scarry goes on to say that this radical decentering makes us no longer the hero of our own story; we become what folklorists call the lateral figure or donor figure. (On Beauty and Being Just, 1999)

Matthew B. Crawford in Shop Class As Soulcraft: An Inquiry into the Value of Work (2009) makes the same point as Weil and Scarry by quoting Iris Murdoch who believes to see the world clearly you need to undergo “unselfing.”

Anything which alters consciousness in the direction of unselfishness, objectivity and realism is to be connected with virtue. Virtue is the attempt to pierce the veil of selfish consciousness and join the world as it really is.”

So I got time on my hands, and I have to “unself” myself. I am not really sure how to go about that. But that will be content of the KBT2FOE blogs and YouTube videos. I have to figure out how to work the flip camera and to get as far away from myself as possible and perceive the world as it really is. I did sign up to volunteer in the food warehouse for Philabundance. Maybe that’s a step in the right direction.