Friday, August 20, 2010

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.” (

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.” (

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. (

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. ( Humans are masters at self-deception, and Michael S. Gazzaniga even hints that this quality separates humans from other animals. (

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.’” ( 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. (

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. (

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.” ( 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.


  1. Actually she says that there may be many systemic factors that impact on care so that reports at the level of the organisation may be more appropriate. In the UK, where most primary care doctors work in shared practice, our results describe the performance of the practice rather than individual doctor. That makes more sense to me.

  2. I'm with Dr. Bottles on this topic one hundred percent. We do deserve better than what Dr. Orfi is offering, and no, I won't trust you just because you're a doctor.

    First, I know that there are incompetent doctors. Every class has someone who graduates dead last. I know that some doctors' reasons for going into medicine are not purely altruistic. I know that some doctors start out with the best intentions and end up disillusioned and angry and, ultimately, destructive. I know that some doctors have a god complex. I know that some doctors are downright criminal (the eighty-year-old man writing bogus scrips for that slimy mail-order pharmacy in Salt Lake City is a doctor and still licensed to practice medicine).

    Second, I believe--I cannot know, but I believe strongly--that many doctors get too wrapped up in the idea that their practice is a business. I do not want my wife's physician, my own surgeon, my daughters' doctors to be thinking about the bottom line when they should be concentrating on my wife's illness, cutting into my flesh, ensuring my daughters' continued health. We don't need distracted doctors. Ever.

    Third, even if Dr. Orfi's claim is true that most doctors, as Kent paraphrases, "are smart and good people who are trying hard to help others," that's just not enough to ensure that they will do their best. In Atul Gawande's 2007, collection Better, he includes an article titled "The Bell Curve," which discusses smart and good people attempting to treat cystic fibrosis and--if not failing--not doing a very good job. In the article, Gawande discusses the effort of the CF team at the highly respected Cincinnati Children's Hospital to improve the life expectancy of their charges by learning from the very best CF team, the Minnesota Cystic Fibrosis Center, at Fairview-University Children's Hospital, in Minneapolis. I'm not going to repeat the entire article here, but suffice it to say Gawande demonstrates that sometimes intelligence and drive aren't enough. Some illnesses require focus, aggressiveness, and the willingness to be absolutely uncompromising and goal-oriented.

    I think smart doctors know that patients are not all alike. Some patients require compassion. Some need a cheer leader. Some require aggression. Some cases try everyone's patience by showing--as in the case of CF--that just being smart and nice and well-intentioned isn't enough. In those cases the doctors who really want to help people should be wondering, can quality metrics find the missing something? Maybe. Maybe not. In any case, they can certainly tell you that Something Is Missing. This is why I have to doubt Dr. Orfi's claim of good intentions for herself and any other doctor who is not knocking herself out trying to correct her slumping quality grades.

    No, Dr. Orfi, I don't believe that you really care about anyone but yourself.

  3. Thoughtful analysis of teacher report cards could apply to physician report cards as well

  4. My fuller response:

  5. Excellent points. "They tracked down the women who were at risk for having cancer even though the less skilled radiologist had read their films as normal."

    I've read a bit about this and remember a similar study where radiologists were asked to look at the mammogram from the year before the one at which breast cancer was detected. In a high number of cases (maybe 40% or more, don't remember for sure) the radiologists detected cancer which had been missed in those earlier mamograms. (Of course the radiologists were not told anything about the study.)

    Some medical work seems as much an art as a science, and checking and second opinions are essential.

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