Saturday, October 20, 2007

The emphasis on core quality measures is dumbing down the practice of medicine

That’s because “quality” measures as they are now promulgated reflect a simplistic view of clinical science, distract from things in medicine that really matter and encourage health care providers to “play for the test”.

Bob Wachter over at Wachter’s World sees some interesting parallels with the unintended consequences of outcome based education and the No Child Left Behind law. In primary and secondary education, emphasis on the core skills of math and reading has relegated the humanities and other important subjects to the status of “soft” content. (Wachter presents data from the San Diego schools!).

Whether in primary and secondary education or in medicine, one hazard of adopting core measures is that the achievement of minimum standards trumps the pursuit of excellence. One of the many consequences in medicine may be the demise of the master clinicians, the Proctor Harveys of the world. Wachter agrees and shares an anecdote about one of UCSF’s master diagnosticians, Gurpreet “Goop” Dhaliwal, concluding:

I’m afraid that Goop’s diagnostic acumen might well be healthcare’s music class: extraordinarily impressive, really quite beautiful in a way, but way off the measurement radar screen. If our students get the message that Goop's kind of clinical intelligence and diagnostic ability are unimportant (after all, they don’t seem to be part of what we’re calling “quality”), I think you can guess what will happen over time. Clinical "artists and musicians" will become extinct.


Chuck McKay said...

Nearly every inspiration involves seeing data from a new perspective.

The "soft" classes oftentimes provide just that perspective. Somehow, a doctor who appreciates classic literature or understands economics seems better educated, and more trustworthy.

And who knows? When it comes to diagnostic ability, perhaps he is.

Zagreus Ammon said...

I respectfully disagree.

Hvae you ever seen a World Series champion without the command of fundamentals?

We may stop at core measures, in which case you win and nothing was accomplished.

Or we may continue defining good medicine in terms of basic measurable processes, gradually ramping up with better and better measures demonstrating the value of what we can deliver.

R. W. Donnell said...

Zagreus Ammon,
From where I sit the core measures encourage gamesmanship, not command of fundamentals. Perfunctory displays of patient education and chart buffing are all too often the result of mandated core measures. Such games don't put evidence into practice in an effective way and don't benefit patients. It's no wonder the OPTIMIZE database, for example failed to show benefits from heart failure measures.

Some measures (e.g. pneumovax) aren't even supported by evidence. Worse, others (the 4 hour antibiotic rule) have repeatedly been shown to lead to departures from best practice.


The real fundamentals, in my opinion, may be slighted as a result of mandated core measures (basic diagnostic skills, for example).

No doubt we will ramp up. It will be interesting to see what that brings. If it merely brings more intrusive mandates without finding *smart* ways to put evidence into practice, considerable harm could result.