Performance measurement has doctors adrift on Lake Wobegon

In the last JAMA issue of 2009 Donald Berwick mused about quality performance measurement. Doctors' skills vary. Measurement uncovers variation. Variation is considered the enemy of quality. Quality Performance “improvement” initiatives seek to eliminate variation. All doctors would become average. That would never do for most doctors, who need to be above average. What are they to do? Game the system, criticize the methods and indulge in self deception. And so, we remain adrift.