I spent 9 days in India, giving 13 talks in 6 days in 3 cities, Chandigarh, Hyderabad and Cochin. India is a country of contrasts and extremes. When it is modern, the modernity equals anywhere in the world. When it is not, the poverty is striking.
I spent much time with physicians, especially internists. Internists are the same wherever I travel. We have the same concerns about patients and interference from the government or insurers.
Internists find the diagnostic process interesting and most important. Indian physicians as well as American physicians understand this. Patients understand that diagnosis is the sine qua non of internal medicine.
We all cannot understand trying to assess value when we cannot easily assess diagnostic accuracy. We cannot understand giving a physician a good “report card” for treating the wrong diagnosis perfectly.
We all understand that medicine evolves and thus we must work to stay current. We all understand that discussing patient presentations leads to the best education.
Patients remain our best teachers. We must all learn to listen to our patients and think carefully about the lessons their presentation teach us. We can use patient stories to emphasize the importance of the natural history of disease or the appropriate pathophysiology or the side effects of treatment.
During my India trip, one physician told me this story. I will try to get the gist of the story correct. He told the story in response to my lecture on the dangers of guidelines and performance measures.
He was practicing in England at the time this incident occurred. England had just started their pay for performance project. An older woman was going to see her physician. She was having symptoms of uterine prolapse. Her daughter accompanied her, but she did not let the daughter come into the examination room because of embarrassment.
The physician comes into the room and starts reviewing each of her known medical problems with a focus on those issues that would impact his performance measures. He never asks for her agenda, and abruptly finishes the meeting.
The woman goes back to the waiting room, and has to tell the daughter that she never had a chance to seek help for her concern.
Performance measures can change the physician patient interaction. We are told that medical care should become more patient centered, while focusing on performance measures changes the physicians priorities. We do not have a good measure this concept.
Since quality has many dimensions, we must worry that focusing on some dimensions will decrease our attention to other important dimensions. This story describes a bad medical visit. But the physician likely scored perfectly on his measures.
Talking with Indian physicians has helped me understand the philosophical underpinnings of excellent internal medicine. Their insights in response to my talks opened my mind to important underlying concepts.
And I really did enjoy the sights and the food.
db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.