Blog | Friday, October 19, 2012

Physician rankings could be perverse

Yesterday's New York Times had a wonderful op-ed, "Want to Ruin Teaching? Give Ratings>"

"This type of system shows a profound lack of understanding of leadership. Principals need to create a culture of trust, teamwork and candid feedback that is essential to running an excellent school. Leadership is about hiring great people and empowering them, and requires a delicate balance of evaluation and encouragement. At Harlem Village Academies we give teachers an enormous amount of freedom and respect. As one of our seventh-grade reading teachers told me: "It's exhilarating to be trusted. It makes me feel like I can be the kind of teacher I had always dreamed about becoming: funny, interesting, effective and energetic."

Some of the new government proposals for evaluating teachers, with their checklists, rankings and ratings, have been described as businesslike, but that is just not true. Successful companies do not publicly rate thousands of employees from a central office database; they don't use systems to take the place of human judgment. They trust their managers to nurture and build great teams, then hold the managers accountable for results."

While this piece is about teachers, it applies wonderfully to the idea of physician ratings.

"A government-run teacher evaluation bureaucracy will make it impossible to attract great teachers and will diminish the motivation of the ones we have. It will make teaching so scripted and controlled that we won't be able to attract smart, passionate people. Everyone says we should treat teachers as professionals, but then they promote top-down policies that are insulting to serious educators.

If we don't change course in the coming years, these bureaucratic systems that treat teachers like low-level workers will become self-fulfilling. As the great educational thinker Theodore R. Sizer put it, "Eventually, hierarchical bureaucracy will be totally self-validating: virtually all teachers will be semi-competent."

We live in a culture that loves attaching numbers to abstract concepts. We have laughable medical school rankings, business school rankings, etc. Now we are talking about physician report cards, implying that we can measure our complex profession with simple scales.

This concept is bankrupt. It ignores a fundamental understanding of physician quality. Our jobs are multidimensional. Some patients require diagnosis; some require disease management; some need pep talks; some need referrals. This list is incomplete. How can we measure all those attributes, and the many more that make us professionals.

Performance measurement can help me reflect on my own practice, but only if we measure things that I have control over and care about. We should not use performance measurement as a proxy for quality, as a method of adjusting pay, or as an excuse to provide inaccurate public reporting. We have an obligation to speak out against the madness.

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 Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.