Blog | Friday, May 23, 2014

Since knowledge evolves, what is the implication for performance measures?

Recently I had a wonderful conversation about how medicine changes. One colleague gave the example of ulcer disease. Those who trained in the 1960s and 1970s know most of this history, but it actually goes back to the early part of the 20th century.

Consider the Sippy diet, the Bilroth 2, highly selective vagotomy, the introduction of H2 blockers, the introduction of PPIs, and then the crazy idea that a bacteria causes ulcer disease.

At many points in time, one could now imagine a performance measure that would now create laughter.

In the early 80s we castigated students and residents for using beta blockers in patients with heart failure, now with systolic dysfunction we would castigate those who did not use beta blockers.

I think we are making progress in our understanding of disease and the management of disease. But what will we say 20 years from now.

We have performance measures based on rather weak evidence. Expert opinion does not substitute for strong evidence.

The naive believe that we can measure physician quality. We cannot. Quality has too many legitimate dimensions. Not all those dimensions are measurable.

In another discussion yesterday, several physicians discussed how history taking (the first, and perhaps most important step to correct diagnosis) requires a variety of skills. We must learn how to ask each patient the proper question. That question changes according to the patient’s background, education, and personality. We must become comfortable reading body language and facial expressions. We must have the patience to wait for the patient. We must convince the patient that we really are non-judgmental so that whatever they tell us is just information and does not induce a harsh reaction.

We are complex beings and we react to disease or diseases in various ways. We have different goals once we have a disease. The best physicians really do treat the patient rather than the disease.

Yet our performance measures focus primarily on the disease, not the patient. Our performance measures rarely measure our diagnostic ability. Our performance measures do not consider the patient’s disease burden and how we prioritize treatment.

Knowledge will continue evolving. We will continue our quest to improve patient care. But will performance measures based on weak evidence help?

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.