The New Yorker reprints Atul Gawande’s commencement address to the Harvard Medical School:
Ok, so times change. No longer can a physician and a couple of administrators do it all. So what’s the problem?
Furthermore, today’s cowboys work like pit crews as well!
Of course every specific is unique. The doc on salary often has pressure from his bosses to produce more and is scheduled at a pace that he has no control over. He has no financial incentive to provide patient satisfaction as he has no skin in the game. And there is no reason to believe that he is any more motivated by professional pride than is the doc paid on production.
How much pay to peg to compliance with guidelines, to outcome measures (including patient satisfaction scores), to productivity, whether to have productivity pay be individual or team based with each member of the team sharing according to their FT equivalent, are tricky things. For medical outcomes to be used as a basis you need to have a group working together and a covered population large enough to off set random variations and some means to compensate for any possible selection bias to a sicker population. The medical outcomes incentive can’t be too granular and have it work; compliance with system improvements that lead to better outcomes for group overall OTOH can be individual based.
The Mayo Clinic has doctors on salary and they claim to be unaffected by volume. They set a salary that is equal to doctors around the state.
According to the UK Royal College of General Practitioners an excellent GP
“Appropriately uses advanced consultation skills such as confrontation or catharsis to achieve better patient outcomes.”
So, a difficult consultation with a rude GP who makes the patient cry may actually be an excellent Dr using advanced consultation techniques.
Sometimes what is best for the patient isn’t what the patient wants. A good doctor will not be universally liked- if every patient walks away happy something isn’t right.
Yeah, I tell my staff that they’re not practicing good medicine if they’re not pissing some people off.
It’s a hard lesson to learn, frankly.
It’s a really hard lesson to teach the residents, especially since I don’t want to turn them into complete assholes.
The salaries are set, but I’m sure when it comes to advancement and such productivity numbers come up. It’s also no small incentive that if productivity drops, the docs are going to have to sit through a bunch of bullshit meetings about how productivity can be improved. 
A huge hijack to be sure, but I would beg to differ about the clinical efficacy of pissing people off. Most of the time when doctors piss people off they are not doing their job well.
“Confrontation” rarely achieves “better patient outcomes” and I have had to be part of many a decision to send docs to anger management programs who have fooled themselves into thinking that they were actually doing their jobs well.
Challenging a patients misconceptions and doing something different for them than they had been expecting you to do is not “confrontation”; the goal is to do that in a way that a patient is led to the correct conclusion.
I have, in other threads, shared (I hate that word, it reminds too much of hospital administrators who always want to “share” things with me, but in this case it fits) that my Dad was a salesman and that I have very much internalized that medicine is also sales. I am not here talking about selling myself (which of course I do, which of course is why it is important that patients do not perceive themselves as having been “rushed”, why would they give my name to friends and family if they felt rushed?) but much more in the sense that I am selling behaviors, those things needed to do and to not do that will result in those better patient outcomes. Confrontation, specifically confrontation that pisses people off, rarely sells any product including, and perhaps even particularly, behavior changes.
I doubt you are doing your residents any favors if you are encouraging them to make people angry
at them and to feel good about that.
Reminds me of a joke, can’t remember which comedian said it: “If doctors can be ranked according to their skills then someone, somewhere has to be the worst doctor in the country.
Someone has an appointment with him tomorrow.”
I try to teach that despite the best communication and teaching efforts, some people will not be happy with what you tell them, and will show it. A good doctor needs to be able to handle these situations. If every patient goes away happy, the doctor has either too much invested in pleasing everyone, or a perfect practice without drug seekers or personality-disordered patients.
There’s certainly such a thing as a good surgeon, and surgical outcomes are easier to measure objectively. Simply because there are clearly ranges of competence in any field, there are obviously good doctors (and hence bad ones).
Ah, that’s something different then.
RNATB, yes, the problem is that defining and measuring that is fairly difficult to do.
Well, thats part of what I’m asking. Is there such a thing as a good surgeon, and if so, how much better are they then an average surgeon?
It makes a certain amount of intuitive sense, but I don’t think its obviously true. Are there surgeons whose patients do better then average, given the same patient population, then can be explained simply by statistical noise?
ETA: I think Dseids links show there are doctors that treat their patients diseases better, (though perhaps more due to institutional reasons then “skill” per-se). But with surgeons, given the same proceedure, is there also a difference?
This reminded me of the inquest done on the pediatric heart program in Winnipeg (and a similar one from Bristol).
Essentially, mortality rates were 3 or 4 times the norm, due to inexperienced surgeon(s) resulting from the low volume of cases since defects requiring pediatric heart surgery were rare and the community served by the hospital wasn’t large. Additionally there was a culture of hospital staff not voicing concerns and poor communication practices in general by all involved. So it wasn’t simply a case of whether the doctor was good or bad, the system was set up to fail.
I don’t think the difference is noticeable most of the time. The odds that any surgeon will cut off the wrong body part or whatever are infinitesimal. The odds that a surgeon will perform a procedure badly are also relatively low. However, the odds that a surgeon will screw up a procedure go way up if he’s done it before. Something like 2% of physicians in general account for 90% of all malpractice litigation.
Partly, that’s a field-specific issue; for example, obstetricians get sued more than anyone else because people are more upset about losing babies than they are about losing kidneys or tendons.
IMHO (IANAD, but one parent is an orthopaedic surgeon and the other is a surgical anaesthetist, or what I think is called a perioperative anesthesiologist in the US), there are two basic areas of surgical skill. One is determining whether a patient needs surgery, and what type; that’s essentially analogous to the practice of medicine in general - “what does the patient need and why?”
The other is actually performing operations. That’s more like a craft, and requires some innate abilities that medicine otherwise generally doesn’t: manual dexterity, visual acuity*, hand-eye coordination and even quick reflexes. In orthopaedics, it can even require an unusual degree of physical strength**.
*My dad is somewhat colorblind, and he’s often said that this is one of his biggest problems as a surgeon. He sometimes can’t distinguish between differing shades of red, which as you can imagine poses some difficulties. Apparently this is less of an issue when you’re looking at stuff on a monitor, but it wasn’t that long ago that all procedures were open.
**Women make up roughly 20% of practicing surgeons in the US generally, but less than 3% of orthopaedic surgeons.
Another thing to keep in mind is that some surgeries are more “surgeon skill-dependent” than others. For example, in the eyecare field, LASIK and cataract surgeries have a reputation for being relatively easy and generally having good outcomes. Trabeculectomies (a type of glaucoma filtration surgery) are known to be trickier and are generally done on sicker eyes to begin with. So certain procedures might indeed require a “good doctor,” meaning a more experienced surgeon with a reputation for good outcomes, as opposed to other surgeries which are more routine.
Something to look out for when considering a procedure/surgery is a fairly consistent correlation between volume and improved outcome - in other words, physicians/centers that perform many of a certain type of procedure are likely to do a better job than places that do few of them.
Hospital X can feature highly trained and overall competent physicians, but if they do for example 1 robotic-assisted prostatectomy a month and Hospital Y does 20 of them, you’re probably better off at Hospital Y.
So that is at least a statistical association - for procedures higher volumes are associated with better outcomes. Often, but not always, also lower cost, so better value as well. Of course even that involves institutional volume and experience as much or more as surgeon volume and experience.
The question of identifying if not “the good doctor” then the somewhat more tractable “good system of doctors” is a big deal right now. Various payors are setting up various definitions of “quality” and pegging, to some degree or another, payments to meeting those “quality” measures. And groups like mine are training our membership and developing the systems to perform and document in a manner that gets credit on those measure. We must have “meaningful use” of the electronic medical record (EMR) to qualify for sizable incentives and the standard for “meaningful use” is fairly strictly defined. The reason for the quotes is that there is “quality” and “meaningful use” and there is quality and meaningful use. We know that we need to meet the measured standards of the first (and we will) but it is important not to let elements of administration lose sight that meeting the standards of the first does not mean necessarily that you have accomplished the second and that the second is important as well, more important actually, even if it does not translate into short term recompense. (Long term of course I believe that a reputation for true excellence and personalized care is the most valuable business asset a group can have.) I can tell you it is not an easy sell and I understand the frustration of teachers who are forced to spend all their time teaching to the test.
By the way, I have an observation: the more an organization has slogans, mottos, and acronyms about the importance of quality, value, and patient centered care, the less the organization actually cares about those issues.