Measuring Success and Quality of Medical Care

Last week we opened the can of worms that is how to achieve satisfaction and success in medical practice. We all realize that many surveys show widespread dissatisfaction and we all know how elusive some valid measure of "quality" is, so we are left with only our wits to find a way to feel good about what we do and the results that it brings. When we left off, we were talking about factors that may obstruct "success" and "quality" medical care.

Poor patient service, not staying on time, not being the ace communicator we'd like or think we are, etc., are real blocks to best patient outcomes, not just practice success. However, we don't like to talk about our soft knowledge or performance in this more commercial service area.

And asking patients how we are doing, as useful as it can be, has its limits too. Yes, we should all be asking with some method what our patients think. But my own experience showed uncritical approval from the majority, while I suspect those (hopefully) few who were unhappy just walked without providing feedback. And that was using both written and phone surveys.

Many patients do not know how to use or properly evaluate a doctor's services, and I am always surprised in this increasingly consumer oriented age how uncommon it is to see a patient who has either done his or her homework in this regard or even just asks, "How can I do a better job with my time with you?" When I bring up the subject of best patient practices and the importance of feedback to their physician so people will feel better about their encounter, many seem interested, but also a bit embarrassed and taken aback.

So, let's summarize. Thus far we have looked at the obstacles to measuring success. Results are hard to measure, they are time consuming and, therefore, they are expensive. And the targets are moving as well. Doctors are not prepared in training to address these issues either. No feedback loop means a lack of understanding and therefore control, which leads to stress above and beyond the work load, financial pressure, and on and on.

So this leads many doctors to find additional ways to cope to find meaning, satisfaction or sometimes just relief. The gamut includes focusing on making money, reducing the scope of their practice and finding other outlets outside and inside medicine. Some of these are constructive and useful, and many doctors find their niche where they can meet perceived goals and are comfortable.

Unfortunately, about 10% of doctors will not find a comfort zone, and under mounting and unrelieved stress, will develop some form of personal dysfunction. There is a developing interest in this area and specialists have stepped forward to help stressed out doctors — in print, in person and via referral services at large groups, hospitals and medical organizations, such as state medical boards.

One does wonder about other doctors whose behavior has not deteriorated to the point of outside recognition, but whose negative experience is having some kind of harmful impact upon themselves, their families and their patients' outcomes.

We all have at least one doctor in our area who everyone knows is struggling, or we might rationalize is "idiosyncratic." You know, "That's just John/Mary...." But the majority can always do better too, even those of us who rationalize that we are doing "just fine" if not "great!"

The important point is that the underlying problems of the difficulty in identifying and maximizing physician success and satisfaction are universal. The casual observer of such a well-regarded, highly trained and affluent group of professionals might be surprised to see the results of survey after survey showing the deep unease that is currently rampant among doctors. Rapid change, inherent complexity and lack of control will do that to you.

And let us not underestimate the prevalent and destabilizing effect of rapid change alone among humans. We like and need stability. We like and need appreciation, for consistency and continuity. Yet in medicine, where so many of society's unresolved questions and conflicts come to a head, we mostly rely upon internal resources for the wherewithal to stay the course.

In my training, a professor once told a group of us to learn to rely on internal satisfaction markers because we would be surprised how little visible credit we would be getting during our careers. I like to think that medicine has done such a good job that people take our caring and our ministrations largely for granted. But study after study has shown how powerful the effect is of a "thank you, well done" — to say nothing of the occasional tray of home-baked cookies for the staff. But you all know by now not to hold your breath.

John Stuart Mill framed what has become known as the "happiness paradox:" "Those only are happy ... who have their minds fixed upon some object other than their own happiness." Or as Nathaniel Hawthorne put it: "Happiness is like a butterfly, which when pursued, is always just beyond your grasp, but which, if you sit down quietly, may alight upon you."

The bottom line is that we will feel more comfort if we come to better understand some of the forces that weigh upon us in our practice of medicine. And we have no real option but to continue to muddle through on the "practice quality" piece until consensus develops on better metrics for evaluation.

In the meantime, we are forced to individually rely upon on our internalized ethics, our Hippocratic sense of what "ought to be." And to realize sometimes just how precarious a perch that can be to stand upon.