Quality is not success

I teach business… one of the things talked about in management classes (and no doubt in some psych classes) is the problem of how do you accurately define and measure what is important - be it quality, performance, expertise.... You are often measuring proxies for what it is you are actually interested in because you can't measure, for example, motivation. You can only measure the outcome behaviors that we presume are caused by being motivated and presume if we don't see those behaviors then the person isn't motivated. Not always completely correct assumptions because so many things, some outside of the control of the person, affects motivation and we might be presuming some thing are under the control of motivation when they are not (for example the person might need more training to do the job right - they are motivated, just not sufficiently trained, or the system's reward system is working at cross purposes to the behaviors you want - there is an article called the folly of rewarding A while expecting B). "Poor" performance is a combination of job related factors, often controlled or affected by the environment (the company, your boss, rules, the patient/customer…) and internal to the employee (e.g. doctor in this case) factors - knowledge, skills, abilities, and other things, which can be influenced by training, incentives, etc. Another underlying problem is deciding what is important to measure. Yet we don't always know everything that goes into "doing a good job" to begin with, or how the different factors we do know interact with each other. How do we define a good job? Then of course how do you measure that? Are our measuring instruments reliable and valid?… What is the end user has a different criteria for quality than the provider? Do we include both sets of criteria even if some seem like they shouldn't be included (for example students often rate extrovert faculty who are entertaining as better teachers than those who are not, even when test performance on what they learned is the same between the two different kinds teachers - so what matters - that they learned what they needed to learned or that they liked one teacher better - does it matter?)... and the list of issues go on and on. Then we have the issue of measuring outcomes vs what goes on in the attempt to get that outcome (means vs ends issues). If someone does everything "right" and the outcome is still bad who do we blame for the bad outcome? If we were evaluating the person by "means" measures they would rate highly. If we were to measure them by "outcome" measures they would do poorly. If we were to measure them by something that included both they'd have a mixed review. Yet in all cases they'd be doing the same things. Then there is the flip side of that. They do all sorts of things wrong but the outcome is still good… how do we evaluate? Complicating that is that behavior isn't always tightly coupled to outcomes and the person you are measuring doesn't always have complete control over the outcome. Then what do you do? What do you measure. We see this in arguments about education, measuring teacher effectiveness, arguments over whether you should be blamed if the horse you brought to the watering hole does not drink despite your best efforts… whose fault is that? And of course in the different medical careers what is considered important, as you mentioned, varies. To some degree it is up to the employee to conform to what is being measured as important or get another job. On the other hand if the measuring instrument is not measuring what should be measured, does not accurately measure what they say is measured (validity issues) and is affected by, for example rater bias (reliability issue) then you have a whole other set of problems. What we often end up doing instead is measure what we can measure, even if it is not really what we want to measure or should measure. This business of defining and measuring quality isn't an easy or simple thing...

This is one of the most thought provoking and open ended question articles that you've written. Quality can mean so many different things to different patients. I think that kindness to patients and creating a team with your values is important. My local MD Anderson radiation clinic is one such place. It even has a little kitchen area for the staff to fix simple and economical snacks for the low-income patients that can't keep their weight up-other patients too, but mostly the weakest. I said that I wish that I could eat some chocolate-stupid ACS guidelines-. The nurse laughed, and told me about the kitchen, and how the most burnt out patient will try to drink a chocolate milkshake, especially if she has a friendly staff member talking about the latest news, etc. I had high powered radiation in a difficult place on my face. The cancer seems to be dead, according to scans with contrast. My taste buds still work, and I can slobber. My smelling abilities are more sensitive than before. I also have all of my teeth. But most of that is genetic, but his expertise helped for this to happen. Another way to count success is the longevity of cancer patients, and this is especially important for research oncologists and teaching-research hospitals. It's a factor in receiving funding from the feds, foundations, and fund-raising organizations. With all of the talk on this site and the many commentators, I'm surprised that nobody has mentioned the the 3 year, 5 year, and 7 year survival rates for success that helps to rate clinics, research facilities, and skills of a doctor. This is important! Who wants to go to a doctor that has a 100% death rate within 2 years? Who wants to go to a clinic with a 90% mortality rate before 3 years? We would howl in rage about about our tax money going to a research clinic with these statistics.Congress, as messed up as it is, would demand the plug would be pulled on a doctor or a facility with these stats. Because of these standards, I think that my clinic tried to pass me off to other clinics, so it wouldn't be saddled with my cancer: one was out of state, but I think that they refused me, I'm sure that part of that was the possible million dollar price tag (Being in a care facility for about 12 months, with extensive facial bone removal, and the therapy to keep my throat open would cost thousands (my daughter used to do and supervise this physically brutal therapy at the VA). I'm sure that nobody wanted to help us financially to relocate to a clinic 2,000 miles away. I am 71, after all. Then the oncologist wanted to send me off to the state's teaching/research hospital. I said the same thing, who do I talk to, how long would it take for me to get in. Nobody got back to me at all. I figured that it was the prognosis and the expenses. My hat is off to Sloan-Kettering that will take rare cancers and do research on them. I had a friend that became very excited about being on a research team for ovarian cancer. I told him that I hoped that he didn't burn out from the 3,5 and 7 year survival standards, because the cancer industry doesn't care about quality of life. It doesn't care if a patient dies 3 agonizing hours after the third year is pronounced and registered. The industry doesn't care if a patient is covered with bruises, wasted, tube fed, etc for months, while the 3 year or 5 year goal is being reached. After almost a year, he came over and told me that the women went through agony-resident after resident giving them vaginal and rectal exams, everyone palpitating the stomach. The women tried not to cry from the pain, even though they were drugged before the exams. He said that nobody cared if a woman died the day after the 3 year survival level, or how much agony the woman was in, as long as they survived for 3 years or 5 years. They didn't care if she was being kept alive artificially as long as she could pass the next arbitrary success rate of 3 years of survival, 5 years of survival, or 7 years of survival. No account is in the research for quality of life, He complained about false promises of hope that were given to these women. Did I say that the day before I met my current oncologist that the newspaper headlines were that there was a new lawsuit against this hospital? They apparently gave the wrong chemo therapy to young children for several years. This causes me to ask what type of oversight or common sense does this cancer clinic have? Usually a nurse blows the whistle after administrating the chemo for 3 to 5 years. I guess it takes that long to realize that the oncologists are nitwits. The clinic always manages to put the blame on the chemo staff-not any oncologist. For the ovary research. they collected cancer cells, cultivated the cancer cells to see exactly the types and properties of the cells. Then to see how these cancers worked, they'd inject the cancer into the wall of a lab rats anal cavity.That gave the fastest results for cancer growth. That's the only part of the cancer care and research. Chemo medications were developed this way, and tested on the poor rats. I also recognise that ovarian cancer can be quite advanced before it is found. Quality shouldn't be about how long a class of cancer patients survive, but how much pain they are in-If they pass 6 weeks later, in the hospital-home or hospice the studies should reduce the success rate. Researchers should not be paid and rewarded for this type of cruelty. When I met my oncology radiologist, he started with the survival percentage rate, and I told him that I did not want to hear about that, because it can be rigged so many different ways for each ACS survival standard. I refused to be kept alive a month, week, or a day just so somebody could say-Success-this treatment kept her alive for 3 years, 5 years, or 7 years. I know that remission is supposed to play a large part in this. I know that oncologists truly hope that the patient will go into a true remission-that a new secondary cancer doesn't appear, but the focus is to extend life, and hopefully that drug cocktail can be tweaked to extend life even further, or patients in the the early stages go into remission. I think this was a factor when I filled out my advanced directives, as I didn't give the doctors any wiggle room to extend my life by a month, a week, or an hour, so they could inflate their success rate. I told them that when my god calls me, I want to be free to go. My current oncologist said that he'd support me. All of my oncologists and doctors asked me how I knew about this. I told them that there was a time when the cancer industry had more transparency with the public, and there was a public dialogue. I'm so thankful that my oncology radiologist was honest and gave me a chance that also included quality of life.