Quality is not success

I recently spent an evening with a group of medical oncology fellows as part of a small panel discussing career alternatives.  There were doctors who worked for pharma, academic medical centers, hospitals and a couple of us representing private practice.  The questions and comments taught me more than I could contribute, but I was surprised to learn not about jobs and personal futures, but about defining something basic; that is the difficulty in defining what is a quality physician.

To set the stage, let me remind readers how an oncologist is trained.  After college, the trainee must complete four years of medical school (student).  Then, three years of an Internal Medicine Residency, at the end of which they must pass the Board Exam.  At this point, they can, if they wish, hang out a shingle and practice General Internal Medicine (Attending). However, if they want to practice oncology, and most will also practice hematology, they must take at least three more years of formal training as a Fellow. After taking the onc and heme boards, they can then treat patients with cancer and blood disorders.

When you complete this competitive, rigorous, 100 hours a week for 10 years path, and you apply for work at age 32, actually getting and keeping a job is of vital importance.  Therefore, the desire to succeed lay at the base of the question asked by the fellows of the panel.  The question was, “what is the most common reason a fully trained, board certified, oncologist and hematologist, loses their job?

 

After a moment of quiet the members of the panel answered:

-The doctor who was there to talk about jobs for oncologists in the pharmaceutical industry, to develop and manufacture new cures said:  “The company decides that the drug, chemical or “molecule” on which the doctor is working will not be financially successful, at least for that company, and shuts down the project.”

-The doctor who was there to talk about jobs for an oncologist in the academic environment to teach and do scientific research said: “The doctor is not publishing enough or is not able to see enough patients in clinics to support his position.”

-The doctor who was there to talk about jobs for an oncologist working for a hospital said: “The hospital has a shift in corporate planning or the doctor does not have enough patient volume.”

-And finally, as the doctor who was there to talk about jobs for oncologists in private practice, I said: ”The doctor does not get along with his or her colleagues and/or is not willing to work hard.”

 

Look again at those honest, real world answers.  No one said the most common cause, or even a reason at all, to lose your job was that “the doctor does not practice quality medicine.”   Can we assume that each of the answers that were given is a quality surrogate?   Do we believe that if the drug company doc’s project does not have financial value, it is a problem of quality? Is publishing key to developing quality medicine so that when one’s job perishes from lack of writing it is deserved?  If a doctor is giving quality care in the hospital clinic will patients automatically flock and will the hospital always be happy?  Do docs get on well with other doctors because physicians only like high quality caregivers?  I think we can agree that such conclusions stretch things more than a little.

My point is that many of these keys to success do not automatically mean the doctor produces quality medical care.  I am sure most of us can think of an example of failed quality and maybe know a successful doctor whose mediocre care proves that survival does guarantee good outcomes.  This flaw in how we judge and select physicians emphasizes the need to press for more accurate quality measures, outside of simply holding onto one’s job.

I believe organized medicine, as a whole, understands these lessons, but has been slow to implement answers. We depend on a system of boards and tests, as well as requirements for basic continued training, to assure excellence.  True quality, the best possible results, with the least errors, given to the largest number of people, at the least cost, cannot be assumed by these passive and disconnected measures, if we are going to continue the maturation of medical care.

Quality requires continuous monitoring and feedback, implementing expert-physician-scientist developed standards, fully integrated by robust real-time top-to-bottom information systems, available in every exam room and at every bedside for every patient. It is hard, complex work and for many physicians and patients a threatening revolution.  Nonetheless, it is a vital and exciting tomorrow, which begins now and is only a short time away.

5 Comments

  • Mary
    Quality, from the patient's perspective, can be something else again. Case in point - rotator cuff injury; see two ortho's. One is in a mega practice, very famous for treating professional athletes, the other more local, more junior, and just took over from a retired famous sports doc. Just for the recorded, I am not a celebrity athlete. So which one had the efficient and friendly staff, the latest imaging equipment, and took the time to show me the damage and explain the pros and cons of various treatments? It was NOT the famous doc raking in the celebrity dough. Oh, he was nice enough in the 90 seconds I was in his presence but the rest of the 2 hour visit was surprisingly annoying. So perhaps both would meet the strict def. of "true quality" but the patient experience should factor in somewhere!
  • Liz
    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...
  • Liz
    Meant to also say in the paragraph that starts "and of course in the different medical careers…" it could be that the employer is focusing on the wrong thing, focusing on the right thing but measuring whether or not you do it wrong… and you as the employee are stuck trying to do what you believe is a quality job (and that is presuming you are right that what you are trying to do is actually quality) and being hobbled by your employer.
  • Mary
    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.
  • D Someya Reed
    Your title for this piece is interesting…”Quality is not Success” for you can provide quality and fail to achieve what you set out to do. So you can have quality and fail, though not intentionally. Some will say quality is based on how much money you make (‘You get what you pay for’). Some will say quality is shown by how many or how long patients stay with you (‘He must be good or no one would stay with him that long’). Some are even saying now that quality is based on “need” even if they don’t realize it (The fight for nurse practitioners to have the same authority as doctors…spurred on by passage of ACA…does the need for more doctors make NPs more qualified now?). As you saw in your answers about job loss, quality as we (collectively) see it depends upon who’s asking the question, their goals, their motivations and even in what context. All the tests and boards and associations and equipment and systems etc, etc, etc are just tools for getting us there and for measuring our progress against some made up scale of how we’re doing. And none of this means very much if it does nothing to help those for whom all this time, energy, cost and development is intended. Yet, we find it hard to agree on quality not only between disciplines but even within a single discipline. I don’t think it’s as difficult as we make it out to be. I think it’s simply doing the right thing for the right patient at the right time. If we all do that, in whatever fashion is appropriate for our discipline or relationship to the patient, isn’t that quality? If so, then is this quality a success? Depends on who’s asking?

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