The danger of grading doctors…

It goes without saying that caregivers are not interchangeable. Quality matters. What else is there other than our health?

From the day I began as a doctor, the absence of a legitimate meritocracy has been a source of inflammation. In 1996, when I started private practice, referrals depended too much on old-boy networks. In 2014, the situation is worse. Now, referrals depend almost exclusively on who employs whom. I could be a wizard of catheter ablation, but referring doctors who are employed by competing systems will not send me patients. They might sneak their mother in, but their patients go to the electrophysiologist employed by their employer.

Speaking frankly, this stinks. Always has. Always will. A ‘good’ doctor should be rewarded with referrals and compensation. I wish it could be this way, but I am doubtful that it can.

In many ways judging doctors is like judging teachers. It’s really hard to do from the outside.

Here in the hospital and medical community, you come to know the good doctors. You see their work and then you see their patients. From the inside, thoughtfulness is easy to discern from shooting from the hip. From the outside, though, judging doctors entails looking at many competing measures. For instance, good bedside manner does not equate to technical skills–and vice versa. Box-checking and guideline adherence–especially the latter–are far from useful quality measures. Even procedural outcomes are tough to judge, as the complexity of people are hard to codify before procedures. And the list goes on.

Another simplistic way to judge caregiver quality is testing. Good doctors should pass tests and maintain certification. On the surface this makes sense.

Digging deeper into the merits of board certification, however, reveals that it is not so simple. Dr. Wes Fisher has led the way in exposing the challenges of testing doctors. His most recent take on the current-day expansion of medical certification is worth a read.

I’m conflicted about testing doctors.

On the one hand, there’s potential to do some good. Let’s call this my pro-testing side:

It starts with the fact that doctors share great responsibility for our current crisis of overtreatment and inefficiency. Where do you think all those deaths from medical errors come from? It’s not just faulty implementation of treatment. The root cause of many medical errors is that (good-intentioned) therapy was initiated unnecessarily. And it’s not fair to say doctors intervene too much because of the fee-for-service system. That’s just a partial answer. The main reason doctors intervene so much is intervention bias. We have been taught, and have come to believe–to the point of hard-wiring neural connections–that action is better than inaction.

Alas, the problem is that modern medical interventions are not like wearing a seat belt. Whenever we order a scan or blood test, or prescribe a medicine, or a procedure, there are real and quantifiable dangers that act to mitigate benefit. That shadow on a CT scan can be a real problem.

It’s possible that more intense medical education might lesson the do-something-doctor bias. Medical education, if done well, would force us to collectively face the actual science behind our beliefs. Such a clear-eyed view of absolute benefits and harms would go a long way to stemming intervention bias. Lessons 1-5 could promote the number needed to treat (NNT) concept. What I want medical education to do is foster the give-peace-a-chance philosophy.

Lest you think this argument is hyperbole, I’ll use a looming a public health disaster to make my point. One of the most common and devastating medical errors is healthcare-related bacterial infection, due in large part to antibiotic resistance. This is on us. It’s as we say, iatrogenic. We got lazy; we ignored the science; we let our intervention bias run amok. We gave Z-packs to patients who “went to the doctor to get something” for their viral illness.

Make no mistake, this sort of stuff happens because of good intentions. Doctors are good people. We aim to do the best we can. We take action so that we can help people. The problem is that we have come to over-estimate benefits while under-estimating harms. Too often, we view it as a knock on us when a patient’s disease progresses. In these cases, which are the majority, as most people are not blessed with sudden painless death, the ‘quality doctor’ would offer care rather than intervention. They are not the same thing.

Besides teaching us how to interpret science, another thing medical education could do is help us recognize the limits of human longevity. One of the greatest mistakes doctors make–me included–is treating death as optional. Oh my, that one is baddie.

That’s my pro-testing side.

My contra-testing side is stronger. Mostly because it stems from realism.

The problem with board certification in its current state is that it too often teaches mainstream dogma. It perpetuates the ‘healthcare’ machine. It leans to belief rather than skepticism.

If we have learned one thing in 2013, it’s that expert guidelines, often written by authors with financial ties to industry, are flawed. Take the cholesterol guidelines. The new recommendations don’t come from any new data. We had known this data for years, but yet, until late 2013, the go-to document recommended treating to surrogate markers. Does that mean those of us who practiced risk-based statin therapy were wrong for years, but now we are right? How much hubris does it take to hold out adherence to such documents as measures of quality? And the AF treatment guidelines: Dronedarone, really?

The most concrete example of this point comes from a sample question from the American College of Cardiology. The question concerned an elderly patient with valvular heart disease. Possible answers included surgery, valve squishing procedures and medicines. Nowhere was the right answer–the choice to discuss all options with the patient, including therapy directed only at controlling symptoms.

In his enthusiastic post, Dr. Fisher rightly emphasizes the compete lack of evidence that board certification (in its current form) improves patient outcomes. I believe it’s worth studying; not because we need to confirm benefit, but rather, so that we can exclude harm.

You see how testing is working out for our education system.

JMM