Doctors, teachers – both are under the gun to demonstrate that what they do makes a difference. In both cases, they depend on people to follow directions and respond the way they should. Except that we’re dealing with people, who don’t follow directions and don’t always respond the way they “should”.
In his opinion piece in the September 9 New York Times, Dr. Sandeep Jauhar cites cases where “pay for performance” (P4P) measures led to unintended consequences. In one case, one hospital started a patient on IV antibiotics on a suspicion that a patient had pneumonia. At the second hospital, they stopped the antibiotics, because the patient clearly did not have pneumonia. The patient, alas, develop c-diff – an infection that can be challenging to treat effectively. Jauhar also cited a survey of heart surgeons where 63% said that they screened out higher risk patients in order to protect their ranking on performance reports.
In both cases, I still place responsibility on the physicians involved for doing the wrong thing. P4P measures didn’t compel hospital one to start antibiotics absent some realistic basis for doing so. To use a current comparison, this is akin to Wall Street firms blaming the lack of oversight and regulation by federal regulatory agencies for our current financial mess. Can you say “personal responsibility”?
In the larger picture, physicians must continue their work to be a central party in the development of the P4P measures that are to be used. On a micro level, you can put your own measures into place within your practice. There are plenty of guidelines and measures available that you can use. On one level, developing checklists for visits for situations which are unusually complex or expensive can be a useful tool to document what is done. In a group practice, common protocols are one way to leverage the value of the group model. This is not a suggestion that we move to “cookbook” medicine – by the same token, relying solely on memory and experience may not always be the best practice. As I’ve written before, the experience of commercial airline pilots is a lesson worth looking at – the five year run without a fatal accident is the result of several key practices. In the world of healthcare, there are two central goals: reducing errors and missed problems, and improving the outcome for patients.