The Crucible of Physician Performance Reports
Individualized physician performance reports are an emerging phenomena. The narrative piece examines one physician’s experience with individualized physician performance reports. Reforming the data collection process could enhance the value of the reports to stakeholders.
Key wordsprimary carephysician performance reportsevaluation
When it comes to the medical board exam, they say a passing score is all that really matters. Most doctors brag with blithe regard about passing tests. I, however, was about to take a test like no other. The questions felt like those on a board exam, but the answers did not rest in any textbook, and like the boards, the score could haunt me to eternity.
The instructions were familiar: “Select the best option.” But this time the options were: “(1) Patient does not have this diagnosis. (2) I have never treated this patient. (3) Patient died. (4) I am not the patient’s regular doctor. (5) Service contraindicated. (6) Patient refused service. (7) If service is documented, enter date of service.” These questions were in reference to questions about a report card—a report card about my clinical care. In California, a multi-stakeholder collaborative recently imposed a new physician report card system. I had received my report card and had chosen to challenge the report card’s findings.
When I started medical practice about a decade ago, the first generation of report cards entered the mainstream. Initially, the report cards measured health care quality at the aggregate provider level, for example, the quality of pneumonia care at a particular hospital. These days report cards strive for a level of sophistication and granularity once considered folly—the individual physician level.
Experts said that report cards would improve the quality of patient care. As a result, report cards mushroomed to the point that they now pass the Google test. Try typing “health care quality report card” in the search box, and Google will complete the phrase as a query suggestion.
Unfortunately, my relationship with report cards got off to a rocky start. Last summer a thick envelope from the multi-stakeholder collaborative showed up at my office. The words, “Your report is enclosed,” bulged over the envelope window. Inside was a report card emblazoned with bar graphs: “Your Percentile Rank Compared to Physician Peers.” My stomach sank after seeing the coup de grace: health plans wielded final discretion on how to use my results. Did the signature at the bottom really end with an “MD”? Why would a doctor do this to his own kind?
Tiny beads of sweat formed as I read through the report. On the graph, most of the bars hugged the left axis, next to the zero. No bars reached rightward, toward the Promised Land, the 100th percentile. One short stubby bar ranked me in the bottom 1 percentile for screening diabetic cholesterol. Another stubby bar ranked me in the bottom 8th percentile for screening women with Pap smears. Bottom line: I gave patients bad care.
Prior to the arrival of the letter, I had always believed that I provided high-quality patient care. Official-appearing diplomas and awards hang on my office walls. Wise role models have mentored my path. A talented team at the office creates order out of chaos on a daily basis. My practice of medicine has also been inspired by the words of an old surgeon, Dr. Frank Spencer, who spoke to us newly minted surgical clerks at orientation day years ago: Be generous with your time, sympathy and understanding in caring for patients.
How could I be such a bad doctor? Sure, I knew that some of my diabetic patients did not follow the game plan. And yes, many women avoided Pap smears. But we primary care physicians accept this as par for the course. We never stop caring for our patients. Did the stubby bars signal that time, sympathy and understanding for patients, individual preferences and complex circumstances should be thrown out as worthless antiquities?
The collaborative had sent the thick envelope because it thought I might want to “confirm or correct” the report card before it was publicized on the Internet. How thoughtful. The envelope contained a 16-page list of several hundred patient names and my alleged deficiencies. Since the office did not have an electronic health record, it meant sifting through hundreds of paper charts to reconcile the data points used in compiling my report card. The deadline was 1 month away. Not much time for a busy practice to turn something around. Maybe, I thought, it wasn’t worth the trouble. Maybe I should just move on with my life. Certainly the collaborative would not send out inaccurate report cards. But I did not feel like a bad doctor. Was I?
I needed help. I met with the office staff and named the problem. It was too complex for the staff to handle independently, but too much for me to handle alone under pressure. Their eyes shifted around. My jaw muscles tightened. We agreed that the only solution was to work together as a team. We would drink from the crucible together.
At the end of the day after all of the patient messages, med refills and documentation were done, I sat down with the list and the stack of charts assembled by the team. Staying late is almost a way of life for primary care physicians, so the burden created by the report card seemed no different. My wife knew I had to do it. I settled into a soft leather chair and sipped some warm chrysanthemum tea, remembering my mother saying that the flower’s essence cooled heated spirits. Cheerful ukulele music streamed from the computer. At least I was comfortable.
The first name on the list was Angel, a career woman too busy to see me much but worried enough to leave messages for drugs and tests she wanted. The list said she lacked a mammogram. How could Angel forget her mammogram? I dusted off her chart and flipped to the “lab results” section. Mammogram done. On the report card’s correction sheet, I circled option 7: service documented and entered the date of service.
The second name was Betty, a middle-aged woman on disability with multiple medical problems. Regular appointments whittled down her problem list to a tenuous steady state. How could we forget discussing a mammogram? I hefted over the chart’s current volume. Mammogram done. Option 7 circled.
Third on the list was Carol. A smart and savvy nurse, she only saw me after first curb siding her ICU colleagues. How could she lack a mammogram? I flipped through the chart twice. No mammogram results. In the progress notes, a scribbled entry: mammogram declined. I circled option 6, service refused.
After a few more names, I sensed an Achilles heel in the report card. Was this just a skewed sample or would the trend hold up? What made the collaborative think they could slide through such an inaccurate report card? I left the office tasting an advantage.
With the deadline looming, I repeated the nightly ritual: review chart, circle response, breathe sigh of relief. The first night’s trend held up. The collaborative had used lousy data to create an inaccurate report card. Imaginary bars began stretching toward the Promised Land.
Like finishing the boards, I felt relieved to survive the process of correcting the report card. The stakes were just as high as the boards, of course—my privilege to practice medicine. Contesting the report card drained a lot of resources, not least my team’s most valuable resource, time. Instead of patient care or practice improvement, we exhausted hours in reconciling data . Moreover, since I felt so personally impugned, the report card triggered a defensive reaction rather than a constructive innovation in patient care. I wondered whether the collaborative cared. It had outsourced the data verification to busy doctors. It had transferred final discretion to the health plans. Since there appeared to be no venue for reporting on the quality of the record care process, what incentive existed for them to reform their data collection procedures?
Today I practice medicine much the same way as I did before the report card arrived. I now know that I practice well enough to earn a passing grade but wonder what that means, how much it matters, and what other items need to be included for the metric to truly reflect the quality of my practice and the benefits of good primary care for patients. Perhaps posing these questions can quicken reform of the report card system. With reform, we as a profession might gain a valuable tool for practice improvement, and we as a society might take another step towards transparency in health care.
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