A tightrope for the '90s - medical care quality

Quality of Medical Care is Difficult to evaluate. Recently, however, HMOs and other types of managed care organizations have been in the process of defining quality in quantitative terms. Physicians who utilize fewer resources and who care for more patients per-unit-of-time are valued as providing better care than colleagues who may work at a slower (more expensive?) pace. Fiscal considerations aside, the pressure to evaluate or treat greater numbers of patients in shorter periods of time produces adverse consequences.

Even before managed care, some physicians, and especially surgeons, were tolerated, sometimes highly respected, because of presumed or real technical expertise, while offering the patient little time, judgment, and/or emotional support. indeed, there are data that support the contention that outcome improves as experience with a disease or procedure increases, but to what extreme can the zeal for quantitative productivity be carried? Erosions in the quality of care are often the consequence of this mass production type of medical care. While there are no published data that demonstrate this point, many physicians and patients are aware or have experienced events that confirm this.

Physicians who see or treat extremely large numbers of referred patients with similar problems can begin to mitigate the quality of care they deliver. These physicians are required, or choose, to see so many patients in limited periods of time that adequate histories and physical examinations are compromised, if not impossible. The ability to carry out the intervention for which they have become an expert begins to take precedence over a considered judgment of an individual patient's characteristics and special needs.

The physician specialist can, as a consequence, develop tunnel vision for his/her specialty organ system to the detriment of the whole patient. So many patients with relatively similar problems are encountered that the physician becomes complacent or even bored, and an in-depth consideration of each and every patient's problem is eschewed. Frequently, the result is a reflexively-executed, stereotypic interventional prescription. In those cases where the etiology of the patient's symptoms has not been appropriately identified, the procedure, while technically adequate, may be without benefit.

Worse yet is the scenario where the intervention results in morbidity or, even on rare occasions, mortality. Alternatively, there is the quick rejection of the patient because his or her problem is not easily seen as remediable by the procedure. The patient and primary care physician are left to find a specialist within whose province the problem falls.

The goal soon becomes large numbers of patients or procedures. The satisfaction is found in the procedure itself, overshadowing the veracity of the indications or the end result. The transition is subtle and insidious, and soon, alternative methods of treatment become totally eclipsed from vision. The intellectual aspects of practice fade and the technical challenge becomes the end-all. The volume of production supersedes in value the quality of the individual interaction. This description does not, by any means, apply solely to the caricature of the surgeon. Interventional radiologists, cardiologists, pain specialists, and even primary care physicians fall victim to attempts to attend to larger and larger numbers of patients.

We begin to delude ourselves that we can preserve the intellectual and personal interactions by developing better systems and, up to a point, this is true. But we may have already reached that point. Both physicians and patients are angrier today. They share in feeling the loss of the human side of medicine, and are beginning to exhibit the same disquiet and unhappiness expressed by the production line worker in industry earlier this century. Industry has learned that workers in those settings were not the most productive, nor the most contributory, to the ultimate goals of the business.

Numbers do not necessarily take into account the quality of the care delivered. There is clearly a middle road. Physicians must take care of a sufficient number of patients with a given problem to gain and maintain expertise and mastery. But they must also guard against the insidious pressure for the procedure to become the end in itself. A reputation as a brilliant technical wizard is very seductive, but does not truly serve our patients. Hippocrates' credo, first do no harm, remains the basis for medicine even today.

Key Concepts: Quality of Care/Defining Quality/Managed Care Pressures/Increasing Volume of Patients

How accurately can you measure quality of care in health care? Recently, HMOs and other types of managed care organizations have been in the process of defining quality in quantitative terms. Physicians who utilize fewer resources and who care for more patients per-unit-of-time are valued as providing better care than colleagues who may work at a slower (more expensive?) pace. The pressure to evaluate or treat greater numbers of patients in shorter periods of time can produce adverse consequences. And numbers do not necessarily take into account the quality of the care delivered. There is clearly a middle road. Physicians must take care of a sufficient number of patients with a given problem to gain and maintain expertise and mastery. But they must also guard against the insidious pressure for the procedure to become the end in itself.

COPYRIGHT 1996 American College of Physician Executives
COPYRIGHT 2004 Gale Group