The Apologists For The Do-Nothing Crowd Are Raising Their Voices

Submitted by on Thursday, September 3, 2015 - 02:33

Newtown, CT – September 4, 2015

And, predictably, the apologists for the do-nothing crowd are raising their voices. They must be ignored – This week's NEJM includes a Perspective from Dr. Lisa Rosenbaum on the public reporting of quality measures, in particular ProPublica's recently released scorecard. As we've said recently about that particular scorecard, the only thing missing in it is a "caveat lector" that the results are solely based on Medicare data and that those results may or may not be the same for commercially insured. For the rest, it's as good an advance in shedding light on variation of surgical care as we've seen in a long time. So let's examine the apologist's arguments. The first is that physicians will readily abandon their ethical duty and Hippocratic Oath to care for patients from fear of looking bad on a scorecard. The second is that scorecards harm patient care more than improving it. The third is that the surgeon can't possibly be held accountable for what happens after surgery, and certainly not for complications that come from patient non-compliance. The fourth is that methods are flawed because the reliability of the measures is poor. The fifth is that only physicians can really tell which of their peers delivers high quality care. Seriously ?!?!?!?!?

What this means to you – First off, there are dozens of studies that contradict the first and second points made, and we'll point you to one and you can search for all the others because they're easy to find. The evidence is really clear that public disclosure of performance for hospitals and physicians improves quality of care. The third point is the same old saw that, when in doubt, blame it on the patient, and reminds me of a meeting I had several years ago at the American College of Surgeons when an outraged surgeon told me it was ludicrous to hold him accountable for an infection caused by one of the nurses spitting in the patient's wound. You're perfect and everyone else is at fault. What a sad joke that reflects the continued mediocrity of medical care in this country. So here's a wake up call for all those who blame others: the world has left you behind. This third point is engrained in physician psyches because they're taught early on in medical school that they are the best, the captains of their own ship. And yet today's shift in payments is forcing through a new dynamic that many still resist. You're not the captain of your own ship, you're part of a team whether you like it or not. And yes you will be held accountable for what happens to the patient after discharge, even if that patient is too groggy or lacks self-awareness to take the proper medication. Because believe it or not, it's not about you, it's about the patient. And this brings me round to the most egregious point made, right from the start of the Perspective, that faced between a choice of looking good on some scorecard or being true to a solemn oath, the physician will choose the former. What a low opinion the author has of her colleagues, and fortunately for all of us, she's also wrong on that point. Clinicians in this country wake up every day thinking about how best to care for their patients, and while there are many forces that break down that motivation, it's still what energizes them. And to debase all of them for the sake of knocking down a public report card is shameful. In this case the apologist should apologize to all her peers. As for the rest of us, we'll turn to public scorecards because the profession has continuously failed to voluntarily provide any meaningful comparative data on the quality of care it delivers. So thank you ProPublica, Consumers' Checkbook and Consumers Union, because if it wasn't for you we wouldn't know anything about the quality of surgical care in the United States.