I am currently stuck in a medical system that wants to treat all doctors and patients like widgets. The bureaucrats want to categorize all patients into neat boxes.
Tonight I had the perfect example. A patient arrived in the emergency room with an acute myocardial infarction. We categorize myocardial infarctions into ST elevation MIs and non-ST elevation MIs based on criteria seen on the ECG. This patient had borderline findings on her ECG and did not meet strict STEMI criteria. However, she had a good story, and an intelligent doctor who understands the underlying process can recognize that she is having an acute infarction. She should probably be treated like a STEMI, although she does not meet the criteria.
The system times us and grades us on our responses to a STEMI. Our reaction time and delivery of care goes into an algorithm that somehow defines the ‘quality’ of our care.
But this patient was not a clear STEMI. It was fuzzy. And dealing with patients is often fuzzy, due to problems with memory, compliance, etc…
So how do we change the system so that we can deliver the best care?
Asking these kind of system questions makes our administrators very uncomfortable. They want all of the patients to fit into boxes and for medical care to be delivered by flowchart. This is not reality.
It is important for people to recognize that patients are all individuals and medical care cannot be delivered by flowsheet. Good medical care takes thinking and accepting that patients often do not fit into neat categories. I do not have solutions as to how to best measure physician quality. A supreme court justice famously said of obscenity “I know it when I see it.” The same can be said of physician quality. Trying to measure quality through measures across a wide spectrum of patients is a fool’s game.