01 March 2005

Grading Doctors

Recently, in between the hustle and bustle of my busy moments, I came across this insigthful essay by Dr Abigail Zuger, who happens to be the regular physician-writer of the New York Times and an attending physician of St Luke's-Roosevelt Hospital in New York. Here are excerpts:

Report Cards for Doctors?
Grades Are Likely to Be A, B, C . . . and I
By Abigail Zuger, M.D.
Published: March 1, 2005

She was an internist by training, but privately I always called her the eye doctor.

Ask her about any of her patients, and the answer would come back starting with "I."

How was Mr. Jones? "I got him to start taking his insulin, and I'm working on his cholesterol."

Mr. Smith? "Wonderful. I fixed up that anemia, and I got him to Weight Watchers."

Mrs. Brown? "I finally got her mammogram done."

All medical information was subtly refracted, worded to reflect the doctor's role as prime mover and chief puppeteer. Health and illness might be considered random evolutionary events elsewhere; her practice was clearly ruled by intelligent design.

When her patients did well, she beamed with pride. When they did badly, she was full of excuses. They had ignored her advice or somehow misled her. She had to make sure you understood it wasn't her fault.

I think of her often now that we are apparently heading straight into an era when doctors will receive report cards for their work.

Are we are all now destined to become something like her?

[NYTimes Health]

I have always enjoyed articles by Dr. Zuger. She writes like our very own fellow medblogger, Dr Craig Hildreth, of The Cheerful Oncologist. Medicine often demands that doctors exercise objectivity in coming up with medical decisions, but humans as we are, we, more often than not, establish warm bonds with our patients. These "bonds" can be both detrimental or beneficial in the big picture of healing the patient.

Too little rapport and bonding may mean that doctors become routine workers --- much like your trusted auto mechanic who fixes or replaces any bad part of your car. Too much involvement with the patient might hinder the doctor's judgment in ordering diagnostic tests which might aid in the overall clinical management of the case at hand.

The most difficult but effective way of dealing with patients is finding the correct blend of rapport and objectivity. One of the difficulties in finding this delicate balance is mentioned in Dr Zuger's essay in which she expressed her reaction regarding Medicare's Performance-Based Payments for Physician Groups in the US, which will make public grading of doctors and reward them with payments if they did good.

As Dr Zuger admits, "sometimes quality of care transcends the usual markers," in an example she cited in her essay about a diabetic patient whom they tried treating but whose sugar levels couldn't be brought down because she refused all the prescriptions and medical advice given. Dr Zuger argues that with a grading scheme like that of Medicare's, a doctor would have flunked outright, even when he is doing his best.

I've always believed that healing is a two-way street, and the first salvo must always begin with the patient. No amount of therapeutics can heal a patient who refuses to be healed, and to be graded as a doctor who failed in such a case would be very unfair.

Even with the best rapport, there are patients who have really, really terrible personal problems that get in the way of healing. The doctor can only do so much. Though we feel that we must strive to break whatever obstacle is laid in our path to get our patients' cooperation, there is no clear guarantee that that can be achieved.

We do our best, and we hope that healing will take place.

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