Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Monday, October 09, 2006

P4P: My Point Exactly

From the comments, regarding the issue of "loyal patients who adore you but still haven't had mammograms and colonoscopies":
Isn't screening a patient's choice? Yes, colonoscopies can prevent cancer. Yes, mammograms might diagnose one of those cancers that are destined to spread before they become palpable, at just the right time. But the probability of an individual benefitting is small - less than 1/1000 after 10 years of mammograms, for example, and this is a pretty optimistic estimate. And screening has risks. Like overdiagnosis, for example, in case of mammograms. Like longer period of "being sick" if the cancer is so aggressive that early detection doesn't make a difference in the course of the desease. Like biopsies for false positives.

So if a rare patient feels that for her personally a higher chance of becoming a cancer patient, for example, is too high a price to pay for less than 1/1000 chance of having her life saved 10 years from now (forgetting that we are talking about desease-specific mortality and not all-cause mortality), how are you going to convince her? Assuming she is really informed, should you waste the precious time of the visit to try to get her to change her mind?

And what is quality? Openly discussing both benefits and risks of screening or just using scare tactic to get more patients screened? If you are not mentioning the risks, if you using relative mortality reduction and not mentioning the real chance of your patient benefitting, are you not misleading the patient?
My point exactly. You have to have something to measure in order to call it "Performance." It's easy enough to count up how many of your patients have submitted to assorted screening tests and other procedures, so that's what is being done in the name of "quality," and that is what I disagree with.

In addition to criticizing my choice of wine, Dr. Sid points out this:
There are some doctors who have better outcomes at lower costs than others. Were it possible -- and I'm not at all sure it is -- it would be nice to see an effort to figure out the differences and encourage them.
This was actually one point the speaker addressed that I felt was valid. He described data showing the number of tests a cardiac patient had from first presentation to cath lab. In cardiologists' offices with diagnostic equipment (echos, treadmill stress tests, etc.) the average was 4.5; in offices without such equipment, it was 1.5 (average number of tests between presentation and cath lab.) This information was made public, and the results were gratifyingly predictable: the overutilizing offices were promptly contacted by referring physicians who said, "We're not sending any more of our patients to you." Surprise: the number of tests from presentation to cath lab decreased. But this valid and useful intervention is a far cry from "pay for performance" in general, and specifically in defining "quality" in the office interaction between patient and primary care physician.

Further down in the comments, in a spirited exchange between Rob and Diora, comes this nugget:
As a patient I have a right to decide for myself whether certain small risk reductions are worth the risks or side effects for me or not. I don't want an incentive for a doctor that would depend on the choices I have a right to make.[emphasis mine]
followed by Fat Doctor's observation which, as always, is right on target:
I am not a salesperson. I am not a factory worker. I am a physician. Who will judge my performance best? I hope it remains the patient.
Amen, sister.


At Mon Oct 09, 10:52:00 AM, Blogger Dr. A said...

Great blog! I found you from a number of people on your blog roll. I'm a family doc also (you can probably figure that out from by blog). I've enjoyed what I've read and will add you to my blog roll. I invite you to check out this post. I know probably what you'll say, but just curious. Click here. Keep up the great work!


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