Why Americans don’t believe their physicians

I still remember the look on my mother’s face when, as a boy, I assured her I had not shot a hole in a neighbor’s mailbox. The look told me she loved me, but she did not believe me.

That is the look America’s physicians are getting these days when we try to assure business, government, the health insurance industry and the public that we physicians can be left to our own devices to systematically improve the quality of the care we give; they care for us, because we care for them, but they do not believe us.

As a result, the way physicians treat patients is now being measured by anyone who can get their hands on data about care we provide. The skepticism is why insurance companies and the federal government are going to pay physicians more if we measure up to good standards of care, and perhaps less if we do not. It is why data about the performance of individual physicians compared to accepted standards of care is being posted on the Web and sent to our patients by their insurers. And it is why physicians can howl in protest like cats in a shower, but the screws are not coming off. They just don’t believe we physicians can do the job on our own, so they will not stop just because we are unhappy about being forced to do it their way.

It would help, of course, if physicians had been doing the job of dramatically improving the quality of the care we provide without being poked, prodded, dragged and rewarded. It would help if many physicians had not objected to efforts aimed at reducing the number of times we operate on the wrong leg, or operate on the wrong patient. It would help if we had pushed ourselves much harder and more systematically to give every heart- attack patient the right medicines, instead of either giving the right medicines or documenting why not in only about 60 percent of patients.

It would help if physicians had, on our own, all systematically adopted aggressive measures to reduce the risk of surgical infections, get every diabetic’s eyes checked for diabetic retinopathy every year, and vaccinated every child to standard. But we didn’t, so it is being done for us and to us, we don’t like it and no one cares.

I was reminded of all of this at a medical conference recently. A panel of health policy, government and insurance experts told a group of physicians how insurance companies and the federal government were going to push physicians to improve the care we give in the office. Some of the physicians in attendance objected to being told how to practice medicine, to the extra cost of implementing electronic medical records in their offices, to insurance companies using billing data to measure physician performance against national standards of patient care, and to Big Brother checking up on us.

They passionately claimed physicians are the patient’s best advocates, and that they were being pushed to the brink of economic survival by the cost of oversight and regulation.

The panelists listened and sympathized, but none seemed to change their minds that physicians will need to be forced to improve the care they provide. In fact, the focus of the physicians there on those issues instead of the quality problems in physician care seemed simply to reinforce the panelists’ belief that when it comes to understanding what must be done to improve the quality of patient care, most physicians just don’t get it.

Sadly, they are largely right, and if physicians look hard in the mirror of our own imperfect practice, we would know that. In fact, we would also know it is time for physicians to stop complaining about everyone else telling us how to practice better and join the crowd; to ask for more prodding, not less; to ask for more incentives, not fewer; to ask for more support to do better, and most importantly, to push ourselves harder than anyone else is pushing us.

Physicians can fight over how we are pushed to improve, and we should. We can challenge the motives of those who push us. We should resist redundant collection of data about our care. We should demand that if there are to be report cards on physicians, there should only be one: a nationally standardized report card for each physician in a specialty, based on one validated set of data. We should reject lousy measurements of our care, but systematically embrace and use the good measurement to drive better performance. First, however, we should stop fighting the idea that we need help improving the quality of our care, because our mothers and the whole rest of the world but us know that we do.

Our failure to stop fighting efforts to improve our care is not only straining our credibility with business, government and the insurance industry, but with our patients. When we cry foul more loudly about being pushed by insurance companies and businesses to take better care of patients than we do at our own inadequate performance, we leave our patients wondering why our priorities are with our independence and not with the quality of their care. When we take years to systematically adopt all appropriate infection-reduction practices shown to improve patient care we leave our patients wondering what else we are doing wrong. When we do not lead on quality we lose the war for leadership of health care policy debates, lose the hearts and support of our patients and weaken our claims to be the ones most interested in patient well-being.

When physicians shoot messengers telling us we need help improving, and fail to do the job on our own, we shoot ourselves in the foot of our credibility and weaken our positions on other issues as well. Then, when we argue for malpractice liability reform, for example, we enable opponents to ask, “Aren’t you the docs who inadequately police your own incompetent colleagues and cannot get heart medicines to more than two-thirds of the patients who should have them? Why should you be protected from lawsuits when you cannot stop making so many mistakes?” Then, when we ask for better reimbursement we face opponents who ask why they should pay us more for our care when the care we give is often not up to our own standards.

By leaving a gap in our performance we give credence to what many now believe about more money for rising health care costs; there should not be any. If physicians (and hospitals) want more money for health care we can wring it instead out of inefficient, ineffective and inadequate care, they say. More and more of the audience with the money – government, business and health insurance – think they are right.

Most physicians have thought it was good enough to try desperately hard to take great care of patients. It isn’t; we now know trying desperately does not produce great care. That includes my care; every year I have practiced, a number of my patients did not get care as good as I should have given them. If I am to do better I need data analysts with electronic medical records measuring my performance and feeding my results back to me. I need computerized systems that allow me to compare care I have given with established standards at the click of the computer mouse. I need support to systematically reach out to patients who have not gotten all of the care they should.

And finally, when I complain about being measured to death and about everyone looking over my shoulder in the exam room, I need to be ignored until every last patient has gotten the best possible care. So should my fellow physicians, much as we love them.

Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems and is on the staff of several hospital emergency rooms in the region.