136 in the collection
A Report Card the Doctor Doesn't Want to Take Home
Data and more data to get between doctors and their patients. It does sound like teaching, doesn't it? Data is what matters, not people.
I had the recent experience of seeing "Wit" performed by the palliative care unit of University of Vermont Hospital--at the hospital. And the Pulitzer playwright, Margaret Edson, who is a longtime teacher, was in the audience. She had been at the teaching hospital all day, talking with various medical groups there. I thought it was particularly brave and important for the medical staff to do this play, as the physicians in the play (roles performed by physicians), intent on getting this patient to complete their research protocol, come off mostly badly--not because they lacked medical skill and expertise but because they lacked people skills. We in the audience were judging the doctors by how they treated this one patient--not whether she lived or died--but how they behaved toward her while under their care.
In a Q & A after the performance, Edson mentioned that writing such an intellectually challenging play was difficult. . . "but not as difficult as teaching."
One reader comment on the article below calls for physician solidarity. That's what teachers need too.
Reader Comment: Sounds like doctors are finding out what public school teachers have experienced for a long time: holding them accountable for results in which they don't control all of the key variables is at best unfair and at worst, irresponsible.
Reader Comment: This will also result in doctors doing everything they can to unload their sickest most recalcitrant patients onto other doctors. Just as teachers will now do anything to get their worst students to drop their class or be assigned to another teacher. Numbers are only part of the story.
Reader Comment; Dear Dr. Zuger,
I have downloaded your report card story for my school bulletin board. As a teacher in NYC with great success for 28 years, I see my own experience depicted in your article. Inexperienced bureaucrats who do not have enough knowledge to analyze what they are looking at in a classroom nor in a medical office, are being given the power to annihilate professionals. What you have succinctly written resonates the reality of all professional life in America. Your article describes profoundly how we have built a system of top down, ascension of bureaucrats. They have rubrics that do not speak to the human, one to one engagement that we all need to value. Education and now medicine seem to be the two professions that have become the whipping post of America. It is capitalists that see a way to make money in both of these professions that is driving this movement. It would be productive for JOFA and NEA to combine efforts to wake people up to how they will become nothing but a number, if this poor trend has its way with all of us.
Reader Comment: Medicine has become a data-tormented profession and information-gathering has almost taken precedence over taking care of patients.
The result is a depersonalized health system made up of discouraged doctors and disaffected patients. But physicians' fall from professional autonomy to subservience to the insurance industry could have been prevented.
If physicians had organized themselves and if they had put in place safeguards in place to protect medicine's humanitarian ideals, they could have prevailed against the large insurance conglomerates that have successfully imposed their will and their business model on that of medicine.
But, except for a courageous few (but not enough), doctors have never learned the necessity of political solidarity and the need to protect medicine. Fortunately, some medical schools are incorporating medical advocacy into their curriculums. The next generation of doctors may do a better job than their predecessors.
But for now, only our lawmakers can stop the insurersÃ¢€™ data-mania. Without their intervention, medicine will continue to become more dehumanized and more depersonalized.
by Abigail Zuger, M.D.
I got my report card the other week, and I must say I didn't do very well. I'm pulling around a B, better than average but not by much. My parents would be appalled.
I am graded these days not by test performance or classroom participation, but by my success in getting patients to do well. Not necessarily to feel well or to be well, mind you, but to perform well on their own tests. They do well, I do well. They do badly, I flunk.
Gone are the days when anyone paid attention to my peer interactions, effort, improvement, or to the difficulty of the assigned material. Most of those variables are now impossible to assess -- and as for the medical equivalent of the essay question, forget it. No one has the stamina to plow through my notes.
Rather, "continuous quality improvement," as we call the process of getting doctors to be their very best selves, requires something snappy and easy to track.
So, every set of doctors marches to its own numbers. Surgeons are assessed by their complication rates, internists by what fraction of their diabetic patients are well controlled and have seen the proper specialists, and by how many other patients are persuaded to accept recommended medications and vaccines.
In an H.I.V. clinic, the obvious number to track is the one that consumes our attention: the H.I.V. viral load. This measurement of viral RNA circulating in a patient's blood generally correlates with disease activity. Successful drug combinations will reduce it so much that it cannot be detected with standard assays, and at that "undetectable" level most of the bad things about H.I.V. infection melt away, including its inexorable downhill progression and its transmissibility.
Undetectable is good for the patient, good for the community -- and now good for the doctor, as we are scored on how many of our patients achieve this benchmark.
Nationwide, about 70 percent of H.I.V.-infected patients receiving medical care are undetectable. In New York State, the numberranges from 79 to 90 percent, depending on how you define medical care.
The number on my report card was 88 percent, not so bad, not so good. I also received a list of my failures by name (not that I wasn't aware of them already, thanks very much) and a few generic suggestions for improvement.
After I brought home a 67 on that history test back in seventh grade, a painful post-mortem with my mother ensued, a slow, defensive slog through question after question. I still say we didn't get to Caligula in class.
Were anyone to take the interest, I could provide a similar set of annotations to my current grade.
Take Patient A, a big failure for yours truly with 11,000 copies of H.I.V. RNA per milliliter of blood. Frankly, Patient A is actually one of my big recent successes. He is a sad, sick loner who trusts nobody and nothing, let alone people in white coats and pills in amber bottles.
He and I struggled alone together far too long, until I had the sense to enlist one of our clinic's wonderful care coordinators who work with patients as a combination of friend and social worker. Patient A has thrived with her help: His viral load has plunged from several million to, yes, 11,000. He has gained 20 pounds, and he is actually planning to see a dentist. Not my idea of a failure.
Take Patient B, another black mark on my record with a viral load of 8,000. She is a middle-aged woman with the gullet of a very small child. She absolutely cannot swallow pills, especially the giant ones used to treat H.I.V. Even the one-pill-a-day combination options are impossible for her to choke down; crushed tablets and all of the pediatric syrups and chewables make her gag.
A couple of capsules seem to be keeping her infection in check, at least until something better comes along. Patient B is my big challenge (and I am her personal mixologist); we have grown quite close over all these years of experimentation. Somehow "failure" doesn't seem like the right word there.
And Patient C, oh yes, I should have put my foot down with him. Patient C was having gothic difficulties with his prescription insurance; medications that were delivered monthly suddenly stopped showing up, and by the time it was all untangled he had been off treatment for months. He came in and announced he wanted to check his blood work.
I suspect he needed the proof that it wasn't all a giant technical error, that he was still infected, that no miracle had occurred. Perhaps I should have argued, but I didn't. And indeed there was no miracle: His viral load was 100,000, another giant ding for Dr. Zuger, and back on meds he went.
I have things to say about Patients D, E and all the others, too -- long shaggy-dog stories, explanations, rationalizations, narratives about life and health, exactly the hangdog commentary you'd expect from a straight-A student gone bad. You could say it's all so much embroidery. Or you could say that the numbers don't tell the whole story.
Abigail Zuber, MD with Ohanian comment
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