Dr. Sandeep Jauhar, a cardiologist, believes with good reason that many physicians have become “like everybody else: insecure, discontented and anxious about the future.” In a recent, widely-circulated column in the Wall Street Journal, “Why Doctors Are Sick of Their Profession,” he explains how medicine has become simply a job, not a calling, for many physicians; how their pay has declined, how the majority now say they wouldn’t advise their children to enter the medical profession, and how this malaise can’t be good for patients.
Dr. Jauhar gets it right in many ways, but the solutions he recommends miss their mark completely.
I was 100% in accord with Dr. Jauhar when he argued that “there are many measures of success in medicine: income, of course, but also creating attachments with patients, making a difference in their lives and providing good care while responsibly managing limited resources.”
The next paragraph, though, I read with astonishment. Does Dr. Jauhar really believe that publicizing surgeons’ mortality rates or physicians’ readmission rates can be “incentive schemes” that will reduce physician burnout? Does he seriously think that “giving rewards for patient satisfaction” will put the joy back into practicing medicine?
If so, I’m afraid he doesn’t understand the problem that he set out to solve.
The truth behind “quality” metrics
There is no question that some physicians are inherently more talented, more dedicated, and more skilled than others. In every hospital, if you speak to staff members privately, they’ll tell you which surgeon to see for a slipped disk, a kidney transplant, or breast cancer. They’ll tell you which of the anesthesiologists they trust most, and which cardiologist they would recommend to someone with chest pain. But none of these recommendations are based on simplistic metrics like readmission rates or even mortality rates. They are based on observations over time of the physicians’ ability, integrity, and conscientiousness–all of which are tough to quantify.
Let’s take, for example, a common operation such as laparoscopic cholecystectomy: removal of the gallbladder using cameras and instruments inserted through small incisions in the abdomen. This is a procedure which most general surgeons perform often, with few complications.
When complications occur, there are almost always factors involved other than surgical error. Patients with diabetes are more likely to develop wound infections, for instance. Surgery on patients who have had prior abdominal operations may take longer and could cause bleeding or damage to other internal organs because of scar tissue. Morbid obesity and advanced age are risk factors too.
The surgeon whose mortality rates are higher, or whose patients are more likely to be readmitted to the hospital, may be dealing with a much different patient population from the surgeon with the lowest rates. An inner-city hospital may admit more patients as emergency cases, in more advanced stages of disease.
It’s difficult for statistics to reflect accurately the dramatic differences among patients that affect surgical outcome. A noncompliant patient who doesn’t fill prescriptions and follow instructions is more likely to have problems, independent of the experience and skill of the surgeon. Trying to distinguish among surgeons with “outcomes data” will only result in more surgeons refusing to operate on high-risk patients.