Essay: Report Cards for Doctors? Grades Are Likely to Be A, B, C . . . and I

Report Cards for Doctors? Grades Are Likely to Be A, B, C . . . and I
"Report Cards for Doctors? Grades Are Likely to Be A, B, C . . . and I
By Abigail Zuger, M.D., The New York Times, 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?

Past efforts to grade doctors have been clumsy at best. The names on all the 'Best Doctor' lists tend to reflect old boys' networks rather than actual merit. Internet sites posting doctors' credentials let consumers weed out true miscreants, but not evaluate the remaining multitudes.

But far more precise rankings lie just over the horizon, with doctors publicly graded and paid by the good results they achieve.

Medicare announced the first such program this winter: a pilot 'pay for performance initiative' will reward large group practices with bonuses for keeping their elderly patients vaccinated, their cardiac patients properly medicated and their diabetics well controlled. It is only a matter of time before individual doctors are similarly ranked and paid.

Any attempt to improve the quality of medical practice deserves a shot, and this idea seems as reasonable as any. Still, it is bound to jar the doctor-patient relationship slightly, altering it just as subtly as the eye doctor's peculiar syntax altered the truth.

All doctors suffer from that 'I' disease to some extent: the success of the enterprise depends on it. Most, though, retain some necessary emotional distance as well - not only distance from tragedy and suffering, but also from the innumerable humdrum snafus, habits and idiosyncrasies that invariably stand between people and their health. When we start getting scores in health maintenance, that distance will be hard to maintain.

The prospect of a report card in my future always reminds me of a diabetic woman from my past. She spent the year after her divorce sitting on her couch eating ice cream straight from the carton. Her medications went untouched. She still came in to see us quite a bit, but she refused to be weighed, refused to have her blood pressure measured, refused antidepressants, refused to see a psychiatrist. Her blood sugar ran so high the lab invariably called us in a panic. We tried everything; nothing worked.

I felt terrible for her, but had anyone been grading me on my management of diabetes that year, I would have felt even worse for myself because I would have flunked. She would have brought me right down with her. With my reputation (or a cash bonus) at stake, would I have done better at taking care of her? Or would I instead have begun to hate her for bringing down my 'diabetes' grade and lowering my income? Would I eventually have told her just to stay home until she could behave, so at least my failure to make her better was not so visible in the record? Would we have lost her trust then for good?

Eventually the patient pulled herself together and got her sugar back under control. She thanked us for all we had done for her in the interim. We thought we hadn't done much, and certainly the quality mavens would have agreed. But sometimes quality of care transcends the usual markers.

Rewarding doctors for good outcomes may well work out fine. Still, I can't quite forget the edge in the eye doctor's voice when she spoke about patients who weren't doing quite as well as she would have liked. A real dislike hid behind all her cheery disclaimers. Her failures, as she saw them, badly interfered with her self-image. She wanted nothing to do with them.

Of course, when she and all the rest of us are prodded to pursue good outcomes with grades and merit bonuses, we will all still have our failures. Will we have the strength to stand by them, or will we just tell them all to stay home?"