Denial ain’t just a river in Egypt

Tags: fiesinger, evaluation, patients, family physician

By Troy Fiesinger, M.D.
TAFP President, 2012-2013

We received our monthly physician quality report cards recently. Software mines our electronic health record and generates reports to tell us if we are meeting our goals. These quality measures are defined by Medicare, our clinically integrated physicians group, and commercial payers like Blue Cross Blue Shield. While some are based on solid medical evidence, others seem arbitrary and not relevant to the day-to-day reality of seeing family medicine patients.

I prefer creating and using our own data instead of relying on the often incomplete and inaccurate claims data from insurance. Despite our efforts to be good sports, often we feel bombarded by the endless number of things we should do to show we are good doctors.

When the CDC announced a new recommendation to screen all adults born between 1945 and 1965 for hepatitis C, I groaned. One more thing to do. My office visits have not gotten longer while my checklist for each visit has. When we are not having to meet new quality measures, we have to make sure our Medicare patients get their annual senior assessments and have all of their medical problems reviewed to make sure that our risk scores are correct.

Everywhere we turn, we seem to face pressure to do more while making each patient feel we spent enough time with them. With all this pressure pushing us in different directions, I am not surprised at my colleagues’ reactions to the report cards. I, too, often feel that I am back in school. I have been tempted to tell patients: “Hey, you’re killing me on my quality report card. Can you get your A1C checked for heaven’s sake?”

While I firmly believe that we must measure our performance to improve, I have been through this often enough to find our reactions humorously consistent. The late, great psychiatrist Elisabeth Kübler-Ross, M.D., could have used us as a case study.

  1. Denial — “These patients aren’t mine. The attribution algorithm is wrong.”
  2. Anger — “I referred him five times to get a colonoscopy. What do I have to do, drive him there myself?”
  3. Bargaining — “If they could correctly identify my patients, then I would know where to start.”
  4. Depression — “This is impossible. I’ve told them a thousand times to exercise. I give up.”
  5. Acceptance — “OK, fine. Schedule those diabetics to see me and our dietitian so we can talk about healthy eating.”

Despite our frustrations, we do learn more about our practice by looking at this data. For example, our colorectal screening rate was at the national average, but only 10 percent of those tests were reported to the insurers with the correct CPT II code. That means we may not get the quality bonus we deserve. You can bet that motivated us all to click the little button for colorectal screening reporting.

We all think we’re good doctors when we sit in front of a patient. You have to have intestinal fortitude to look honestly at clinical data and admit that you are not as good as you think you are.  So step by step, report card by report card, we pass through Stage 5 and get back to work.

1 Comment

  • Daniel Porter said

    Thanks for your thoughts on this issue. Your last sentence of the first paragraph is the crux of my concern over outside forces looking at our performance. The number of agencies and the number of quality measures we are being held to seems to increase on a daily basis. Over the last few years there has been an exponential rise in the number of measures and my concern is: Where does this lead us to projecting forward? I think that we as a profession must recognize that frequently in the course of history what we took as fact has been shown to be laughable years later. If we allow outside entities to create these measures without any apparent limits to their number will it serve to frustrate us and possibly discourage medical students from entering primary care? Are we losing something at the bedside in the name of "quality?"

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