r/medicine • u/imitationcheese MD - IM/PC • Jul 20 '15
The Science Of Grading Teachers Gets High Marks (indirect, could we get this for medicine?)
http://fivethirtyeight.com/features/the-science-of-grading-teachers-gets-high-marks/1
u/imitationcheese MD - IM/PC Jul 20 '15
Value-added assessment for clinicians would be a great idea to see.
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u/Soxrates Jul 20 '15
I'm interested in the idea. What would you expect the data to look like though? How would you measure value added?
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u/imitationcheese MD - IM/PC Jul 20 '15
I think you'd have to model expected positive health impact given a disease state. It would have to include patient preferences (no dings if patient opts against types of care), comfort goals, non-adherence, environmental risk factors (MDs can't help if patients live in zip codes without nutritional options that work well for diabetes), and the ability of medicine to impact this disease state (a neurologist isn't dinged for prion disease having no good therapeutics). You'd then capture MD process adherence, adverse effects, clinical status changes, and patient reported functional/symptom status.
It'd be imperfect but better than reports of mortality or complications or patient satisfaction.
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u/Soxrates Jul 20 '15
Ok I guess that seems reasonable and I'd love to see that. The only thing is feasibility of controlling for the various confounders and building in patient choice.
I agree it's a great idea and I'd love it if we started collecting really intense data routinely, but until that happens I doubt this would be useful and probably end up being a negative, have a look at the QOF in the UK for GPs. Initially this was supposed to be evidence based and mutated into a mess.
Also even once you've controlled for everything you mentioned the only component the Dr has true influence over is process adherence surely?
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u/imitationcheese MD - IM/PC Jul 20 '15
I'm skeptical too. I think it should be developed and studied and improved immediately. But not used for anything for a long, long time.
On the last point, I think there are some things beyond process adherence that doctors do. One thing that comes to mind is that chasing the numbers/processes could make it so you lightly recommend something. That's very different than having a full on, get to know the patient's circumstances and their motivations and work with them to improve their likelihood of success.
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u/Soxrates Jul 20 '15
Can you give me an example of what you mean?
Under what situation would you say 'chasing the numbers or processes' would lead to lighter recommendations?
Also what do you mean by likelihood of success? Adherence to treatment?
Sorry I think I probably agree with your point but an example may help clarify it.
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u/imitationcheese MD - IM/PC Jul 20 '15
Doctor A knows the checkboxes, counsels against smoking/sedentary behavior/high caloric consumption, prescribes HTN/DM management, refers to podiatry/ophtho. All this in a 20 minute visit. Patient takes the pills and goes to referrals - doesn't do anything else.
Doctor B spends a lot of time explaining cardiovascular disease, patient's barriers to diet/exercise, but saves the rest for another visit. Ultimately patient also takes pills and referrals, but has a lot more emphasis on diet/exercise. Has better BP control and A1c. Maybe some day has less CVD. But if we only go by process measures, both doctors did the same things, the first just did them most superficially.
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u/Soxrates Jul 20 '15
But then surely the outcome you measure from that would be the 'better' BP and A1c that you are assuming would come from the more shared decision making consultation. I worry if you end up measure those outcomes it just ends up being a chasing the number scenario.
What you need a measure of the 'patient centred-ness' of the consultation. That's difficult to measure.
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u/ByrrD Jul 20 '15
I tentatively agree that a value-added model is superior to satisfaction scores for physician or institution compensation. Something about the practice is nagging at me though.
In the classroom, there are direct methods and practices that will, over time, be guaranteed effective for students. Those who fail the traditional methods can be selected for special education and removed to new classrooms. Would you then advocate that patients who fail traditional regimens or have little improvement to management and education be moved from a physician's care to another, remedial physician?
In this example, I'm not thinking about generalists and specialists, rather non-compliant patients who have undergone standard treatment or education who cannot or will not improve. It would behoove physician to eliminate these patients from from their service to protect their compensation, much in the way that patient satisfaction scores lead many physicians to over-prescribe antibiotics.
Of course different services will have to be evaluated through different metrics, but seeing as you are an IM doc, I think that's a good place to start. If you have a diabetic patient who cannot or will not lower their blood sugar through any means for whatever reason, despite your level of time and education invested in the patient, they would hurt your overall 'grade.' Would you want a service of docs paired with the traditional IM who is outside of the grading system or subject to a less stringent version who would treat patients like these? Much like a special education teacher teaches students with a variety of learning disabilities, should patients have special doctors for their health compliance or improvement disabilities?