Whistling in the Wind, Or, You Can’t Judge A Doctor by the Numbers

How do you judge how good a doctor is? By personal interaction? By what relatives and friends say? By whether he or she is on time when you go for your visit? By doctor rating websites on the Internet? By patient satisfaction surveys conducted by doctors themselves or rating agencies?

Or do you do it by the numbers? The federal government and health plans are increasingly issuing periodic “report cards” containing “objective” evidence of how well doctors are doing in achieving “quality” goals.

How can one argue with this approach, which may become the basis for “pay for performance” programs? After all, if you can’t measure something how can you judge it? This is the cornerstone of management “science.”

The answer, according to Danielle Ofri, MD, PhD, is that these numbers and these reports are often meaningless to individual physicians (“Quality Measures and the Individual Physician,” NEJM, August 12, 2010).

Here is how she, an internist at New York University School of Medicine and Bellevue Hospital explains her reaction.

“The quarterly ‘report card’ sits on my desk. Only 33% of my patients with diabetes have glycated hemoglobin levels that are at goal. Only 44% have cholesterol levels at goal. A measly 26% have blood pressures at goal. All my goals are well below my institution’s targets."

“It’s hard not to feel like a failure when the numbers are so abysmal. We’ve been getting these reports for 2 years now, and my numbers never budge. It’s wholly dispiriting.”

She is beginning to wonder if these numbers really mean anything. Are they a valid measure of physician competence? How would patients react to them? Should the numbers be used to judge and compensate doctors?

One thing she does know. “These statistics cannot possibly capture the totality of what it means to take good care of patients. They merely measure what is easy to measure.”

So what does she do with the numbers?

“ I don’t even bother checking the results anymore. I just quietly push the reports under my pile of unread journals, phone messages, insurance forms, and prior authorizations. It’s too disheartening, and it chips away at whatever is left of my morale. Besides, there are already five charts in my box – real patients waiting to be seen - and I need energy for them.”

Judging doctors by the numbers may be the metaphoric equivalent of whistling in the wind. It sounds good, but it is largely meaningless in the total scheme of things. When I think of these numbers as a means of judging physicians, I’m reminded of Mark Twain’s comment about Richard Wagner’s music, “It’s not as bad as it sounds.” Similarly, numbers for judging doctors are not as bad as they make doctors sound.