When someone inside the healthcare community develops a health condition, they usually have enough contacts to determine who might be the best provider to help them. When someone outside the healthcare community develops a health condition, they don’t have access to the same network. Ideally, these patients could consult their primary care provider who has an intimate knowledge of their preferences and tolerance for uncertainty to help identify the right consultant to help diagnose, treat and manage the health condition. Given current visit times in a provider’s office (page 40 of this summary of 2016 National Ambulatory Medical Care Survey results) and how much that time providers spend staring at computer screens, that seems unlikely. They may have to rely on publicly available government-generated provider scorecards or commercial rating websites that use patient experiences to determine who to see (at least one trial found that patients weighted these two sources equally). What tools could we develop to help patients determine who might best meet their needs?
In 2001, the National Academies of Sciences, Engineering and Medicine outlined a national statement of purpose for the healthcare system. Health professionals, policy makers, public and private purchasers of care, regulators and consumers would commit “to continually reduce the burden of illness, injury and disability and to improve the health and functioning of the people of the United States.” Health care would be safe, effective, patient-centered, timely, efficient and equitable. The organization further defined “patient-centered” across six components: respectful to patients’ values, preferences, and expressed needs; coordinated and integrated; provide information, communication, and education; ensure physical comfort; provide emotional support; and involve family and friends. Payers and care managers might suggest they can augment the “care coordination and integration” and possibly the “provide information, communication and education” components, but the other four components seem to driven within a patient-provider relationship. Four years later, the National Academies endorsed a starter set of performance measures while acknowledging that most existing performance measures are provider-based, rather than patient-based.
In 2010, Medicare created the Physician Compare website as required by the Affordable Care Act. In a recent research letter, University of Michigan researchers only found provider-level quality data for 0.3% of the included physicians. Couple that with fact that providers volunteer for specific quality measures where they know they are performing well, it seems that the website is unlikely to provide meaningful information to help patients make decisions about who they might see to take care of them.
I believe patients value a few characteristics with varying degrees of importance across patients. First, patients expect providers to be competent. State licensing boards and specialty board certification groups should fulfill that requirement. Patients may assume that finding a proceduralist or surgeon who has performed many cases before would reduce the risk of complications, but the association is weaker than you might expect. There is low-to-moderate quality evidence that choosing a gynecologist who operates more than once a month may reduce the risk of complications. One meta-analysis found that most of the relationship between the number of cases and better outcomes was explained by ICU-level factors (e.g., intensivist staffing model, nurse-to-bed ratio) and hospital-level factors (e.g., technological capacity, trauma center designation).
Second, patients expect providers to act as their fiduciary. The most relevant definition would be “ethically bound to act in the other’s best interests.” Although not explicitly stated in Lasagna’s interpretation of the Hippocratic oath, it would appear that fiduciary responsibility is the basis for the trust patients place in their physicians. This fiduciary responsibility extends into shared decision making to determine the best course of action for diagnosis or treatment using the patient’s preferences and the provider’s knowledge of available options. The responsibility implies an accurate assessment of patient preferences with periodic updates to match changes in patient preferences over time.
Finally, patients expect providers to help communicate with them and their families in ways that are empathetic and meaningful. Within the National Academies’ framework, these patient-centered measures would include “provide information, communication, and education,” “provide emotional support,” and “involve family and friends.” As we in the physician community become “woke,” methods to measure how well physicians demonstrate this responsibility are as crude as how many seconds they wait before interrupting patients during a medical interview. A recent meta-analysis found no published studies of patient-provider communication tracking several psychometric properties, including reproducibility or responsiveness. Commercial rating websites track this dimension most closely. Unfortunately, communication proficiency is not necessarily correlated with competence or fiduciary responsibility.
Without validated, publicly available measures for fiduciary responsibility and communication, what’s a patient or caregiver to do? Bob Wachter penned a New York Times editorial in early 2016 suggesting an over-reliance on quality measures may be counterproductive in healthcare. Don Berwick advocates that healthcare move from an inspection-oriented framework to a change-oriented framework using a new technique (the Associates in Process Improvement’s Model for Improvement), a new culture (focused on testing changes and learning together) and a new strategy (around continuous learning and development). Perhaps the best we can hope to expect is providers, medical groups and hospital systems sharing their learnings with patients and caregivers on their journey toward higher levels of patient-centered behavior and communication.