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Monday, April 09, 2007

A physician can "expect some bad outcomes" but a patient should expect physician will do the right thing

I have written about the essays of Dr. Lawrence J. Hergott before.His writing has have appeared in the " A piece of my Mind" section of the Journal of the American Medical Association and most are available in full-text form for free.

His "Playing the Moonlight Sonata from Memory-celebrating the Wonders of Our difficult Life"and his other JAMA essays should be part of a handout package of readings for medical students or house officers. He is able to extract experiences from physicians lives and the principles that govern them and put them into words with skill that I envy.

In the "Moonlight Sonata.." piece he candidly writes about a clinical encounter that went very wrong and which although it occurred decades ago still replays itself with"uncomfortable clarity and a surge of briefly incapacitating sadness and guilt" .

He quotes the following advice of a pioneering, invasive cardiologist, Andreas Gruentzig:

"If you are are going to be a physician ,deciding hourly about things that affect the health and lives of patients and their loved ones, expect some bad outcomes. They will occur , no matter how careful or how good you are."

Hergott continues

"We remember forever the suture that tore,the obstetric delivery that went bad...but we quickly forget the decision to order a lung scan that clarifies the diagnosis and saves a life in a subtle case of pulmonary embolism" He is right, we agonize forever over the bad outcome but quickly move past the good decisions that made major favorable differences in our patients lives. The physician who strives to do the right thing for his patients agonizes when things go wrong and he does it not because of momentary incentives.

In another essay entitled Galileo's Grapes Dr. Hergott says the following:

"...in matters of patient care the physician decides and acts alone-and lives alone with the results of those decisions.It is this aspect of medicine that delineates reputation from character. Reputation comes from things we do that others know about.Character emanates mostly from actions taken while no one is looking."

I wonder what accepting pay-for-performance (P4P) payments and playing the P4P game will do to physician's character. The exercise is,at best, accepting a bribe for doing the right thing. ( Again, my gratitude to Dr. Faith Fitzgerald for pointing out the bribe nature of P4P).
However, it often may really be accepting a bribe for doing the wrong thing (adhering to a general quality guideline even though that is harmful to a given individual patient.) I recently wrote about that referencing a post from Health Care Renewal.P4P is accepting a bribe for doing something that a guideline or quality indicator says is right with no consideration of the particular facts of the case at hand or the values of the patient.

Dr. Edward Blum has argued that P4P is- at the core- unethical. I agree. For physicians to accept it is to admit and announce that our fiduciary duty to do the right thing for the patient is not enough-we have to be paid extra to do it.We are saying that we will not know and will not do the right thing unless some organization or group tells us what to do and and then gives us a tip for doing it their way. Our efforts to fashion a good reputation,i.e. a profitable one with the insurers, will do the obvious to our character.

Many good arguments have been raised regarding how P4P will have negative consequences in terms of quality and patient outcomes but, in a sense, these arguments , as cogent and reasonable as they may be, may really beg the larger issue. The larger issue is that P4P is unethical and should we be haggling about the technical details of something that is clearly wrong in the first place.

1 comment:

Anonymous said...

The ethical thing to do is to not take part in the P4P travesty.Doctors are so dependent on third party payers that few are going to take that route.Why are there no P4P plans being proposed for lawyers,architects or anyone else? For those services people use their own first dollars.