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Whining About Physician Ratings

By Brian L. Grant MD

Until reading this interesting Forbes article, I had never heard of the Press Ganey company and their ratings for hospitals and doctors. I am familiar with online ratings such as those on Healthgrades.com.

Ratings are problematic to the degree that they may reflect low sample sizes. Especially when responding is optional, those most likely to rate the quality of their medical care may be patients with complaints. And satisfaction with care may be correlated with important issues like listening, time spent, and other behaviors important to patients.

However, one is not guaranteed the best care from a doctor who has great demeanor and a brusque physician may have great clinical judgment and provide better care and outcome in many situations.

To those physicians who complain that the surveys force bad behaviors on their part, one can only bow one’s head in shame.

Integrity means doing the right thing regardless of whether one is not being watched, or in this case, when one is being watched and scored. If the scores are flawed, so be it. It does not justify over-prescribing or any other actions that do not further the right medical decisions and care.

Nobody ever said that doing the right thing is always easy. But really colleagues, is it that hard to say no to a few extra dollars based upon flawed ratings? Is it really that hard to say no to an administrator trying to tell you how to practice medicine? Is it really that hard, if all else fails, to find another job?

The comments in this online article add more color to this interesting topic.

Medical Record Abuse

By Brian L. Grant, MD

The timely New York Times article, “A Shortcut to Wasted Time,” describes problems arising from improper use of record keeping.

It is important that those involved in medical care and treatment review, including those requesting these services understand the capacity of electronic systems to be misused.

There is nothing wrong with such systems and they are not going away. But as with most information tools, the quality of what is generated is only as good as the input, in this case the clinician doing the work.

Electronic systems can be abused and misused in many ways. And one does not need an expensive record system to misbehave. Microsoft Word will do. In the course of reviewing records, I have seen a number of abuses.

Here are a couple of ways to identify the misuse of medical record systems:

  • Boilerplate used where unique data is required: A psychotherapist working with a patient over time reports the exact same mental status findings from week to week, in the same words. People change and emotions are not static. The clinician demonstrated laziness and questionable competence when each note read substantially the same, courtesy of cut and paste or template.
  • Normal findings reading exactly the same: Physical and mental status findings have many variations. This includes normal findings. When an orthopedist reports the same range of motion on multiple patients, where the normal range can and does vary, a reader can conclude that the measurements are likely inaccurate, and the overall credibility of the examination is in doubt, including whether the measurement was actually taken.

In the old days of handwritten or dictated notes, each entry was unique and required that the clinician take specific action to report a given finding. Now with a click of a mouse, one is capable of filling a page or more with content. Just because one can, does not mean one should.

If you create records, demonstrate thoughtfulness and do not use boilerplate for findings. A template can be useful as a guide to what content should be included for a particular assessment or complaint. And typed records are legible unlike most handwritten notes.

If you read records and see findings reported in such a way to suggest that they were computer and not clinician generated, it should raise red or yellow flags about the overall quality and credibility of the treatment records and the clinician describing the treatment.

The abuse of record systems is a significant unintended but entirely predictable consequence of the technology. I invite readers to comment on their own findings and observations from working with or reviewing the work product of such systems.

Read More…

Medical Payment Collection Gone Wild

By Brian L. Grant, MD

Emergency rooms sit of the front lines of the health care payment crisis as they must provide care to all who come though many can’t afford to pay. Photo by Adam Gault / Digital Vision / Getty Images.

Emergency rooms  sit on the front lines of the health care payment crisis. On the one hand, they must provide care to all who come – by law, custom and ethics. On the other hand, the care is expensive and many can’t afford to pay. Many of the uninsured use ER’s as their care sources rather when they lack access to clinics and physicians. Creative companies have found ways to profit and help pay for the care provided. In this case, one such company crossed the line of decency and legality. Our fee for service health care system assumes that personal responsibility and solvency can be relied upon. Is society served by financial triage for essential or urgent medical needs?

One day not too far off, stories such as the one featured in the New York Times article “Medical Debt Collector to Settle Suit for $2.5 Million” will be looked at with the same shame we feel towards the discrimination practiced in our country based upon race and other factors in past decades. We would regard it as abhorrent to deny access to K-12 education for the poor. Why do we believe that different standards ought to apply to access to health care? Why should employers have the burden and responsibility of providing health care for their employees, rather than this be a basic part of the social contract as members of society?

Do we as citizens and particularly those of us who have chosen to enter the field of health care have obligations beyond caring for our patients – to address systemic shortcomings and abuses the adversely impact the public health? Or is medicine just a job, and our goals to maximize profit?
Read more here: “Medical Debt Collector to Settle Suit for $2.5 Million”