Name tags and Paper

Some people have very impressive "paper". I mean the pieces of paper that are mounted in frames and hung on the wall. They make proclamations that the person who owns the paper is of some special significance. We use paper as a surrogate measure of quality. The paper says, "This person is of quality." And this is what we rely on. I have some fancy paper. At one time, it hung on the wall. I'm not really sure where that paper is right now. I suppose I could dig out of a closet somewhere here in the office.
Now, there are some who aren't happy with paper. Medicare wants to measure quality, as do most of the insurance plans. Of course, there's some worry about this. Medicare wants to withhold 2 to 5% of hospital payments and then return it to them based on quality. They have already begun a 1.5% "bonus" for physicians. The "bonus" comes from paying less than normal to everyone. It's a re-distribution to the "better" physicians.
I think we need to try to figure out what quality is. The problem, though, is that no one knows. We do have some "standards". There are recommendations that people should know. The problem, though, is that whether someone follows recommendations or not is no measure of quality. There are often very good reasons to avoid the recommendations. I'll give you a good example: There are times when you should jump out of your window. I generally advise that "Jumping out of the window should be avoided." This is based on sound scientific evidence that has shown this behavior may create injury. However, if there is a fire that has consumed the entire building below you and you are about to die of smoke inhalation, it may be advisable to ignore this particular "guideline".
Outcomes are also a bit of a problem. A very prominent heart surgeon was removed from an HMO panel. They didn't think he was a "good surgeon" because too many of his patients died. Almost every cardiac surgeon in the area fought to have him re-instated. That's because he was the surgeon that every other surgeon sent the patients who were too difficult. They would say, "You're going to die. There's nothing that I can possibly do for you. However, I can call Dr. Smith." And invariably, "Dr. Smith" would operate on them. Well, he didn't have good "numbers". So he was felt to be a poor surgeon.
Well, if we can't use paper, we can't use guidelines, and we can't use outcomes -- what is there?
There is a book I read once, a long time ago: Zen and the Art of Motorcycle Maintenance. It was mostly an attempt to address the question of "what is quality".
There are two variations of intelligence. One of them is what I call "academic thinking". This is the vocabulary, calculations, logic and all of that kind of thing. Another, less understood intelligence, is intuitive knowledge. Some people just know. They can't explain it at all. I guess we can call it "faith".
I think we only can know quality on faith.

It's "Just Business"

A colleague saw a patient for shoulder surgery. The patient was sent to him by another orthopedic surgeon. His family doctor had sent him there. It was strange, because that surgeon asked the patient: "Why did he send you here? I don't do shoulders." So he sent him to this other orthopedic surgeon. You would think, perhaps, that maybe the "primary care" physician thought the other surgeon was better. However, that wouldn't explain why he had sent his wife to the second doctor. In other words, he would send his wife to one physician for surgery and he would send his patients to another one - one who doesn't do shoulders. Well, it's not really much of a surprise. People send the patients where they're "supposed to". That may be the best specialist for the job in some people's minds. However, if you are an administrator who employees physicians, the physician that your employees send patients to may be the one who has the best economic performance gains for your interests. It's "just business," after all.
I hate the medical "business".
In my town, the new hospital CEO has spent the last two years buying every internal medicine practice that can be bought. At this point, they are all owned except for two. So what the CEO says is what happens. Since they are now going to be hiring a neurologist, all of the referrals for neurology are likely going to go there. But that's "just business". I'm lucky, because a great deal of my practice comes through referrals from patients that have seen me previously. But it's still disconcerting. I think patients expect that their doctors are going to make referrals on the basis of quality.