Most folks who go into medicine have some overt and/or covert altruism in their minds and hearts. And they assume that they will do good and well in their careers in a way that they can identify, even possibly that others will also note. However, individual public recognition is oddly uncommon in medicine and usually an undiscussed side product.
As inevitably as "the day follows the night," doctors will have a series of unpredictable and unpleasant epiphanies in their training and, more importantly, in their practice careers. It will dawn on some, and shock others, that informational and/or nurturing feedback is irregular and unpredictable in its occurrence, its value and its utility. And surveys regularly document doctors’ lack of satisfaction. "Success" is another subject we will visit.
Personal goals in the practice of medicine are infrequently discussed or sometimes not even personally identified. The average doctor would probably be somewhat embarrassed and vague, reaching for acceptable platitudes. But upon scrutiny, many of us might say that what we set out to achieve should be visible, measurable and emotionally rewarding.
Unfortunately, there are obstacles to each of these that we are not prepared to plan for, and therefore understand, for an optimal result in our careers and for our patients' outcomes. For instance, unlike all good medical studies, few doctors have the time, money or focused interest to assess in a methodical way the results of their individual medical activities.
Instead, most fall back on the unconscious human need and ability to look for pattern recognition. This often gets euphemized as "clinical judgment," the great default authority left over from the pre-scientific age where there was no hard data upon which to base an evaluation.
Today we have advanced to "best practices" and "evidence-based" medicine, which is a step forward, but even these are not practiced widely enough. Again, it is time consuming and therefore expensive to do, as well as emotionally demanding to stop and change course repeatedly as we learn more. This is particularly so in a private practice that also feels the pressure of running a small business without benefit of current knowledge on management, my oft-harped upon mantra.
Doctors are often not fully prepared to capably assume the surprising array of tasks in and out of the science of medicine that are required of a modern physician. These include both keeping up with rapidly changing science and technology, and smoothly running a business or effectively using the larger organization that they are a member of. Both affect "quality," outcomes, the bottom line and outcomes.
Doctors do the best that they can with the tools that they have, often falling back on past experience and innate intuition. But we too often confuse the urgent with the important, sometimes sliding into expedient rationalization and self-deception.
If you know a health care management consultant, ask him/her how many practices, large or small, and how many doctors, are well prepared and well organized. There are a large number of consultants who make a good living helping us avoid losing money and improving patient care because we quickly learn that we cannot do the best job for ourselves and our patients without post-training learning and/or help. It is apparent that the requirements to do well in practice have been steadily rising in complexity with only the promise of more to come.
And this raises another important question: Do most doctors realize the difference between patient satisfaction/good service and "good quality" health care? And then act on that knowledge of difference? Many of us do not or rationalize away our inattention, in part because it's as tough as grabbing an eel in a tank of water.
First of all, what is "good quality" care? Health and management literature has been full of ideas and arguments on this question for years. Defining it has been made more difficult by the fact that it is a moving target. Suffice it to say there is no simple accepted standard yet, although many groups have made earnest, if flawed attempts at it. The hazard here is that when you have a metric in place, you attach too much validity or value to its sometimes shaky assumptions. I have seen this happen in group after group.
So most doctors, working hard to do their best, use "belief dependent reality," which is what Michael Shermer calls our need to cling to what gives us comfort in his The Believing Brain. This assumes that we are doing a helluva good job for our patients, without much objective measurement.
When I once asked a prominent local surgeon, who was also the chief of staff at our hospital, how his personal surgical outcomes compared to national benchmarks, he was offended and said he "didn't bother" to keep track. How many of us do keep some sort of objective stats on our work? I was taught that we should, and should ask others, but most of us learn how hard it is to do so and so we keep our mouths shut.
I am sorry to say that this probably is an obstacle to optimum patient care, even if we don't want to admit it or talk about it. Just one more ding against the knowledge that may allow us to feel good about what we are doing and to back it up with some kind of evidence. And on that disturbing note, we'll plan to explore further next time, looking for a safe harbor.
Jeff Brown, MD, is a Board Certified Family Practitioner, currently doing geriatrics as a Medical Director, and is also a consultant for the California Medical Board. Dr. Brown can be reached at email@example.com.
Jeff Brown, MD, is a Board Certified Family Practitioner, currently specializing in geriatrics as a Medical Director, and is also a consultant for the California Medical Board .