For centuries, doctors have followed the lead of Hippocrates, who advised physicians “not to discuss with patients the nature of the illness and the treatment. ” Even worse, health professionals have not always provided their patients with realistic estimates of possible outcomes. This reticence on the part of our doctors—combined with our unrealistic expectations that high-cost, high-tech medicine should be able to “fix” virtually any health problem — has produced a common medical scenario in which layfolk experience health care as a realm controlled by magic. Within this world, the physician is the all-powerful shaman, medical knowledge is composed of a treasury of secrets reserved “for doctors only,” and patients are expected to adopt an attitude of blind obedience to doctors’ orders.
Back to Reality. This arrangement has produced serious problems. Consumers who have little or no information about their problems and the range of possible solutions can’t make good decisions about their care. Uninformed patients can’t check for professional mistakes. And laypeople who are led to believe that doctors have a magical cure for every possible illness are set up for inevitable disappointment.
“Public expectations of health care in this country are substantially removed from reality, ” says Dr. Dennis O’Leary, president of the Joint Commission on Accreditation of Hospitals. “Blind trust in medical treatment is not in anyone’s best interests. Consumers can make better decisions if they have better information about all their available choices. “1
It was only about ten years ago that popular attitudes toward these matters began to change. Just over a decade ago, when I was still in medical school, I accompanied one of my patients to the medical library to help him find information on the various treatments available for his condition. The librarian refused to admit him. She had been instructed to keep laypeople out of the medical library. Her superiors assumed that the only consumers who would seek such information were hot-headed “problem patients” gathering ammunition for malpractice suits.
Fortunately for all of us, there has been a massive change in such attitudes. Today that person would doubtless receive a good deal more encouragement and support. During this same period, we have seen an unparalleled explosion in the quality and amount of medical information available to the public—everything from coverage of the latest high-tech breakthroughs to practical tips on common personal health problems.
From Orthodoxy to Outcome. The prestigious Joint Commission on Accreditation of Hospitals recently announced plans to evaluate hospitals based on clinical outcome measures. Each hospital will be graded for its effectiveness in dealing with every possible type of health problem. When this data is made available to the public, consumers will for the first time be able to determine which local hospitals really do offer the highest-quality medical care.
In a few cases, hospital administrators currently have these figures but refuse to disclose them to the public. But in most cases, even the administrators themselves don’t have this information. This has made it extremely difficult for them to root out pockets of poor quality care.
If, for instance, a certain hospital experiences an unusual number of deaths in the intensive care unit, an in-house quality control committee can investigate the problem immediately. If it persists, the accrediting body would send in an investigating team.
The U. S. federal government has already begun providing information on some medical outcomes. Peer review groups already disclose data which shows:
The overall death rate, by hospital, for different types of surgery.
The number of patients who develop postoperative infections.
The average length of hospital stay for a given condition.
How frequently each surgical procedure is performed at a given hospital.
Quality-of-Care assessment will eventually extend to all health care institutions and all providers. Patient outcome will be the key measure. Until now, physician credentials and organizational factors were the key measures. In the past, it was simply assumed that doctors who had the proper credentials did top-quality work. In the future, reviewers will be looking at actual results.
Individual departments—and individual physicians—will also be subject to outcome-based review.2 In one recent study of intensive care units (ICUs), George Washington University researcher William Knaus found that ICU death rates in the worst ICUs were 2.7 times higher than those in the best. Another recent study of physician performance revealed a 3.2 percent overall rate of medical mistakes for inpatient care. Of these medical errors, 23 percent involved unnecessary medical services, 29 percent were life threatening, but did not result in injury or death, 4.0 percent resulted in delayed recovery, 6.0 percent caused a non-life-threatening illness or injury, 6.0 percent caused a life-threatening illness or injury, and 4.4 percent caused death.
The emergence of clinical outcome measures raises two thorny questions:
Are hospital administrators the most appropriate people to administer such a quality-control program or might they be unduely influenced by the increasing pressures of cost consciousness and by narrow concerns for the viability or success of individual departments, institutions, or enterprises? The answer here seems clear: We must include consumers as well as professionals on quality review boards.
Will these new clinical outcome measures be able to account for such subtle variations as genetic, economic, and social status, level of individual responsibility, and what clinicians sometimes call “good and bad protoplasm?” Although much recent progress has been made, the best of our present clinical outcome measures leave much to be desired. The development and application of effective clinical outcome measures must be among our top medical priorities over the next decade.
Deprofessionalization. On the brighter side, some observers believe that the availability of more accurate outcome data will provide health care institutions with a greater degree of flexibility in developing more cost effective treatments. The quality control methods of the past, based on credentials and degrees, led to placing M.D.s in virtually every responsible position. Quality outcome measures should allow institutions to develop more effective ways to perform specialized techniques—e.g. using surgical technicians to perform heart bypass surgery or surgical robots to perform cataract surgery. If an institution is able to document the fact that the patient outcomes from such new procedures are equal or superior to those achieved by M.D.s while costs are substantially lower, it will be very difficult to argue that they should not be allowed to provide these services.
Thanks to Dick Fine, Jesse Hall, and Charles Inlander for their valuable contributions to this column.
I. “JCAH Accreditation Linked to Outcomes,” Medical World News, 27: 19, pp. 21-22, Oct. l3, 1986.
2. “Outcome-Based Review Will Extend to MDs,” Medical World News, Vol. 27, No. 19, p.24, October 13,1986.