Fam Pract Manag. 1998 Mar;5(3):11-15.
The current mantra of the Continuous Quality Improvement movement is, “Variation is the enemy of quality.” The gurus of CQI would warn that such a slogan simplifies their science, but many managed care organizations seem to operate on the principle that there is one best way to treat every illness. If all their doctors would only get in line and fly right, they would all use the same CPT codes, ICD diagnoses, lab tests and formulary drugs. They would all achieve identical results: optimal outcomes at the lowest cost. Clinical practice guidelines, care pathways, disease state management programs and outcome measures have all proliferated based on these articles of faith.
Attractive as it may be to the cost accountants who rule managed care corporations, this formula is too simple, too easy and takes too much of what we do as family physicians for granted. As Einstein warned, “Everything should be made as simple as possible; and not one bit simpler.” The technology of improving patient outcomes through performance measures based on clinical practice guidelines is still largely unproved. Like any major new medical innovation, it deserves trial and evaluation. As with electronic fetal monitoring or home terbutaline infusion for premature labor, we risk being carried away with enormous costs and worrisome liability risks if we do not make a critical appraisal of these methods before accepting them as standard practice.
Variation is not the enemy. Nor is the practicing doctor. Death, disease and disability are the enemies. To do our best to help patients overcome these risks, we family physicians should base our practice, insofar as is reasonable, upon available evidence of outcomes, responsible use of resources and support of patient preferences. The job is not so simple as the bean brains suppose. CEOs can please all their stockholders the same way: one dividend check at a time. Family doctors, however, must provide care to many persons in all their variety. We have to care for each patient as an individual, orchestrating a sensitive approach to multiple problems, many of which are undifferentiated and all of which are usually in different stages of their natural history. Many of the problems we treat don't fit conveniently into ICD-9 codes, no matter how many decimal places we use. The “C” in CPT does not stand for “care.”
True enough, variation is an out-of-control problem in today's medical care. Each of us is bombarded weekly with conflicting directives on patient care — guidelines, pathways, formularies and who knows what all. They come at us from managed care organizations, government agencies, liability insurers, employers, disease and organ societies, specialty organizations and other special interest groups. The stack of printed materials alone is a Tower of Babel that frustrates our efforts to plan, evaluate and improve how we treat patients. Add to that the overwhelming variety of restrictions payers are pushing on us to control prescriptions, tests, referrals, procedures and hospitalizations! Every aspect of what we do for patients is coming under an increasing variety of conflicting directives. Almost all are aimed at reducing the cost employers and insurers pay for the care we provide. They make simple measurements of quality to plug into their proprietary formulas for value. Usually this means simplistically measuring selected benefits and dividing by what costs are convenient to glean from their billing records. In their rush to promote their products and cut out their competitors, plans choose to avoid the clinical complexities and human costs that we deal with every day.
Simplicity is the hobgoblin of small minds, according to Benjamin Disraeli. Variety is the essence of humanity; it is certainly the soul of family practice. The executive who believes that medical care is as simple to measure as widget production either has never been in a family doctor's office or has been in the board-room so long that the ozone and cigar smoke have blurred his or her vision of the real world that physicians and patients must face every day. The excellent family physician values variety, manages uncertainty and adapts evidence-based practice to the needs of each patient as a person. Evaluating and improving our patient care is an essential challenge. Continuous quality improvement is one tool we can take from industry if we keep it sharp, know its limits and use it wisely. We all have room for improvement, and sensible managers with sound science can help us identify opportunities to improve the care we provide to our patients. I believe family physicians must provide leadership on these rapidly moving fronts. But we must refuse to let the suits simplify our work and devalue the added value that the family physician brings to patient care. The challenge is not simply to measure how well I treat diabetes, or even how well I treat Mrs. Jones with her diabetes, hypertension, depression and vaginitis. The challenge is to evaluate — not for its cheapness but in its richness — how well I care for Mrs. Jones.
Copyright © 1998 by the American Academy of Family Physicians.
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