With the recent announcement that Zagat Survey and WellPoint have partnered to assess patient satisfaction with their physicians, consumers will be able to research doctors in much the same way they investigate local restaurants.
Some might point out the limits of customer ratings of doctors based on the politeness of the receptionist and waiting room decor, but Zagat, a compendium of consumer reviews of leading restaurants and hotels, asserts it is not evaluating medical skills. A number of rating schemes make the assumption that physicians already have basic medical knowledge and technical and analytical skills, but how can the consumer be assured that this is true?
Even many clinical-performance measures that populate report cardssuch as achieving targets for diabetes, hypertension and asthmacan be accomplished by a well-functioning office staff. What most report cards dont assess is whether a doctor can sort out confusing symptoms and identify a correct diagnosis; has the ability to select the best course of treatment given how rapidly medicine is changing; or can effectively manage multiple conditions.
My colleagues at the American Board of Internal Medicine argued recently in the Journal of the American Medical Association that in addition to performance measures, clinician knowledge and judgment matter when it comes to quality care and should be key tools in the physician-assessment toolbox. Through ongoing board certification programs, physicians are able to test and enhance their clinical judgment and skills, and consumers are able to track if their physician has the knowledge needed to deliver quality care.
Medicine overall, and diagnoses in particular, are incredibly complicated processes, requiring information collection, processing and clinical judgment that must be accurate and skillfully performed. The word diagnosis is derived from the Greek words dia, which means by, and gnosis, which means knowledge. The ability to identify patterns, to recognize that a given constellation of signs and symptoms means diabetes or lupus, depends on knowledgenot knowledge that is looked up, but knowledge that is woven into the fabric of a physicians analytical framework.
Because of this complexity, we need a multifaceted, yet aligned, approach to assessing the range of physician competencies that can help ensure high-quality healthcare. Unfortunately, many of our first-generation performance measures used to evaluate physicians cover only a fraction of the myriad health problems seen by doctors on a daily basis. These measures also assess performance after a diagnosis has been made, and, in fact, many of these measures assume a correct diagnosis.
In addition to assessing diagnostic acumen and clinical judgment, many certifying board assessment programs, including that of the American Board of Internal Medicine, also use data from physician practicespatient-experience survey data, information about practice infrastructure (e.g., reminder systems, electronic health records) and clinical data from medical records, whenever possible based on National Quality Forum measuresto help doctors better understand why they have gaps in practice.
For example, is poor glycemic control among a physicians diabetic patients a result of inadequate patient-education programs, lack of a reminder system to systematically bring at-risk patients into the office for regular monitoring or the physicians lack of knowledge about how to manage diabetes? A single measure will not provide the answer to this or other knotty questions, which is why the board programs take advantage of multiple tools to help diagnose gaps in practice.
Further, board programs require that physicians design a quality-improvement plan to address gaps and report back what happened after they implement the plan.
The fact is that physicians are under ever-increasing scrutiny in their delivery of healthcare. Health plans, hospitals, Medicare and a variety of other organizations are requesting that physicians submit performance data to a variety of sources. Given the importance of clinical judgment and skills in providing quality patient care, policymakers need to consider expanding their notion of performance to include recognition of ongoing board certification as an effective means to assess whether physicians have effectively incorporated new knowledge over time into both their thinking and practice, and have taken steps to address gaps in practice.
Growing numbers of hospitals and health plans are beginning to recognize that board certification is an important marker for quality. Some require certification for credentialing. More specifically, a growing number of national health plans (UnitedHealthcare, various Blues plans, Aetna and others) are recognizing certification in pay-for-performance programs, quality tiering networks and provider directories. Congress recently suggested that maintenance of certification might be one approach to fulfilling the quality-reporting requirements for Medicare under the Physician Quality Reporting Initiative program.
There is an old African proverb that says, Knowledge is like a garden; if it is not cultivated, it cannot be harvested. Physicians are surrounded by an ever-expanding scientific evidence base that is challenging to keep on top of. Yet evaluation processes like ongoing certification can help stimulate cultivation of this growing knowledge base as well as provide tools for physicians to use in digging into their performance data so that they can better understand gaps in practice and drive toward better quality care. Their patients deserve nothing less.
Christine Cassel, M.D.President and chief executive officerAmerican Board of Internal MedicinePhiladelphia