It’s not a choice: Good quality needs relationships and measurement

photo-joshua-tepperI was thrilled when Dr. Joshua Tepper, CEO of Health Quality Ontario, responded on Twitter to a popular post: Medicine is Relationship, Not Quality Metrics.

Josh has a true heart for patient care and the centrality of the doctor-patient relationship. He is also passionate about quality.

He asked if I would post a response from him, if he wrote one.

I said, “Of course! I’d make it a stand-alone blog post!

So, here is Dr. Tepper’s response. I think it’s excellent and look forward to hearing what you think of it, too.


It’s not a choice: Good quality needs relationships and measurement

Pursuing the six dimensions of quality for improved patient outcomes

This blog is inspired by a posting from Dr. Shawn Whatley a couple months ago.

Shawn is a family doctor, health care leader and an active member of health care’s social media sphere. He does a nice job of bringing a range of different views to the forefront.

In his blog, “Medicine is Relationship, Not Quality Metrics,” Shawn shares the perspectives of two physicians who feel that the doctor-patient relationship is more relevant to good patient outcomes than quality metrics. He quotes Dr. Michel Accad, who says that measuring quality-related outcomes “actually makes quality worse.” He also shares the perspectives of Dr. Michelle Vilcini, who talks about what she sees as one of our collective failings: “trying to measure things that can’t be measured.”

I’ve had a few people ask me via Twitter for my thoughts, so here they are.

First and foremost, it is a false dichotomy to see this as an “either/or” choice. A good doctor-patient relationship is actually one aspect of quality; it is captured within the concept of being “patient-centred” – one of the six recognized dimensions of quality, as defined by the Institute of Medicine. The six dimensions, including safe, equitable, efficient, effective and timely care, have been widely adopted as a framework for quality here at Health Quality Ontario, where I work as President and CEO, and elsewhere. Patient-centredness is also the cornerstone of the College of Family Physicians medical home model.

The importance of patient-centredness is also reflected in a blog by Dr. Ashish Jha, a physician and health policy researcher. In one posting, Ashish reports the results he got after he asked his Twitter community for a one-word response to the question, “What makes a good doctor?” The top five responses were “empathetic”, “good listener”, “compassionate/caring/kind”, “humble” and “competent/effective.” His conclusion: “Most people assume that physicians meet a threshold of intelligence, knowledge and judgement and therefore, what differentiates good doctors from mediocre ones is the ‘soft’ stuff.”

There is no doubt that the “soft stuff” – being patient-centred, and nurturing doctor-patient relationships – is part of quality.

But there are a couple places where Shawn and I might have some differing thoughts on the matter.

With regard to the suggestion that we can’t measure the doctor-patient relationship, Shawn suggests that there is no way to accurately gauge the encouraging friendship between patient and provider. But I’d point to the many ways in which the primary care field is increasingly trying to measure that relationship through surveys that target the experience of the patient. There are examples of patient-centred metrics in the Primary Care Patient Experience Survey and the Commonwealth Fund Survey, two among many, which ask for ratings on aspects of the doctor-patient relationship. These surveys can clue individual providers and entire teams into some of the more subtle areas of their care that need improvement. It’s worth noting that there has also been at least one study suggesting a troubling link between patient satisfaction scores and the propensity to prescribe opioids and/or unnecessary testing. This speaks to a need to measure patient experience in addition to other dimensions of quality, such as safe and effective care, and it leads to my second point of divergence with Shawn’s posting.

Building a strong doctor-patient relationship and concentrating on patient-centredness is just one dimension of quality and good care. But care also needs to be safe, equitable, efficient, effective and timely. Naturally these dimensions overlap, and a strong patient-centered relationship will make the other dimensions easier to achieve, but I feel we must be conscious of all six dimensions – especially when discussing improving patient outcomes.

Finally there is the suggestion in Shawn’s work that having a good doctor-patient relationship means you don’t need “a bunch of numbers” to measure it. In response to that, I’d go back to Ashish’s Twitter exercise. One of his Twitter followers responded to Ashish’s question with the following comment: “If your doctor doesn’t use the best data available to them to take care of you, do they really care about you?” Quality metrics and relationship building are connected more than we might think. Of course we can and should comfort, support and listen to our patients. But we also need to let them know when they are due for a Pap smear or a colorectal cancer screening test, or when a cholesterol-lowering medication might increase their chances of living to see their grandchildren graduate from high school. These are the metrics that make a difference.

I’d argue that we shouldn’t try to choose between good relationships or measurement – one is a dimension of the other. Similarly we should be cautious in suggesting that important things like the doctor-patient relationship can’t in fact be at least partially measured. We’d be doing a disservice to our patients to dismiss all quality-related outcomes when data about our practice can help us provide better care.

Thank you to Dr. Irfan Dhalla and Anna Greenberg for providing their input and advice on this blog.


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Medicine is Relationship, Not Quality Metrics

Kate and Emma in poolRelationships change us. Like walking in rain, we cannot be untouched in relationship.

Doctors make a living building doctor-patient relationships. Sure, we manage cardiac risks, renal function and multiple comorbidities. But more than these, our care starts and ends with relationship.

Dr. Michel Accad, a cardiologist, wrote a brilliant piece: The Doctor-Patient Relationship and the Outcomes Movement. He quotes an article, Strong Patient-Provider Relationships Drive Healthier Outcomes:

With over 50% of primary care providers believing that efforts to measure quality-related outcomes actually make quality worse, it seems there may be something missing from the equation.

I tweeted Dr. Accad’s post as it sped around social media. That afternoon, Dr. Debra Boyce shared a response she got from an “exceptionally smart family doc – very hardworking but rarely rants about anything”, Dr. Michelle Vilcini:

I love this!  I have thought for years that governments are missing the boat on what quality in health care truly is – measuring the wrong things, and trying to measure things that can’t be measured.

Our role as physicians is not only to “prevent hospitalization”   “cost less”  “reach diabetic and BP targets” and “have fewer C-sections” but to guide, empower, and support through friendship our patients who are struggling, who are vulnerable, who need a mentor who understands their health issues and their psyche and will be there for them, even if the outcome isn’t going to be good –the crusty old obese diabetic who smokes, drinks, lives in poverty, has no education, and was abused as a child, is not going to have a great outcome. 

But if I establish a relationship, an encouraging friendship, and he comes to see me every 3 months, shares a joke, reveals pieces of his childhood, cries for the first time in decades when sharing a tidbit of his past, he feels cared for (when no one else cares for him).  Not helpless. 

So when he doesn’t lose weight, doesn’t stop smoking, doesn’t improve his A1c, and then has another heart attack, does that mean I have failed? In the end, our family practice patients all die (so by definition they have a bad outcome).  On paper, I haven’t done a good job.    

But if the patient or the family has felt comforted, supported, and understands better their illness and the consequences by having me walk with them as they are experiencing their bad outcome, I have succeeded.  I don’t really care about anything else.

She went on:

I do truly believe that a caring family doc provides better holistic care to my (actually real) patient than sending him to multiple silo chronic disease management clinics…diabetic clinic, renal insufficiency clinic, CHF clinic, smoking cessation clinic…. he can’t afford the parking and none of those clinics address the guy as a fallible human being who isn’t really interested in meeting their targets and getting put on Ezetrol and Lantus and whatever else.  He only wants to see me because I am a friendly face….

Does this mean doctors can do whatever they want with no accountability to measurable outcomes?

It might appear that way. But we know that patients without any primary care have worse outcomes overall. Patients with chronic disease, who try to manage with episodic visits to clinics and emergency departments, create medical nightmares.

Medicine is Relationship

Having a relationship with a doctor improves health. If that is true, we should not have to prove it again with lab values.

Redefining medicine as a technological intervention undermines care. It changes the essence of medicine – its ontology – from a doctor-patient relationship into applied technology. And it ignores the physician-end of the relationship (see Dr. Bernadette Keefe’s excellent articleQuadruple Aim – Care of the Physician).

The burden of proof should rest on government to show that patients would be better off without doctors than for doctors to prove their worth by how well they adjust lab values.

Doctors are competitive. As they bear increased scrutiny for performance against physiologic outcomes, more doctors will slavishly aim for better lab values. They will improve their metrics. But will patients benefit in the process? Or will we just improve a bunch of numbers?

The doctor-patient relationship serves as the basis for all medical intervention. Relationship is the only therapeutic manouver in many cases. Without it, treatment fails. Perhaps we need greater protection and support for relationships than accountability to lab values and ‘quality-related outcomes’?


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Zero tolerance, Zero Empathy?

zero tolerance signHospitals and government services like to put large posters up that list all the things they do not tolerate.

  • Abusive language
  • Acts of violence
  • Inappropriate behaviour
  • Harassment
  • Bullying
  • Yelling
  • Profanity
  • Verbal threats

Zero tolerance seems a good solution for all kinds of social problems. Whenever anyone wants to say they really don’t support something, they say they have a zero tolerance approach. Here are some example from the headlines:

Hospital leadership adopts zero tolerance policies to support staff. Policies plus proper doors, panic buttons and modern approaches to security best practices help protect an organization’s most valuable asset.

But for some, zero tolerance means zero empathy.  That angers patients.  Upset patients act poorly and make staff feel unsafe. Staff cry out for stronger zero tolerance, and the cycle continues.

Should professionals, trained at managing the emotions of all kinds of emergency situations, need to have giant posters telling patients what they will not tolerate? Is there a chance that zero tolerance promotes callous and pitiless treatment of patients?

In schools, zero tolerance fosters the opposite approach that behavioural concerns require. In Kicking the Nasty Habit of Zero Tolerance, Julia Steiny reports that some teachers say:

I teach the good kids.  I don’t give the bad kids the time of day.  They shouldn’t be here.

When students need to hear:

I care about you.  It is my job, if for no other reason, to invest in your success…

A recent article in Nursing Times suggests the same thing: Do Zero Tolerance Policies Deskill Nurses? Zero tolerance policies assume that dealing with aggression is not part of a healthcare professional’s job.

Zero Tolerance For Staff?

Instead of advertising what we won’t tolerate from patients, why don’t hospitals advertise what patients won’t have to tolerate from staff? Why don’t we adopt a zero tolerance for staff and post that on huge posters in hospital waiting rooms? We could adopt zero tolerance for

  • Staff talking about vacations while ignoring new patients
  • Sneering skepticism
  • Snide remarks and innuendo
  • Condescension
  • Patronizing remarks
  • Unnecessary delays
  • Being bothered by interruptions
  • Abandoning patients to go on breaks
  • Profanity
  • Anger

The worst of zero tolerance attitude tends to seep in and change culture. It takes huge effort to maintain excellence, teamwork and a positive attitude . Ignore excellent behaviour for just a short time and culture risks becoming callous, pitiless, dismissive and cruel.

Healthcare requires professionals trained to handle patients at their worst. Even nice, polite, otherwise normal people can scream and swear when in unbearable pain. Professionals know this. Professionals pay attention to safety, but then they manage bad behaviour with grace and magnanimity.  Zero tolerance posters should be beneath them.

[photo credit:]


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