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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26 Replies to “Medicine is Relationship, Not Quality Metrics”

  1. BRILLIANT Shawn — thank you for reminding me why, in this morass of politics and powerlessness and anger, why oh why I became a physician. It’s the relationships that help me become empowered and impassioned. It’s the relationships that help empower my patients in turn to be passionate in their lives — even if they fall below that perfect number.

    1. Thank you, Nadia!

      I hope it was obvious that the guts of this post came from others. They inspired it.

      I sure appreciate you reading and taking time to comment!

      Best,

      Shawn

  2. My grandmother ruined my intervention skills. When I was kid I remember her being upset that cigarettes and alcohol were always being taxed more. She didn’t smoke and rarely drank a thing. But she said “people work hard and don’t have much and their only pleasure is a beer and a cigarette on Friday night”.
    So while I would encourage my patients to quit smoking and not indulge too much…I eventually would know who was ever going to quit, and who had bigger problems to worry about, and I imagine my pleadings were less convincing over time. But I could tick the box.

    1. What great, humane comments, John. How rare to hear this message delivered from a central planning committee. We lose more and more of the human element in medicine without ever acknowledging that medicine is nothing without the human element.

      Your comments capture the unmeasurable heart of clinical care.

      Thanks!

      Shawn

  3. Great blog Shawn. As Einstein said “not everything that can be counted counts, and not everything that counts can be counted”.

    1. Great quote, Brad. Thanks for sharing it! Someone else said, “The most important things in life are not things.” Maybe we could say the most important metrics in medicine cannot be measured?

  4. Thank you once again Shawn for giving us the big picture and putting it all into perspective.
    So many of us have been so upset with the ridiculous shenanigans of this Liberal government and so caught up with just trying to get through that we have likely forgotten what it is all about.
    Thank you for bringing me down to Earth and reminding me about what is important about being a doctor and just what a wonderful, privileged profession and opportunity that we all have just to be with our patients.
    Ken

    1. Thank you for this, Ken. I feel a huge sense of relief to imagine not having to measure up to someone else’s definition of quality, to not worrying about clicking off all the EMR reminders about screening and prevention just in case I have a peer audit, and to just focussing on meeting the patient’s felt needs.

      I agree, we have a privileged profession. We need to make sure it doesn’t get ruined.

      Kind regards,

      Shawn

  5. while taking care of a palliative 80 year old I got into an altercation with the diabetic educator. she insisted I talk to the patient about the gummie bears at his bedside. the dude was a sugar addict and it was one of the last pleasureable activites he had left.

    after trying to reason with her about the ridiculousness of keeping his blood sugars in target range, given that he had 1-2 months to live, and failing…I ended up writing the the following as an order in his chart: “gummie bears prn”.

    treat the patient. not the numbers.

    1. Wow. What a great story! You captured the heart of the issue. So many people cannot see beyond numbers; they cannot see the patients.

      Thank you so much for adding this.

      Best regards,

      Shawn

  6. Emily Dickinson’s poem has stuck in my mind since high school:

    IF I can stop one heart from breaking,
    I shall not live in vain;
    If I can ease one life the aching,
    Or cool one pain,
    Or help one fainting robin
    Unto his nest again,
    I shall not live in vain.

    … and then on our first day of medical when the Dean quoted Dr. Edward Trudeau’s famous aphorism that a physician’s role is, “To cure sometimes, to relieve often, to comfort always,” I felt that I had come to the right place.

    Shawn, I will be sharing the link to this blog with all of the medical students who spend time with me.

    Thanks!

    1. Bruce, I always say that the comments make the best part of a post. You just proved it! Thank you so much for taking time to share. You captured the essence of the post in a few words. Powerful.

      Thanks so much for reading and taking time to share!

      Best regards,

      Shawn

  7. Shawn, I love everything you write. 23 years in primary care, I couldn’t agree more with what you state. We are in the relationship business and I wish there were good ways of objectively measuring that unlike A1c and LDL results. I don’t think the MOH’s idea of the patient surveys for the NGEP program will quite do this (though I have no idea what questions they plan). Wouldn’t it be nice if this government had physicians amongst its members who understand the value of relationships? Oh, Dr. Hoskins, are you reading this? Didn’t he train in primary care or did he throw out all HIS values when he entered politics?

    1. Thank you for such kind encouragement, Ira! It means a tonne.

      I’ve heard back from some docs by phone and on social media. They defend metrics as a way to elevate our game, to keep us all improving. I agree. I am not Ned Ludd trying to lead a revolution against all metrics. But I do think we need a stronger balance to the Outcomes Movement. The most important aspects of care cannot be measured and reported in a Quality Scorecard. Unless we make space for the heart of medicine, with intention, effort and persistence, relationship will continue to wither. Patients, and doctors, will suffer for it.

      Thanks again for taking time to read and comment!

      Kind regards,

      Shawn

  8. This is a wonderful reflection, and a fantastic reminder of the type of care many of us strive for. In our results-oriented society, I fear that caring professions (not only physicians) are chronically undervalued. Outcomes mean $$$, and the caring is expected to come for free.

    1. Great comment: “Outcomes mean $$$, and the caring is expected to come for free.” !

      Accountability – the current fad in healthcare – demands money for outcomes, nothing else. But evidence based medicine has a terrible time with qualitative research. It looks too soft and wooly. Therefore, the tiny bits of medicine – the BP or A1c – come to define what we do; it’s what we get paid for.

      As cuts make us run faster and faster, and as regulators make us tick more boxes and track more metrics, we might find a revolution building that says, Enough! Care takes time and cannot be measured with the tools bureaucrats use. I hope it happens sooner than later.

      Thanks again for taking time to write!

      Best,

      Shawn

      1. I truly hope we can one day recognise the value of all our caring professions.

        It’s easy to lose track of what we truly want to measure when we use so many surrogate outcomes. You mention BPs and A1Cs – we often forget that these are not outcomes in and of themselves and mean nothing on their own. We spend so much time treating risk factors (even risk factors for risk factors!) and patient priorities sometimes gets lost in the shuffle. I agree that we need to redefine quality care!

        Thanks for your thoughtful reply,

        Katherine Larivière

        1. Great comment, Kathherine – “risk factors for risk factors!” Thanks again for writing. Best, s

  9. Shawn,
    I read most of your posts, but this is by far my favourite one.
    While bureaucrats are trying to push physicians into churning numbers that look good on reports, the patient does not get cared for, just the disease. Every time I hear of a new clinic in my community dedicated to looking after a specific disease, I cringe because I know the patient will get passed around like a bucket of Halloween candy, each provider gets a piece and the patient is left empty.
    Believe it or not, I had this exact thought on my mind this morning as I was driving to a coroner call, frustrated with reading comments from peers who value most efficiency and income in their practices rather then the caring, which is not exclusive to one model of primary care.
    Unlike many peers who blog, I truly feel you are standing amongst us and not on a pedestal with your posts.
    Thanks again.

    1. What a great analogy, Monique! “…get passed around like a bucket of Halloween candy…” You describe exactly what happens to so many patients. And we feed into it. We aren’t funded to spend the time, so we send patients off to special clinics that are funded. But patients get dumped after the clinic has provided what they were paid for.

      I sure appreciate your kind comments. This post came 90% from others. I just added a little flavour. The best posts always come from thoughts and ideas shared by you, colleagues and readers.

      Thanks again for taking time to read, and to comment!

      Kind regards,

      Shawn

  10. Indeed, this is the crux of being a good family doctor – how do we get to know if we are indeed serving our patients well besides just saying it is so?

    So far we can measure
    a) access
    b) a survey created in a consultative process by HQO that asks patients about their experiences within the practice

    AFHTO is looking for physician input on “measures that mean something” and I was disappointed that there were TWO physicians of hundreds invited that attended a recent teleconference on the issue.

    CONTRIBUTE your ideas! Contact the OCFP, or AFTHO, or the OMA. Be a part of helping our profession show its worth to our population and our government and funder in ways that do a better job of capturing the essence of our daily blood, sweat and tears.

    Jennifer Young

    1. What a great call for input, Jennifer. You are right. If we do not provide input, others will for us.

      Thinking more about this, I wondered how we decide which accountant to use. They must do accounting well; that’s a given. But they also must be able to explain, relate and creatively solve problems for us. These last features determine which accountant we use, assuming the basic accounting skills exist. If we find our accountant under-performs on everything beyond the essentials, we change accountants.

      The analogy falls apart if we assume that essential accounting – getting the numbers right – is the same as essential medicine. In medicine, the essential part is the relationship. Without relationship, all of medicine falls apart. But the solution for identifying and dealing with under-performance could be the same, let patients change docs. We need to let patients have a greater role in determining value by voting with their feet.

      Just a thought.

      Thanks so much for sharing your comments!

      Best,

      Shawn

      1. After writing the reply above, I thought to add the old adage, being a good family doctor is ALL of being:

        Available
        Able
        Affable

        I totally agree that relationship is central to family medicine, but it is not the only thing. In addition, we will hopefully find out from our patients how to improve on all these aspects of being a “good” doctor before they decide to leave our practice.

        Regards, Jennifer

        1. Thanks so much, Jennifer!

          I agree that medicine requires research to improve, and that medical care includes all sorts of things to function. Using your example above, we can have availability, ability and affability, but without relationship, no medicine occurs.

          We can see the same thing for metrics. Measurement helps improve, monitor and influence change in medical care. But without relationship, they are not medicine. They are interesting, useful and essential to progress.

          We can save a life and do it well, without any performance metrics. That does not mean we should stop measuring.

          The current fad of accountability and quality metrics has taken centre stage ahead of the doctor-patient relationship. That’s all I was trying to say. It’s a category mistake, confusing ontology with performance.

          One last philosophical wrinkle pops up. Technology now allows us to care for unconscious patients. Can we still say that medicine is relationship? Can we be in relationship with an unconscious person? I will leave this to the professional philosophers of medicine to sort out.

          Thanks so much to taking time to comment!

          Best regards,

          Shawn

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