What the Numbers Don’t Show

One of the cool things about being a parent is that from the moment you welcome your new baby, you become the expert in him or her. You can already identify certain personality traits within the first few months of life.

You know whether they really, really hate broccoli or only like it when it’s cooked or prefer the “trees” to the “trunks” parts. When the teacher sends home a few choice comments on the most recent report card, you can read between the lines perfectly. “He has difficulty focusing on the task at hand sometimes” is easily translated into “he’s goofing off at school just like he’s been doing at home.”

Similarly, although not always quite as enjoyable, as a primary care doctor I get to know my patients quite well. That is why it can be so darn frustrating to get scored on things like the number of patients who’ve had an LDL checked in the last year or the percent of your diabetic patients with an A1C at goal. Fortunately, no one expects me and my patients to be 100% perfect, but I think the expectation sometimes is still too high. I want to put an asterisk next to some of my patients to explain the why behind their poor scores.

For example, I have a patient with diabetes and paranoid schizophrenia. She is still on my panel despite the fact that she doesn’t trust me or particularly like me. She refuses to get blood work done and has very definite ideas about what the right dose of insulin is for her. She’s neither up to date on her labs nor at goal for her A1C. Should I fire her because she’s making me look bad? Of course, the answer is no. I can’t do the best for her but I can do as well as she’s willing to let me.

Now that I am part of a healthcare system that really emphasizes “quality points” and compensates you, in part, based on these metrics, I am carefully considering how to approach the patient with an LDL of 101. With a target LDL less than 100, I am “dinged” whether his LDL is 101 or 191.

Honestly, if getting the LDL from 101 to < 100 is going to involve switching from a generic statin to a pricier option, I’ll stick with the generic and accept the LDL being 2 points above goal.

Already though, I feel the pressure to always make sure the LDL, A1C or systolic blood pressure is well within goal. This is less about compensation and more about my own Type A need to reach the goal. I also acknowledge that getting a score on certain things, like immunization rates, does improve my performance which should translate to better patient care.

That said, I wish quality metrics allowed a broader vision of the people (not numbers) that we treat. I know so much more about my patients than whether their LDL was last measured 364 or 366 days ago. Since my knowledge of them as people is, in many cases, more influential than the latest guideline or professional society recommendation, I am disappointed that it is not part of the accounting formula.
 

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