Jarrod Shapiro, DPM Practice Perfect Editor Mountain View Medical & Surgical Associates, Madras, Oregon

How good a doctor are you? I’m sure the vast majority of those reading this post would answer at least “good,” and most of us would answer “superior.” But are you really a good doctor? How do you know? Your patients love you, your postop radiographs look beautiful — works of art. None of your patients return with complaints. They send their family and friends to see you. That’s all well and good, but I ask again, how do you truly know?

How do I truly know?  Let’s be honest.  I DON’T KNOW.  Why do I say this?  Because I don’t have data to show it.  Everything I’ve mentioned thus far has been pure anecdote.  Perhaps none of my patients return with complaints because they’ve moved on to another physician.  Perhaps that bunionectomy patient will have pain or recurrence 10 years after I’ve done surgery with those beautiful radiographs.  Yes, my patients love me, but maybe those who don’t have already moved on to someone else.  This is sampling bias — not an indicator of quality. 

	Tonight's Premier Lecture is Ankle Sprain Evaluation, Conservative Treatment and Rehabilitation by Steven Spinner, DPM

How do I know I’m performing the best toenail matricectomy?  How do I know my personal recurrence rate?  What about complication rates for fracture repairs?  What’s my hallux varus rate for bunionectomies? (Thankfully, I know this one — none.)  More importantly, what’s my rate of post-bunionectomy joint stiffness, recurrence, and postoperative pain?  What’s my ulcer recurrence rate after healing wounds?  For any of these measures I can state general numbers but not specifics.  I tell my bunionectomy patients about postoperative edema as a common “complication” after foot surgery, but how much edema do I truly see and how long does it actually last?  I don’t know.  That’s my honest answer to most of these questions: I don’t know.

My inspiration for this article comes from a fascinating book called Better: A Surgeon’s Notes On Performance, by Atul Gawande, MD.  Dr Gawande is a general surgeon practicing in Boston and staff writer for The New Yorker.  He identifies three core requirements for success in medicine: diligence, doing it right, and ingenuity.  Throughout this read — which I highly recommend — he discusses ways in which the medical community is trying to improve its methods, from hand washing to polio eradicatio.

Dr Gawande provoked a few thoughts in my mind while reading.  First, I realized this concept of improvement has been going on for quite some time in the general medical community.  Consider hospital core measures.  When a patient with an acute myocardial infarction presents to the ED he should be given aspirin on admission and discharge and a beta-blocker on admission among other necessary treatments.  Similar “standard” treatments exist for pneumonia, heart failure, and surgery.  Hospitals who participate (those with Joint Commission accreditation) must maintain careful records and publish their results, comparing against other hospitals.  Consider also the Physician Quality Reporting Initiative (PQRI).  Medicare participating physicians — podiatrists included — may receive a 2% reimbursement for their patients if they voluntarily report certain quality measures.  Similarly, clinical practice guidelines — present in just about every medical specialty I can think of, including podiatry — are attempts by leadership organizations to improve the care we provide to our patients.

Second, I asked a question: Why doesn’t the podiatric community have a “betterment” program?  Why don’t we have core measures?  We as a community constantly discuss the variable scope of practice across the county, the variability of podiatric residencies, and parity with other specialties.  Wouldn’t one of the ways to improve all of this include methods to measure our successes and determine our weak points in clinical practice?  Clinical practice guidelines are only a first step.  We need more.  More on the national scale and more on the individual physician level.

The Problem

Here’s the problem as I see it.  Our current methods of both self- and national evaluation rely primarily on anecdote and personal history, leaving podiatrists with a biased and likely inaccurate method to determine quality of performance.  Clinical practice guidelines and evidence based medicine are good starts but are not enough to guarantee the best performance possible.

The Solution

In next week’s issue, I’ll present a few suggestions to make the evaluation of performance more scientific on both a personal and national level.  Hopefully, this will stimulate some discussion and interchange of ideas.  Until then, think about it: how do you know you’re truly a good doctor?

What do you think?
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Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

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