Tuesday, December 18, 2007

Physician Review by Patients

Physician review is a front burner policy issue. The hope is to provide prospective patients with guidance of the sort most of us seek out in Consumer Reports for purchases large and small, to give quality-improving feedback to physicians, and, sometimes, to inform pay for performance schemes.

This is a personal story about physician review. One patient reviewing one physician.

Today I had a final appointment with someone who has been my psychiatric patient for 13 years. The treatment has been relatively successful. Major symptoms have gone into remission and the person’s capacity for health-promoting self-management has improved markedly.

For many years we have done an “annual review” as a humorous but serious practice. Since perfectionism had been a VERY problematic symptom, we created a constructive paradox. The only way to get an outstanding “review” was to be “less than perfect.”

At this final meeting we set out to do a final review. In accord with good review practices, my patient had done a very thoughtful self review, and we drew together the large themes of the treatment, where things stand now, and plans for the future, which involves a new treatment setting.

At this point I said, “We should be reviewing me as well.” My patient said, “of course,” and took out a typed review addressed to me, divided into meaningful categories.

The review was largely quite positive, as the treatment had gone well. But the positive feedback was not simply pleasing. In its details, it was useful. Under the “prescriber” category my patient wrote: “I’ll miss your telephone calls to tell me that the clozapine white blood count was fine [clozapine requires a regular blood check, and under our arrangement I left a phone message about the results]. To hear from you was a highlight for my weeks.” Sometimes little, low tech things that we do – here a 15 second telephone message every four weeks – matter more than we realize. This was action-relevant, educative feedback.

But what made the review most meaningful to me is that not every category was uniformly laudatory. Under the “Positive Thinker” heading my rating was “”satisfactory,” not “excellent.” Here is the comment: “For the most part it has been great to have your positive thoughts, but at times I have called you “PollyAndy” because you always see the good side. At times I just wanted you to see my negative side and to acknowledge my pain.”

I told my patient that I knew this area was a vulnerability and that when they were growing up my sons used the term “poptimism” for this trait. Insofar as I had not conveyed acknowledgement of pain I apologized for that in retrospect.

Not all people are prepared to give candid feedback to their physicians, and among those who are, not all have the skill at giving feedback that my patient displayed. But whatever happens in the arcane realm of physician review and pay-for-performance, direct 1:1 feedback is more valuable by far.

Perhaps if the medical profession had been more diligent in seeking meaningful patient (and collegial) feedback over the years, the tidal wave of effort to establish formal review mechanisms would not seem so urgent.

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