Wednesday, November 27, 2019

Billionaires and Prejudice

There's an old story: what do they call a black neurosurgeon in South Carolina? Answer: Boy.

Labelling, or profiling, can be an awful thing. Our society has actually made a lot of progress in fighting prejudice. Now, sometimes there is actually something valid about it, maybe. Are Jews generally funnier, do blacks have better rhythm, are black women louder, are WASPs more repressed, are pediatricians generally nicer? There can be probabilities that pan out, and other stuff that is just labelling. Almost none of it is genetic, except blue eyes.

I play a game with myself – I see a shitty driver (no lack of them on the road), I make a prediction for gender, ethnicity, age, etc., and then I catch up and look to see who it is. My guesses have proven time and time again to have zero predictive value.

We are schooled now to beware of such labelling, and publicly we usually avoid doing it. No one disses a black on TV, we're very careful. Few people mention the predominance of Catholics and Jews on the Supreme Court, you don't hear about religious denominations for presidential candidates, you don't even hear that much about Pete Buttigieg's sexual orientation, at least publicly. We understand generally that yes, some labels mean something, but there is so much more to the individual that labelling doesn't tell us.

Which is why the internet information gatherers have been so successful. They have gathered real information on people, not labeling information, and it must work or they wouldn't be so successful as they are. In depth information works, superficial labeling information doesn't.

Which is why I'm struck with the opprobrium that Mike Bloomberg faces because he is a super-billionaire. “Do we really need another billionaire candidate?” Yes, having your own money to finance your campaign is a singular advantage. But does being a billionaire really tell us any more about a person? I mean – who could be more different than Donald Trump (maybe a billionaire, but certainly rich, at least for the moment before all the litigation after he falls), Howard Schultz, Tom Steyer, and Mike Bloomberg? Personally, so different. Policies, different. Personal style, different. Experience, different. Would we say, “Do we really need another white male candidate?” Oh, whoops, yes we would, “white male” has been dominant, so it's OK to label them. But would we say, “Do we really need another woman candidate?” Or, “Do we really need another black candidate?”

It's true that we expect officials to have a point of view that generally reflects their own personal background and interests. White males have predominated in the past and unconsciously or consciously pursued white male domination, or at least acquiesced to it. We expect black candidates to do something to help their oppressed race. We expect women to stand up for women. But, should we expect billionaires to protect their own wealth and the wealth of their financial group? Trump does it, but the others have been in the forefront of saying that the wealthy should be paying more. So to reflexively think that billionaires are in the race to protect their own wealth is demonstrably false.

Should we feel sorry for the poor oppressed billionaires? I hear your snorting laugh – I wish I had their problems, you say. Right. It's not something to feel sorry about, for them. But it is something to feel sorry about, for us. At this point in this confusing race for President, I'm a Bloomberg supporter. It's quite possible that he is really the best candidate the Democrats will have to offer. I'm not going to get into that whole discussion other than to say – you wouldn't eliminate someone like Barack Obama from consideration because he's black, and we shouldn't eliminate Mike Bloomberg because he's a billionaire. Or Jewish. Or a white male.

This whole identity thing -- shouldn't we insist that everyone have equal access to run for president, and then decide on who we want on an equal playing field?  We shouldn't want "a woman," or "a minority."  We should want the best.

Shouldn't we concentrate on the quality of their character, the policies they espouse, and the abilities they bring to the table? If we discount their candidacies because of extraneous factors, like how wealthy they are – try predicting the gender and ethnicity of the next bad driver you see.

Budd Shenkin

Sunday, November 17, 2019

The Joys of Prepubescence

I remember fourth grade.  It is in the running for the best year of my life. There were so many younger kids where I had once been; I was now senior.  The older kids didn't seem to matter; they were in another world, somehow.  Fourth grade, 9 years old, king of the world!  Still no responsibilities except school, didn't have to take care of anyone else, healthy without effort, fed and housed by people who loved me, friends without reservation, almost no self-consciousness.

And, no thoughts of girls.  The hypothalamus was still quiet, the pituitary receiving no signals, just the usual background level of testosterone.  I had a "girl friend," Connie, who clearly admired me and vice-versa - she even gave me her Dixie cup ice cream when she didn't want it and everyone had their hands up vying for the gift.  But what was that, really, but a beacon for the future?  Fourth grade!

The girls must have been the same.  I see it in my granddaughter Lola's class, girls in groups, animated talk, musical theater class, play dates, videos, and still stuffed animals!  There is a little bit of recognition of boys - "I like him but I don't LIKE him..." is about as far as it gets.

It will change in the next couple of years, to the confusion of everyone.  Junior high is the toughest, they say.  The whole rest of your life is the hardest part, I'd say.

Fourth grade!  Savor it, girls, savor it.  Fourth grade is top of the world!

Budd Shenkin

Tuesday, November 12, 2019

Recipe: Rock Cod à la Budd

Rock Cod à la Budd

10 minutes preparation
serves 1-2

olive oil 2-3 tablespoons
2 medium brown mushrooms
2 cloves garlic
1/2 small white onion, diced
¼ orange bell pepper, chopped I/2” squares
rock cod 1/3 pound, in 1” pieces
tahini, 2 tablespoons
apricot jam, 1-2 teaspoons
honey, 1 tablespoon
½ avocado, sliced

heat olive oil in 12” deep skillet
add each ingredient serially as listed, ensuring browning for all ingredients until the avocado, which should be added only at the very end, and warmed without browning.

Serve warm.

May serve along with pasta or rice, but serving with tomato and cucumber salad is particularly recommended for the overall freshness and lightness of taste and feeling.

Sunday, November 3, 2019

My Parents' Friend Lou Wilderman

When I was growing up in Philadelphia, my parents and all their friends were first generation Jews whose parents had emigrated from Eastern Europe. They were all politically liberal, not a Republican in sight, and many if not most of them had been commies in the 30's. They had left that behind as they matured, and by the time I hit my teens and became aware of them. They were doctors and lawyers and one friend, Vince Young, owned a lumber yard. The women were stay at home moms, mostly, cocooned and impeded by what the world did to women in those days, except for my mom, who went back to school to be a social worker when I was in my teens. We were four children in our family, two boys and two girls, and I was the oldest. We were a close family, informal and loving, and they included the kids in their talk, at least to a certain extent. In fact, there was a lot they held back, and I think if asked I would have said, yes, that's the way it is. I knew enough not to speak too much when their friends were there, I don't think I was a very good talker anyway, but I listened, I noticed a lot, and viewed the world and their friends mostly through the eyes of my father, I think. I didn't know then that I had a good memory, but I guess that I did, because I seem to remember a lot.

My parents had what I guess it's best to call a circle of friends. They seemed to have known each for a very long time and seemed to have a band of trust. It might have been the times, it might have been memories from the shtetl of how communities interacted, it might have been the 30's and radicalism, it may have been Jews, I don't really know. But they had a circle of friends who all knew each other. Today, we move around so much, that my circle of friends is all over – thank goodness for email and free long distance. But then they were all right there in Philly.

Among this circle of friends, the famous Jewish sense of humor was alive and well. Especially among the men, I think, a good joke was never far away. Mom and Dad appreciated the jokes, but they weren’t too good at telling them. My Mom loved to laugh at jokes but could never tell them. My Dad loved to laugh at jokes, too, and he could tell a joke OK, although he would laugh after telling it, lean toward you and say, “Pretty good, huh?” which a good joke teller usually doesn't do. A good joke teller just tells the joke and looks for the reaction. My Dad made actively sure you were laughing, too.

Apparently, our families best joke teller was mother’s father, Ike Friedenberg, who grew up in Baltimore and was a boxer in his younger days, a haberdasher in downtown Philly as an adult, a wiry, bald man who seemed friendless in his old age, when I knew him. He was well known to be funny, but since my parents and grandparents didn't get along, any of them, we didn't get to see it, and we could enjoy his humor only by reputation. What a shame. Fortunately, maybe because of genetics, my younger brother and I can both tell a joke. My mother always said that I was the best audience for my brother Bobby could hope to have. “Buddy always thinks Bobby is so funny!” she would say. My Mom looked at us and sized us up a lot, and she and Dad would talk about us as though we weren't there, which was disconcerting, but there it is. They watched us, and watched out for us. As for Bobby and me, siblings always jocky for position, and since Bobby was the jokester, although he could laugh at my jokes and enjoy them, his goal was always to then say something even funnier. It's still the same way. Families, families. Brothers.

In my parents circle of friends, the funniest one, apparently, was their friend Lou Wilderman. Lou was a labor lawyer and represented unions, as would befit the politics of the circle. My Dad told me that Lou’s stories about his clients were so funny they left his audience of friends in tears. “Oh, the stories he would tell, his clients were so nuts!” said my Dad. For some reason I never met his wife. I guess that was because my parents and Lou weren't really close friends, they were just part of the same circle. But it was well agreed that Lou was the funniest man any of their crowd knew.

Lou was of average height, wore tortoise shell glasses, I think, was rather pale, and spoke self-consciously, interspersing short little laughs as he told his anecdotes, keeping people going with his ability to modulate his speech, and build to a climax. He had a little urgency in his voice, he talked in little spurts, and then there were the little chuckles as he delivered the little humorous observations along the way. I think what was more remarkable to me than just him, was the regard all the others had for him when he talked. They were all primed for the joke, or the series of humorous observations, even before he started talking. They wouldn't want to miss a word.

The other thing that was remarkable about Lou was that he was also a serious, verified hypochondriac. It was the days before health foods, but if there were a rumor that cinnamon was good for one’s health, be assured, Lou would be taking cinnamon regularly. What a combination that was for a man! An extraordinary sense of humor, and a serious case of hypochondria.

The best story about Lou, and the only one that I retain, is one that Lou told about himself. I doubt that I heard him tell it first hand, but I know my father told it more than once. I know that because my father told every story more than once. Here's how it went.

It was springtime in Philadelphia, and it was a beautiful day. The leaves were on the trees, the birds were chirping, the sky was very blue. Lou was walking down the streets of center city Philadelphia on this beautiful day. He felt great! What a time to be alive! Then he thought - what should he do when everything was so perfect?

By happenstance, he was walking up Lombard Street and came to 19th Street. There on the corner was the Graduate Hospital of the University of Pennsylvania. Immediately, Lou knew what to do on this beautiful day. He said to himself — what better thing to do on a beautiful day like today? I’m going to treat myself to an X-ray!

I'm laughing again as I recount this story, told by Lou about himself, gathering all his friends into his own mishegoss. My Dad loved to tell this story, and to laugh with astonishment and affection, and to make sure that you laughed, too. Imagine Lou – he knew he was nuts with his hypochondria, and he knew he couldn't do anything about it, and he knew that he could laugh at himself as much as he laughed at the antics of his clients in the unions. Maybe with today's drugs Lou could have been cured, I guess, probably, but maybe not, I don't know. In those days you lived with a lot of stuff we give medicine for today. Then they only had psychiatry, and everyone was distrustful of the Freudians, and that was pretty much all psychiatry had to offer. So they laughed.

Like so many funny people, I think that Lou might have been one of those people funny on the outside but tortured on the inside. Maybe his humor and his hypochondria were accompanied by racing thoughts, I don't know. Maybe he was tortured and creative. He did write a play, or a movie script. I remember I actually saw the bound script, and was amazed — an ordinary man that I knew actually wrote a script? I imagined, knowing Lou, that it was a comedy.

But it wasn’t. It was a tragedy of some sort. He showed it to his friends in his crowd and they marveled that he had written it. Someone asked, I think it was Vince Young, the owner of the lumber yard (who sold the lumbar yard and retired for a while, then reentered the labor force as a social worker of sorts for a hospital), who would you like to get to play the part of the protagonist, if you could actually get a movie made? Lou came up with an answer that showed he had been ruminating about it, although he had to know that getting it produced had to be a pipe dream. Anyway, he answered that he would like Paul Muni to give it a shot. Paul Muni, I thought, that's pretty strange, a man of the past. Paul Muni? I knew him only as a name. You could see that Lou was a dreamer. But what a dream – Paul Muni, a man of serious mien and purpose, to be the star of a play you wrote. Wow. That would have been something. But I knew it was kind of crazy when I heard it.

I think that this play was the last time I saw Lou in person, and maybe after that there could have been a mention or two of him, but times changed. My family had started out in West Philadelphia not far from the Penn campus, moved to the suburbs for the schools, and then moved back to center city when all the kids were out of the house and to college and beyond. I think they lost track of Lou as everyone got older and moved on to other friendship groups, but only to a certain extent. The group kept in touch enough so that my sisters heard that when Vince’s wife died and Morrie Samitz, the dermatologist member of the group died, Vince and Morrie’s wife Doris lived out the rest of their lives together. My sisters wondered if anything had gone on before the spouses had died, with a little spice of prurient interest. Strange, I thought, Vince and Doris? Things sure do change.

I really don't know what happened to Lou after the play. I have an inkling I heard something once, but I'm damned if I know what it is. I wish I knew. I wish my parents were still here and I could talk it over with them, ask them for the followup, and so that my father could correct my story as I have written it down here, as he surely would, hiding his admiration for my writing, and his pleasure at having his own life remembered and even chronicled a little. But I would know that his love for me would be in there.

If they were here, and if we would talk about Lou, I know that they would smile, perhaps a little sadly. Sometimes you are happy and you don't know it, or think about it, until afterwards.

Budd Shenkin

Thursday, October 24, 2019

Comparing what's happening now to Watergate

My book club has men of a certain age, and several are lawyers.  As it happens, two of them worked on the Nixon Watergate inquiry, one on the House side and one on the Senate side.  They reflected on the current Republican objection to the investigatory process -- you know, the  Matt Gaetz led foray into the secure room, first invasion and then 17 pizzas.  Here's what Jeff and Bruce had to say:

Impeachment Inquiries


The Nixon impeachment inquiry staff conducted private interviews with key witnesses.  Some came voluntarily, like John Dean.  Some were under subpoena, like G. Gordon Liddy.  In my early days on staff, I would sometimes escort these fellows from the downstairs security checkpoint upstairs.  Liddy refused to tell us anything more than his name, his military ID no., and his citizenship (United States).  He refused to sign his name in the logbook. 

These interviews were not conducted by members, and they were private.  I believe staff from both parties were present.  I don’t recall public hearings until the Judiciary Committee members began debating articles of impeachment. 

Bruce, What’s your recollection of how the Senate treated its witnesses in the Watergate investigation?  Public hearings we recall; but were their interviews first, so Senators knew what to ask?

Interesting that we have a Book Club with both chambers represented.



Interviews first.

As I recall, most of the interviews, either under subpoena or not, were conducted by staff who were hired either by Sam Dash, Chief Majority Counsel or Fred Thompson, Chief Minority Counsel. All interviews were attended by staff representing both the Democrats and Republicans who then reported back to the Counsel who relayed the contents to the respective senators and their staff on both sides of the aisle.

I did sit in on interviews of members of the Domestic Council within the White House (John Ehrlichman) as a member of the Majority Staff of the Committee.


Right – staff representing both parties would sit in on interviews and then report to the members.  The Trump impeachment inquiry has House members from both parties conducting the interviews, no doubt with staff whispering in their ears.  So in terms of transparency, this is a fortiori what we did with Nixon.  If this is correct, why the Flash Mob of Republicans yesterday?  What’s their complaint?

Budd Shenkin

Sunday, October 20, 2019

A Small Poem

When a man of 77 dreams of an undiscovered future,

It could be presumption,

but it is really habit,

now made sudden by time.

Thursday, October 17, 2019

A Practical Quality Agenda in a Primary Care Practice

If you ran a primary care practice, how would you approach the issue of quality of care?  I faced this issue in my practice, and I thought about it in depth.  Twelve years ago I wrote this paper on how I thought about it.  It's very practical.  Much of what you read here you will not have read elsewhere.  I commend it to your attention.

One note - although much of it holds up despite the time lapse between when I wrote it and now, EHR's were not widespread then; now, they are ubiquitous.  So that part of the paper is partially outdated.  But other than that, as I read it over, I think much of it still holds true. 

If you want to improve your practice quality, you will need a roadmap.  I think this paper might help.

Editorial note: I have 48 footnotes for this paper, but somehow it's hard to put them into this blog, but trust me, what I say is well founded!



We have known for some time that our medical care system is failing to implement what we know and what is theoretically possible.  The Institute of Medicine found that the medical enterprise has outgrown the capacities of our basic institutions, the great variability of care implies quality deficiencies, indicated preventive measures are inconsistently applied, diffusion of knowledge is chillingly slow, and indicated care is offered a random adult patient at an estimated rate of 55%.  Most recently, the UCLA-Rand group has extended their findings to indict ambulatory pediatric care as well.  They conclude: “Strategies to reduce these apparent deficits are needed.”

Indeed they are.  Our primary care group (mostly pediatrics) has been addressing ourselves to quality improvement (QI – used here to denote general quality efforts rather than any specific method) for five years in an organized way, and in doing so have discovered approaches that might help others to find paths for QI for their practices.

Our first discovery was that there is indeed no current roadmap; we could find no articles in the literature examining QI in offices in detail.  If only we had the know-how to diagnose and treat practice as we do a patient: take a history, do a physical examination, take measurements, and proceed with well established plans for prevention and treatment!  But quality science has not yet provided office practices with the equivalent of even vital signs, let alone a diagnostic outline, a Practice Quality Index, or established modes of action.  Consequently, if you are designated the Quality Officer in a group practice, at the moment of your appointment, you face near-virgin territory, and will need to invent and discover your own path forward.

Practice roadmaps will differ, of course, since practices differ widely in their abilities, needs, proclivities, visions, patient populations, and organizational structures.  Nonetheless, every practice seeking an organized approach to QI will most likely need to ask similar questions.  For the question, “What area does quality encompass?” we have found three separate sectors.  For the question, “What modalities of action do we have?” we have found two distinct modes.  For the question, “What are the constraints on our activities?” we have found three impedimental areas.  And for the question, “What practical projects suggest themselves?” we have found so many that there will clearly be no end to this quality journey.


Pay For Performance (P4P)

Pay For Performance (P4P) is the most conspicuous current embodiment of QI.  P4P identifies elements of quality that are important and which are putatively easily measurable through claims data, thus finessing the difficulty of actually measuring quality on a non-research basis.  P4P then rewards either health plans or individual practices that score well on the measures chosen.  A practice will be tempted simply to take the P4P measures, aim at them, and call that their program.

To do so, however, might be a mistake.  The elements of practice are generally important, true, and the financial rewards are of course attractive.  But P4P has marked weaknesses.  P4P measurement validity is itself questionable.  Scoring well on P4P items does not indicate general practice quality, especially if the practice “teaches to the test” of P4P indicators, and concentrating on P4P may well “crowd out” more important QI efforts.    “P4P programs are being implemented in a near-scientific vacuum.  There is scant evidence about the appropriate focus, effectiveness, and the general circumstances in which they may work best.” Thus, although P4P might well turn out to be an element of a practice’s QI program, it will be too thin a reed upon which to build an entire QI program.

Three Realms of Quality

A wider view of practice quality can be obtained from looking closely at the definitions of quality.  Most obvious to us is biomedical quality, defined by the Institute of Medicine: The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.   A second area, the way in which care is provided, is also defined by the IOM: timeliness, patient-centeredness, safety, effectiveness, efficiency, and equitableness.  These qualities would apply both to how clinicians function (tending to labs and X-rays promptly, involving patients in decisions, etc.) and how the office as a whole functions (waiting times, respect from staff, ease of navigating the system, etc.).

The third definition of quality would be even wider: How well a practice helps its patients.  Unlike definitions one and two, this wider definition includes the humane services of counseling, befriending, understanding, and supporting patient, not only directly in the office, but by referral to allied resources. 

As scientific clinicians we would adopt objectives from the first definition and the clinical aspects of the second; as directors of a practice we need to consider the second part of the second definition, the office experience for patients; and as humanitarian clinicians we want to consider the third definition.  Clearly, then, when faced with the possibility of choosing objectives for QI, a practice can choose from a very wide field.

Two Modes of Intervention

Each QI objective chosen will need a matching means of intervention.  The plethora of approaches to QI  can be divided into two types.  Professional Enhancement (PE) aims to improve the mind, skill, and motivation of the clinician.  Systematic Reengineering (SR) aims to improve the operating mechanism of the practice within which the clinician performs.

Clinicians almost reflexively tend to think of QI in terms of PE.  They want to improve their knowledge, memory, understanding, and motivation.   They think of following the literature, continuing medical education, certification and recertification, clinical performance assessment, being reflective, listening to and caring for each patient, searching for the hidden meaning behind patient visits, and detecting disease early from small clues.  Clinicians tend to remember instances when they stopped short in leaving the exam room when a small remark of a patient hit home, how they returned to the patient for more history and examination, and how two weeks later an operation saved a life.  They remember when a bit of knowledge popped up in their minds and led to a smart and important diagnosis.  They recall the meaning they bring to some patients lives, and vice-versa.  This is traditional, palpable quality.

Health services researchers and administrators, by contrast, tend to think in terms of SR.  SR comes from the industrial quality experience, where establishing regular procedures aims at decreasing variability, with the mantra “do-it-once-do-it-right.”  The SR approach finds recurrent stereotypic situations within medicine’s endless complexity that can be choreographed for standard execution with low variation, and hence higher quality.  SR thinks of care plans, flow sheets, and forms.  The goal is to imbed the clinical team in a system that makes it easy, rather than a constant challenge, to do the right thing at the right time.  For system engineers, the clinician is sometimes thought of as a standard commodity. Instead of individuals, SR thinks of teams: “Ranking (of personnel) is a farce.  Apparent performance is mostly attributable to the system that the individual works in, not to the individual himself.”

A practice can and should use both approaches.  True, the effect of PE is more assumed than documented, in contrast to the well-measured impact of SR.   True, that the obstacles to effective education are remarkable.    Nonetheless, some of the assumed superiority of SR must emanate from the more easily measurable nature of SR applications.  Stereotypic situations are inherently more easily measured than the qualities PE aims at -- human relations, complex diagnoses, unique situations, and judgments as members of adaptive organizations.  Sometimes SR will be appropriate -- narcotics control is better handled by a computerized check-in, check-out system than by education on the harms of addiction.  But other objectives require PE --- education, training, and reinforcement are more appropriate to improve empathy than signs on the wall saying “We Care.”  Both matter: the quality of the clinician, and the system in which he or she operates.

Three Constraints, and Possible Solutions

If there were not severe constraints on the abilities of practices to pursue a QI program, programs would be popping up everywhere, yet even in academic faculty practices are “in an infancy stage” of QI.  The constraints on QI actions can be summed up as organization, cost and effort, and measurement.


Realistically, for a QI effort above minimal scale, it will be easier to envision an organized QI effort than to actually accomplish it, because highly organized group practices are a rarity.  Most small groups (groups of six or fewer physicians deliver about 2/3 of the primary care in the United States) are partnerships with individualistic physician-partners, which are inherently hard to lead.  While many physicians are natural leaders, few are trained in management and quality science.  Moreover, the QI effort will require time and energy to analyze needs, to meet and communicate, to strategize, to revise practice protocols, to produce practice aids, to track progress, etc.  The time taken will need to be stolen either from clinical time (which, unlike QI work, is directly remunerative), or from scarce time off.  Yet most practices will not want to pay a clinical leader for this time and effort because of the traditional debilitating conceit of practitioners that only patient care should be compensated, and that administration is “pushing paper.” Some clinicians, fired by idealism, will enroll themselves as a “champion” of a QI project once, or perhaps twice.  But beyond that, without payment, the champion’s QI leadership will recede.

By the same token, QI innovation in office operations requires a sophisticated practice manager, one able to envision programs, collect and analyze data, and manage personnel with changing roles.  But such managers are scarce, and hospitals, specialists, and multispecialty practices compete strongly for their services.

To be well enough organized to pursue a serious QI program, the practice will need to make a leap of faith, and break away from prejudice.  It will need to support talent that is already in place, or recruit new organizational talent.  It will need to believe in the ultimate advantage of investing in organization.  The increased cost of an improved organization may not be directly recompensed by QI efforts themselves.  But as a side benefit, a highly organized and well-run practice may bring other advantages to the practice.  Better-run practices can become more productive and thus make more money.  Better-run practices can use mid-levels or contract physicians, and may expand to additional offices and extended hours.  They might expand into other allied clinical fields, such as travel medicine, or lactation classes.  They can negotiate with insurance companies in a more organized and successful fashion.  They may attract more talented graduating physicians.  Morale in well-organized practices can be superior.  They can become, in fact, the cream of the crop and face the future with increased confidence.  In other words, the solution to the organizational obstacle may be to face the music and invest in oneself.


Organizations run two kinds of costs.  Routine QI costs are those of maintaining competence, such as fulfilling a required 25 hours of CME per year, or reviewing employee performance in patient relations.  Investment QI costs involve more substantial efforts to upgrade and improve.  For example, the American Academy of Pediatrics has apparently endorsed 162 separate points of advice that a pediatrician should impart to a family over the course of pediatric care.  If a practice endeavored actually to follow the Academy’s directives, this Herculean effort would clearly be a significant effort to upgrade and improve its service.  The costs would occur both at the initiation of the project – change – and the ongoing effort – maintenance. 

From a business point of view, one would expect routine maintenance to be included in general overhead as “the cost of doing business.”  Investment costs, however, would need to be covered by enhanced revenues.  It could be that psychic “idealistic revenue” could cover the cost off one or two practice innovations, but over time idealistic energy would usually wane, and financial enhanced revenue would be necessary.  This would be equally true for for-profit and not-for-profit enterprises.

What makes QI investment particularly hazardous is the well-known difference between innovation in medical care and other fields.  In a classical free market, consumers recognize higher quality and may pay more for it, and/or higher quality at the same price accrues more business and increased profit.  Higher quality clinical care, however, is often invisible to patients, payors, and even colleagues.  Raising prices often accrues little increased revenue since prices are set by insurance companies.  If additional patients are attracted, many practices see little or no benefit, since they are often already very busy, and adding additional clinicians can yield little profit under the partnership model, since new clinicians quickly become partners and share in the proceeds, leaving little if any additional profit for the innovators.  Thus, investing in QI is often likely to reward patients with improved care and clinicians with psychic well-being, but to penalize practices with unrecoupable investment costs.

Solutions to the financial problem are at least threefold: (1) adopt changes that are low-cost; (2) discover changes that are billable and thus support themselves; and (3) find innovations that produce a joint product – for instance, a change that simultaneously improves quality and efficiency, thus enabling a practice to make more money indirectly.   Examples for solution (1) would be many PE interventions, such as journal clubs and in-house educational meetings.  Examples for solution (2) would be achievement of P4P objectives, use of screening tools which can be charged for, and making additional patient appointments to monitor chronic disease (this latter profitable only if the practice is not working at highest capacity already).  Another example would be convincing an insurer to pay higher rates in light of improved quality.  Examples for solution (3) would be using encounter templates and questionnaires that would improve visit efficiency at the same time as improving quality. 


Clinical quality measurement has a long history in research, but few examples applicable to a practice on a routine basis.  As scientifically trained clinicians, we know the importance of measurement to ensure validity of accomplishment; as practice managers, we know its importance for motivation of personnel.  If the practice should adopt laborious data collection, however, this allocation of resources could restrict QI efforts to only one or two objectives for years, and become so burdensome as to sink the whole QI enterprise.

If the practice could be nimble and inventive, however, measurement would not bog down progress.  The goal, after all, is improvement in a single practice, not scientific proof of replicability to other practices, nor achievement of statistical confidence levels.  Some QI steps can prove their worth on a prima facie basis simply by their existence – for example, instituting a regular channel of communication with a social service department, thus improving referrals.  Other improvements may be obvious – for instance, the dwindling height of the pile of pending laboratory reports, or the newly-empty waiting room as check-in procedures are improved.  Some will have intermediate measurability – for example, using P4P biomedical objectives as generated by either practice or insurer, but in the latter case rechecked by the practice.  Another example would be measuring total visit times (time from patient check-in to check-out) using appointment software along with other in-office adaptations. Subjective measures may have validity – for instance, increasing spontaneous compliments from patients, improved scores on patient satisfaction surveys, and the feelings of clinicians about their work.  Some objectives will be stubbornly immeasurable – for instance, the performance of clinicians with non-stereotypic complex diagnoses.  Importantly, the practice needs to resist the impulse to improve only the measurable: “Everything that counts can’t be counted, and not everything that can be counted counts.”


In this welter of considerations and absence of a standard approach, how can a practice proceed?  The important first step will be for the practice formally to accept the QI challenge, and to appoint a QI leader who is apportioned time and payment to do the job.  The leader then needs to start planning, involving practice members widely to ensure that the results aimed at are highly valued. The planning process will be constant and reiterative, as values, objectives, interventions, organizational feasibility, and financial reward are constantly balanced and rebalanced. The hope would be that not only the agenda, but also the process itself would initiate or strengthen a Culture of Quality in the practice, where quality is not in the back of the mind, but a constant preoccupation.  This culture will in itself breed success, perhaps in unforeseen ways.

The resulting QI agenda, whether narrow or wide, will need to generate objectives from quality definitions one, two, and three; choose SR and/or PE approaches for each objective; and find ways to overcome obstacles one, two, and three. Table One gives some idea of the variety of objectives a practice could consider, and the criteria by which they could be judged.

Practices are so different that it is clear that agendas will need to be very individualized. Emphasizing PE or SR would depend on a practice’s self-assessment – for instance, are strong clinicians hampered by disorganized processes, or are clinicians in need of stimulation, or both?  Likewise, is organizational capacity so low that only PE strategies are possible?  For all practices, it would make sense to include initially some “low-hanging fruit,” since initial successes are important, as well beginning on longer-term objectives.  P4P objectives would often be the “low-hanging fruit.”

A Concrete Example

To help in visualizing possible practice agendas, here is an example of a two-year initial agenda with some explanatory detail. 

Several P4P objectives successively, according to offers of reimbursement by payors, probably starting with immunizations.  Each objective would have to be accepted according to the extent of necessary effort – in other words, will it be worth the work.  PE would include educating clinicians on “immunization opportunity visits.”  SR would be clear charting on a separate chart page, medical assistant reviews, and patient recall from billing data. The financial obstacle would be mitigated by health plan payments, and perhaps additional visits from the recall program. Conceptualizing and organizing the effort would be the biggest obstacle, but once done, the same organizational pattern could be used on further P4P projects. Measurement would be by the health plans – as checked by chart review by the practice, as necessary.  These objectives could be “low-hanging fruit.”
Production and implementation of templates.  These practice aides (SR interventions) promise to reduce variability and, as a joint product, to improve efficiency. They change acquiring and imparting standard information from oral-aural to the more efficient and effective utilization of questionnaires and handouts. Pediatric examples would be a questionnaire for a first visit for wheezing, well visit encounter forms for various age groups, and handouts for anticipatory guidance.  Adult examples would be use of routine questionnaires for alcohol use, tobacco use, and depression; and introduction of diabetic flow sheets.  

They would require some organizational leadership and cooperation to produce among the clinicians, and while they would take time and effort of no small degree, there would be little out of pocket costs.  If well designed and accepted by clinicians, implementation would not be difficult, since it would consist merely of inserting printed forms into the visit.  The net financial result might be positive, since templates such as these make a clinician’s work easier and more efficient.  Measurement requirements to assess the innovation would be minimal, since there would be prima facie decrease in variation.  But unquestionably these projects would require significant thinking, cooperation, time, and effort.  Predicting ultimate profitability would not be certain.

Total visit time (TVT) reduction and improved telephone performance.  These efforts would aim at the second quality definition, service.  Since this would involve primarily non-clinical staff, they could run parallel to clinical efforts without overstretching the practice.  Interventions would start with measurement of TVT, and telephone surveys of service conducted by fake patients.  SR interventions would be procedure outlines for staff, supplemented by training (PE).   These would require extensive leadership and design, and possible information technology consultation.  Improved service will be obvious to patients, and thus more patient volume might result.

Periodic case conferences.  In-house conferences where clinicians trade their puzzles, triumphs, and even failures, promote learning and quality consciousness.  Another version calls for mutual chart review, where the clinicians read each others selected charts, and discuss not only the cases but also the documentation and workups.  Conferences on “difficult patients” with experienced guests or group members can improve empathy (definition three).  A PE effort, it requires little organizational effort, entails little financial input and no risk.  No objective measurement is possible.

Encouragement of participation of one practice member on hospital QI committee.  Another clinical, PE action, this would educate and perhaps inspire one clinician at little cost, although one must recognize that 12-24 hours or more spent per year is not insignificant.

Establishment of personal liaison to one social service worker.  This would be an easily accomplishable step requiring initial telephone inquiries and perhaps a lunch meeting.

These steps would constitute an ambitious program.  Clearly, some projects would end quickly and could be replaced by others, while others would take several years of effort.  If this much activity were embarked upon, one would expect that a major change in the zeitgeist of the practice would result.

The Electronic Health Record

A note is needed about EHR’s, since EHR proponents frequently assume that much of QI would be accomplished it information technology such as EHR.  It is true that many QI steps discussed here as paper-based technologies might be more elegantly accomplished with EHR’s.  EHR might also provide easier chart review, easier use of patient registries, easier reminders of clinical practice guidelines, easier communication among providers, etc. EHR would also force reluctant clinicians to use tools that they might ignore were they only on paper.   No one doubts that EHR is in the future.

Introducing EHR to an office, however, is expensive and risky, and the financial upside very limited.   The contribution of EHR to quality remains in question.  Many desired computerized functions (patient registries, immunization lists, etc.) can be provided by a computerized billing system, already standard equipment in most offices.  Critics wonder why “the doctor should be asked to invest in medical record systems when primary systemic beneficiaries are elsewhere?” It is doubtful that one marginal business case (EHR) will facilitate another marginal business case (QI).  Since most QI steps will be translatable to EHR when they appear in a practice, and since much of what EHR do can be done with paper charts and billing systems if not so elegantly, indeed since QI beforehand may actually facilitate QI after EHR implementation, QI should not wait on EHR’s, and above all EHR’s should not be viewed as a substitute for QI.


While the need for QI is clear, the obstacles are formidable, and the incentives beyond idealism appear weak.  There is no specific road to follow, and few practical measures. Many objectives, however, can be reached rather easily.  It seems clear that if quality is to improve, practices must consider issues of their own organization very seriously.  Despite the current climate of cynicism, medicine has historically been a repository of idealism.  It does appear that if a practice is idealistic enough to want to pursue QI, and if it adopts an intelligent plan, it need not suffer for having chosen to do so, and indeed, might benefit as much as its patients for the effort expended.