Judging the Quality of Healthcare

quality.jpg

As in every other field of practice, healthcare has practitioners who’s skill-set ranges between exceptional, good, bad, indifferent, to “they deserve to lose their license”. As patients, we understandably tend to focus on our needs, with little thought given the issues that impact how our clinicians do their work. Patients can be quite judgmental at times. Certainly, we all want quality healthcare.

The US Medicare/Medicaid Services published a Quality Strategy in 2016, itemizing six objectives that comprise quality healthcare delivery:

1.   Make care safer by reducing harm caused in the delivery of care.
2. Strengthen person and family engagement as partners in their care.
3. Promote effective communication and coordination of care.
4. Promote effective prevention and treatment of chronic disease.
5. Work with communities to promote best practices of healthy living.
6. Make care affordable.

Within APOPS’s patient support forum, we hear both glowing praise for clinicians (whether nonsurgical or surgical treatment specialists), and complaints about skill-set or mindset. The nature of a relationship is two-way flow. It would be hypocritical for patients to expect more from their clinicians than they are giving them. It is imperative we make every effort when possible to find a clinician we feel comfortable has the skill-set to treat POP appropriately. It stands to reason that at times that is not possible due to healthcare systems and insurance restrictions.

That being said, I felt it important to share the mindset of an individual who is both a healthcare practitioner and a patient within APOPS’s support space (who chose to remain anonymous). I asked her to share: 

1.  What are issues medical professionals must address when suggesting treatment choices for POP?

2.   Can you share how and why opinions may vary from clinician to clinician?

3.   At times, when providing repairs for more than 1 type of POP, a surgeon changes the surgical plan discussed prior to the repair. Can you share why this may occur?

This was her response:

As a medical professional, I may differ on this one. I work with a multitude of surgeons across a variety of specialties and I see these types of decisions play out on a daily basis. I am one whose urogynecologist chose not to repair my rectocele because things went back into place (and stayed there). He told me that it was better to do no harm in my instance. This way he preserved the tissue in case a further repair should be needed as, obviously, my tissues tend to be lax. This is a risk vs. benefit calculation.

 It is easy, as a lay person, to make judgments about what a physician should have done or not, without having the actual medical basis for making that decision in front of them. I too often see in APOPS’s POPS Support forum women trash-talking doctors for doing things that are medically sound simply because they disagree with them. It's usually a lack of communication/education. Everything we do in healthcare can have an adverse effect, and we should take that into consideration continually.

Specializing surgeons such as FPMRS urogynecologists and urologists have 10+ years of education, are often very experienced, and are sworn to do no harm - and that includes making decisions on the fly regarding what is in the particular patient's best interest. The surgeons I work with, while not all stellar surgeons, share a sincere wish to do the very best for their patients. Their training differs, their philosophies differ, but they really are not all in it "for the money" (I hear this one on occasion) or the glory.

Surgeons have a responsibility every day (as do all of us in healthcare) to first do no harm, providing the best care possible for a body that is human and prone to imperfections, as well as to educate. In this world of Dr. Google, that is imperative. I saw a forum member rant about a medication ordered for her as a pain adjunct saying that she had looked it up and it could cause heart rhythm disturbances, and that it was only given to her because it would ease anxiety like she was hysterical or something. In actuality, the medication she referred to has been used for many years to boost the effects of the narcotics she had been given because she wanted to limit the quantity of narcotics. The doctor here was trying to ease her pain safely.

I really feel for any woman whose repairs fail in the early post-op period. In my case, a few years down the line, if things need further repair, I would not see it as a failure. I would see it as a progression of an aging body that has been used well in its years on this planet.

I see bodies not behave the way we'd hope on a daily basis. When surgeons shift surgical direction, they need to be able to explain his/her reasoning to their patients. They make these decisions based on the medical research available to them (and yes, they do keep up on current research), their training, and their own personal experience. Every body is different. I work with an orthopedic surgeon who is considered #3 in the nation. If you met the man, you'd think he was your average "Joe on the street." He is one of the most basic, down to earth guys. He has head-banging rock music screaming in the background as he operates, and he drops more f-bombs than the average truck driver. But he is a rock star when it comes to total joint replacement surgery. You'd never think of him as sitting in his office reading medical journals, yet he does, and he has had less than optimal outcomes on occasion despite his best efforts, and they haunt him.

Clinicians have no intent to harm patients. Research is priceless and bad docs need to be weeded out. What patients may not know is that every hospital (I can only speak to the US) has a peer review board. Surgical outcomes are monitored and, when one is less than optimal, they are reviewed with the surgeon and a board of his/her peers. Whether the outcome is due to an error, equipment failure, or other factor, it is addressed and dealt with. I have sent surgeons to peer review as an RN in my day. We take this seriously.

Additional thoughts: When looking at medical issues, we tend to look at factors that can be modified vs. those that can't when making treatment decisions.  For example, things that can be modified that contribute to POP are: weight/BMI, smoking status, lifting, types of exercise, chronic constipation.  Things that can't be modified that contribute to POP are: age, childbirth status (young age of first delivery, forceps, type of delivery, etc), prior hysterectomy, heredity, gravity, menopause status, connective tissue disorders.  Those things are an additional factor taken into consideration regarding surgical decision-making.

It is important patients recognize that clinicians have good and bad days too. Complex aspects of running a medical practice with multiple employees, patients with diverse health issues, work days that often begin long before they get to the office, their personal family dynamic (clinicians have lives too!), and navigating the extremely varied insurance coverage dynamic are just some of the concerns that plague them daily. It is imperative whether patient or practitioner that we do our best to be understanding and patient. Communication is key.