A patient consulted me years ago for a draining sinus in his right leg. He previously underwent several surgeries in the leg for multiple open fractures in the lower extremities sustained from a motorcycle crash. The fractures got infected despite repeated surgeries. After almost 6 months of treatment, clinical and laboratory findings suggest the infection is “controlled’ and the draining sinus is healing. The surgeon applied a closed circular leg cast on his right lower extremity.
“I asked the doctor if he can place a cast window over the wound” said the patient. The doctor replied “there’s no need for that”. “Your wounds are healed and I’m placing cast so your leg bones will unite”.
Two weeks after, the cast emitted a foul smelling odor. His right leg is still on circular’ long leg cast when he came to our clinic. The foot part of that cast is nowhere to be found and the patient is “walking” with crutches on his affected leg. After opening the cast, a draining sinus is again right where the wound is supposed to be “healed”. The worst part of this experience according to the patient is not that he had another draining sinus heralding an infection, but this.
“We asked the surgeon to place a cast window over the wound, but he didn’t listen. The odor is unbearable, I couldn’t clean it. Everybody avoided me because I smell very bad.
The phrase “he didn’t listen” stuck even now that I am in my private orthopedic practice. It served as a constant reminder for me of how I will ultimately gauge the quality of care I deliver as a physician. This may arguably be, a very controversial mantra of service for a healthcare professional. Personally though, I’m reminding myself why I am in the business of medicine and who I’m supposed to be “servicing” first . Patients. They are exactly why I wanted to be a doctor in the first place.
A very interesting offshoot of this patient encounter was the fact that he wasn’t really concerned of another infection. It is the fact that the doctor “didn’t listen to him”.
Scientific evidence and Peer reviews
Quality of care for physicians is measured by how well we render service using available scientific evidence and peer reviews by colleagues. No matter how we try to convey these scientific evidence into understandable bits of information, patients seem to have a “different” criteria of measuring the quality of care we render to them.
In the example I mentioned above, the patient measured the “quality” of care rendered not by how “scientific” his chronic leg infection was managed, but by how the doctor “listened” to his suggestion.
No matter how physicians strive to be objective, patients will always take their “health experience” as personal. The context of this health experience is a manifestation of their personality, values and expectations. Thus patient measures health care effectiveness by making comparisons of what physicians do against what they understand, of what they “experience”. In short, patients uses proxy measures- a reasonable default because often, the complexity of medical science baffles even the best of its practitioners.
What is a Proxy Measure? A proxy is an indirect measure of the desired outcome which is itself strongly correlated to that outcome. It is commonly used when direct measures of the outcome are unobservable and/or unavailable. An organization should use a proxy measure when there is little or no data available about the program being implemented, but the outcome the program is designed to influence has an existing and commonly accepted proxy.
A lady patient once whispered to me asking my team to leave the room for a moment and come back after 5 minutes. “I just had my bedside bath and I’m still in my underwear when your service entered my hospital room”. She said he would appreciate it next time if the station nurses warned us before going inside the room. Respect for the patient’s privacy as an individual or a person rather than just as a disease or medical condition is another proxy measure most patients used to gauge us physicians.
A third proxy measure that is of interest to me too is how well coordinated is my whole medical service team. A patient once asked a nurse who was dressing her wounds why she and not the surgeon is cleaning her wound bedside, the nurse replied “I’m did because I was ordered to”. When patients sees the healthcare team in disarray or is uninformed about his or her treatment plan, it reflects bad on the whole healthcare team.
These are just some of the proxy measures that patients use that I personally had experience. Some physicians would argue for or against the validity of these proxy measures. Personally though, many patients do not really care what “99.99% of patients with this medical condition get well” meant for their own illnesses. Their health experience matters most. If this is true and valid, why are proxy measures not included in the physicians criteria for assessing the quality of care we deliver?
Join us this Saturday, August 13, 2016 9PM Manila time as we discuss the importance patient proxy measures in assessing the delivery of care by health professionals
- T1. Are patient “proxy measures” valid measures for quality of health care? Why or why not?
- T2. What are your top three patient proxy measures of care and how do you validate (investigate) these measures as a physician?
- T3. Is it helpful if we incorporate “patient proxy measures” into our system of assessing quality of service? Why or Why not?
Again, see you this Saturday 9PM for another lively, interesting tweet chat by using the #healthxph.
- Gitbooks https://centerforgov.gitbooks.io/benchmarking/content/Proxy.html
- Patient Safety Quality Improvement, Department of Family and Community Medicine, Duke University School of Medicine http://patientsafetyed.duhs.duke.edu/module_a/measurement/proxy_measures.html