Guest Post: Is It The Right Time To Introduce Real Supervision Into Medical Practice? 1

Editor’s Note: Dr. Schloss, the medical director of cardiac electrophysiology at Christ Hospital in Cincinnati, OH, originally submitted the following post as a comment on my previous post in which I compared HCA to Barclays and JP Morgan. I’d be very eager to hear responses from other physicians about this subject.

Is It The Right Time To Introduce Real Supervision Into Medical Practice?

by Dr. Edward J. Schloss

One thing hospitals and banks have in common is that the quality of their work is obscure and not easily measured by the consumer. Systematic abuses can go undetected without direct supervision and public reporting.

At least a banker’s work is directly supervised by their peers. In a hospital, there is no direct supervision on the actions of the doctors. It is quite easy to work alongside another doctor for years without really knowing how good or bad they are. Current quality measures are easily gamed and do not really measure what they are intended to measure. Any practicing physician will tell you that.

Because our patients are not able to evaluate the quality of their care and external quality metrics are so poor, I wonder if the time might be right to introduce real supervision into medical practice. In his excellent piece in the New Yorker this week, Atul Gawande spends some time discussing ICU doctor supervision via the electronic ICU system. It may be time to extend this type of “check and balance” system into more clinical arenas. Imagine a physician supervisor making rounds into cath labs and ORs, reviewing charts and interviewing MDs. This sort of thing would likely be resisted by many doctors, but would be a better way to pick up outliers than computerized checklists.

Now that most doctors are employees of hospital systems, it would be feasible to set up such a supervision system (assuming federal privacy rules don’t get in the way).

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One comment

  1. Really appreciate the points raised by Dr. Schloss. I have a few random thoughts…

    Dr. Gwande, in a separate essay than the one cited above, gives an excellent example of how he personally benefited from “coaching” or supervision from a senior colleague. Here is a link: http://www.newyorker.com/reporting/2011/10/03/111003fa_fact_gawande?currentPage=1 . (If you have the attention span of a millennial, like me, skip to page 6.)

    One of the issues that Gwande does not address in his essay is the level of training and experience of the coach. In his case, Gwande is an accomplished Endocrine Surgeon who has the humility to seek advice from a former teacher, a recognized master clinician, who has received countless teaching awards over decades.

    I think most physicians would welcome training and supervision of this kind… but I think doctors would be much more resistant to unsolicited oversight (even from other physicians) who may not even have an equivalent clinical case experience. This becomes an even larger issue for Interventionalists and Electrophysiologists, a very small proportion of physicians, in general, and with very specialized expertise.

    Also, to whom would the Supervisors report to? If the Supervisor directly reports to the Supervised physician for the purpose of medical education, then this is probably benign and actually helpful.

    It would probably be more ominous if the Supervisor reported their findings to employers or payers… and would not likely engender much buy-in.

    Physicians, as a Profession have a social contract: We are allowed special privileges (eg. examining people, cutting into people) in exchange for the duty of self-regulation. When the process of supervision is imposed on us by payers or employers, we become less of a Profession and more of a Trade.

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