Fwd: PDF - www.pnas.org;Re: [IMPROVEDX] HHS, CMS, RVUs, APMs, & Burnout

Sommers, Lucia Lucia.Sommers at UCSF.EDU
Wed Aug 31 20:18:39 UTC 2016

I am a new subscriber to the IMPROVEDX  list and also not conversant with current approaches to 'improvement processes' and 'physician champions'. (I was one of the first quality assurance coordinators in California in the late 1970's but left the field in the early 80's). Nonetheless, the comments in response to the piece, "Boosting Medical Diagnostics by Pooling Independent Judgments,"  particularly those touching on issues of group-based diagnostic approaches and their application to daily clinical life, possibly to reduce diagnostic error, encouraged me write and let you know about the work my colleagues and I have been doing in the SF Bay Area for the past 11 years as part of a UCSF CME program.

In brief, we are about marshalling collegial support in regularly-scheduled, practice-based meetings to help primary care clinicians engage case-based clinical uncertainty, be it diagnostic, management, relationship, prognostic, or any combination thereof. You can read about practice inquiry (PI) colleague groups, as well as other small group approaches to case-based work, in "Clinical Uncertainty in Primary Care: The Challenge of Collaborative Engagement." (http://www.springer.com/us/book/9781461468110).

Of the ~ 450 cases presented in the PI groups I personally have facilitated over the years, clinicians presented 11% as adverse events, seeking help in trying to understand what had happened. (We are planning to present and write about cases that very much look like diagnostic mishaps.) The good news about this work is that most of the colleague groups that began meeting regularly lasted at least 3 years with some going strong as long as 10 years; the bad news is that we have yet to do anything close to an RCT to look at impact on practice.  Nonetheless, with newly-minted PCPs looking for support within many of the large networks in Northern CA (e.g., Kaiser, Sutter, and federally-funded health centers), we're finding people eager for a lunch meeting with their older colleagues who, in turn, welcome the breath of fresh air the younger ones offer. We struggle with the 'pile on' (our term for the-blind-leading-the blind) and in training clinician group facilitators, we diligently practice 'And what else could be going on?,' and 'What would be the name of the article that could inform this uncertainty?'  No question that clinicians bring cases to their colleagues where they are very well aware that they are stuck. Yet every now and then a colleague at the table says something to the effect of, 'I didn't know I didn't know that,' and it feels like, just possibly, an error down the line might have been prevented.

So we soldier on, no hard proof of effectiveness in improving decisions but keen on improving the facilitation process when leaders are willing to get together and talk about what's happening in their groups, a relatively infrequent occurrence given the treadmill most clinicians are on these days. Recently, in two systems, physician administrators have seized on PI as an antidote to burn-out and freed up more clinician time for training. This is fine and if fear of burnout can result in better clinician decisions and fewer errors, so be it.
One of these days, it would be terrific to study error and burn-out rates beyond self-report as Williams et al did back in 2007. (http://journals.lww.com/hcmrjournal/Abstract/2007/07000/The_relationship_of_organizational_culture,.3.aspx)
I'd welcome your comments.

Lucia S. Sommers, MSS, DrPH

Adjunct Assistant Professor

Department of Family & Community Medicine
University of California, San Francisco

Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine

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