Tag Archives: doctors and teachers

“Good” Doctors and Teachers (Part 2)

1. Has the definition of “good” teachers changed over time as has the one about “good” physicians?

2. Are there many different versions of “good” teaching as there were for “good” doctors?

3. Even with the differences in definitions over time and setting, are their core characteristics that transcend both as there were among “good” doctors?

4. Are “good” teachers dependent for success on their students, as doctors are on their patients?

The answer to each of the four questions is yes.

1. Has the definition of “good” teachers changed over time as has the one about “good” physicians? 

From the 1960s, researchers laid out the following personal traits and behaviors that “good” teachers exhibit:

[E]ffective teachers carefully monitor learning activities and are clear, accepting and supportive, equitable with students, and persistent in challenging and engaging them.

In the 1980s and 1990s, researcher findings added up to the following attributes of “effective” teachers. They:

*are clear about instructional goals;

*are knowledgeable about their content an strategies for teaching it;

*communicate to their students what is expected of them and why:

*make expert use of existing instructional materials in order to devote more time to practices that enrich and clarify the content;

* are knowledgeable about their students, adapting instruction to their needs….;

*address higher- as well as lower-level cognitive objectives….;

*accept responsibility for student outcomes;

*are thoughtful and reflective of their practices.

Then there are the features of “good” teachers that progressives then and now hold dear:

*A classroom that is student-centered:

*Teaching methods that are inquiry driven and organized around problem-solving and investigation:
*Instructors who are passionate about their subject’s real world significance.
*Metacognition—critical reflection about content
and pedagogy—is an integral part of the classroom
experience.

Lists of attributes and behaviors of “good” teachers appear every decade. Some lists overlap, some do not.

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2. Are there many different versions of “good” teaching as there were for “good” doctors?

Surely, there are. Consider that since the 1990s, policymakers have rushed to raise academic standards, hold teachers and administrators accountable for student outcomes, and expanded testing. In that push, a narrowed view of what constitutes “good” teaching has unfolded that focuses more on direct instruction and teacher-centered behaviors.

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Yet there are students who see “good” teaching as different than this current mainstream view (e.g., “What makes a great teacher is being kind,” “A great teacher is someone that cares for his or her students,” “Someone who can make learning fun and someone who can be funny and focused at the same time”).

And for many, but not the majority, there are parents, practitioners, and researchers, who define a “good” teacher as going beyond high test scores. They want their children’s teachers—reflecting another age-old tradition of teaching—to work daily for the well-being of the child, see students as whole human beings, believe in active learning, create structures for students to collaborate and explore. In short, these folks embrace a progressive ideology of teaching believing with supreme confidence that students exposed to this tradition of teaching will do well on tests, graduate and go to college. They would point to Los Angeles teacher Rafe Esquith, kindergarten teacher Vivian Paley, and Foxfire teachers in rural Georgia as “good” teachers who nurture, inspire, and connect to students.

3. Even with the differences in definitions over time and setting, are there core characteristics that transcend both as there were among “good” doctors?

Yes, there are. Just as when medical staff, patients, professionals and non-professionals define “goodness” in physicians, two essential features crop up again and again for teachers: competence and caring.

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4. Are “good” teachers dependent on their students as doctors are on their patients for success.

Yes. they are. To see how the dependence works, one has to sort out the notion of “good” from the idea of “successful.” They are often seen as equivalent terms. They are not. Once sorted out, it becomes clear that both teachers and doctors depend on their students and patients to learn and heal.

Keep in mind that doctors and teachers using “good” practices do not automatically yield “good” results. Following the best practices in either job leads, from time to time, to failure, not success. Why? Because motivated students and patients have to participate fully for “good” teaching to turn into “successful” learning and the same is true for doctors and their patients.

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Here is how the distinction works for teachers. Good” teaching pursues morally and rationally sound instructional practices. “Successful teaching,” on the other hand, is teaching that produces the desired learning. As Gary Fenstemacher and Virginia Richardson put it:

“[T]eaching a child to kill another with a single blow may be successful teaching, but it is not good teaching. Teaching a child to read with understanding, in a manner that is considerate and age appropriate, may fail to yield success (a child who reads with understanding), but the teaching may accurately be described as good teaching. Good teaching is grounded in the task sense of teaching, while successful teaching is grounded in the achievement sense of the term.”

Another way to distinguish between “good” and “successful” is when a 8th grade teacher teaches the theory of evolution consistent with the age of the child and best practices of science teaching (the “good” part) and then has her students complete three written paragraphs filled with relevant details and present-day examples that demonstrate their understanding of the theory of evolution (the “successful” part). These teaching acts are not the same nor does one necessarily lead to the other.

For the past quarter-century, however, policymakers and politicians have chopped, grated, and blended the goals of schooling into a concoction seeking to make education an arm of the economy. They scan international test scores, focus on achievement gaps, and boost teacher pay-for-performance plans. This policy direction has shoved the notion of “good” teaching into one corner of the ideological debate and thoroughly erased the distinction between the “good” and “successful” in teaching. Now “good” teaching means test scores go up and students go to college. A big mistake.

Why a mistake? Erasing the distinctions between “good” and “successful” teaching muddles policy prescriptions seeking to improve how teachers teach and what students learn. Best example of that muddle is evaluating teacher performance on the basis of student test scores. Consider, for example, the stark differences between Houston’s pay-teachers-for-performance and Denver’s ProComp plan.

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The answers to the four questions are monotonously “yes.” The string of “yes” answers reveals that policymakers have, as so often they do, ignored the history of diverse teaching traditions and different ways of teaching that parents, practitioners, and researchers prize resulting in an unfortunate monopoly on only one way of teaching while students—in their glorious diversity–learn in many different ways.

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*The quote marks are there to signal that “good” (or “great,” “excellent,” “effective”) is an adjective that varies in meaning among parents, teachers, students, researchers, and policymakers.

 

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“Good” Doctors and Teachers* (Part 1)

During the 1930s, my grandmother saw a specialist about a melanoma on her face. During the course of the visit when she asked him a question, he slapped her face, saying, ‘I’ll ask the questions here. I’ll do the talking.’ Can you imagine such an event occurring today? Melanomas may not have changed much in the last fifty years, but the profession of medicine has.  Eric J. Cassel, 1985[i]

Today, a stinging slap to the cheek of a patient who asked a question of her doctor could lead to an assault charge. Doctor-centered practice–paternalistic authority is no more. Shared decision-making between doctor and patient has become the ideal. In short, the definition of a “good” doctor has changed dramatically in the past half-century.[ii]

Even with this 180 degree shift in defining “goodness,” there remains much variation even among former TV doctors Welby and Kildare and today’s Dr. House. All are seen as “good” in different ways as times change.

And that is why I put “good” in parentheses. Personal features (e.g., communication skills, empathy), expertise (e.g., credentials on walls, medical specialty), what others say, and context matter greatly in judging how “good” a doctor is.

Here is how one doctor puts the issue of defining “goodness” among physicians.

In my view, there are many ways a doctor can be good, so it’s difficult to know what someone means when he or she says a doctor is good.

For some people, being a good doctor is all about bedside manner, personality and communication skills. Other people value smarts, technical skills or expertise in a particular condition. Still others rely on credentials, such as where a doctor went to medical school or residency training. I’ve even known patients who care little about these other factors and instead care most about how the office runs, how quickly the phone is answered or how friendly the receptionist is.

The type of doctor may also determine how a person defines a good doctor. For example, many people I know say they don’t care about a surgeon’s bedside manner as long as his or her patients have outstanding results. Yet those same people might say that a good bedside manner is much more important for their primary care physician.

Then there are those magazines that list “best” doctors in their cities annually. How do they compile such lists? New York magazine, for example, depends upon a private firm that polls doctors for their recommendations:

The idea is that medical professionals are best qualified to judge other medical professionals, and if one recommendation is good (think of your doctor referring you to a specialist), multiple recommendations are better. Licensed physicians vote online (castleconnolly.com/nominations) for those doctors they view as exceptional.

So if the notion of a “good” doctor varies by time–doctor-centered then and patient-centered now– it also varies by what patients and doctors, each having quite different perspectives, value most in medical practitioners (e.g.,competence,  empathy, bedside manner). In short, there is not one single definition of a “good” doctor that covers all settings, perspectives, and times.

Yet even with all of this variation over what constitutes a “good” doctor, even with all of those lists of personal and technical features that patients want in their doctors, two generic characteristics emerge from the flow of words time and again. These basic features: competence and caring–turn up in studies (see here) and public opinion polls among both physicians and patients.

Keep in mind, however, that even the most competent and caring doctor depends upon the patient for any success in diagnosis and treatment. The truth is that expertise and caring are necessary ingredients for any definition of “goodness” in medical practice but, overall, insufficient in the helping professions without the patient’s cooperation.

While doctors can affect a patient’s motivation, if that patient is emotionally depressed, is resistant to recommended treatments, or uncommitted to getting healthy by ignoring prescribed medications the physician is stuck. Medical competence and empathy fall short when patients cannot or do not enter into the process of healing.

This basic predicament in the helping professions of being dependent upon the cooperation of the patient for any success–often unremarked upon–hobbles any definition of a “good” doctor.

Does the historical shift in definitions about “good” doctors and the fundamental dilemma they face apply to teachers? I answer that in Part 2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[i]Epigraph story in Christine Laine and Frank Davidoff, “Patient-Centered Medicine,” JAMA, 1996, 275(2), p. 152.

[ii] Ronald Epstein, Md., et. al. “Communicating Evidence for Participatory Decision-making,” JAMA, 2004, 291(19), pp. 2359-2366; Simon Whitney, Md., et. al., “A Typology of Shared Decision Making, Informed Consent, and Simple Consent,” Annals of Internal Medicine, 2003, 140, pp. 54-59.

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*Synonyms for “good” are “best,” “great,” “effective,” “stellar,” etc.

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Failure and Error among Doctors and Teachers

I had a conversation with a friend* last week about the two posts detailing my failures as a teacher with three students I have had over the years. He has practiced Family Medicine for over a half-century in Pittsburgh and for years helped resident physicians in doing medical research and now works with hospital residents in improving communication with patients.  He pointed out to me how similar teachers experiencing failures with students is to physicians erring in diagnoses or treatments (or both) of their patients.

I was surprised at his making the comparison and then began to think about the many books I have read about medicine and the art and science of clinical practice. In my library at home, I had two with well-thumbed pages authored by doctors who, in the  first dozen pages, detailed mistakes either they had made with patients or errors committed by other physicians on them or their families.

In one, Jerome Groopman, an oncologist, described what occurred with his 9-month old child after a series of doctor misdiagnoses that almost caused his son’s death. A surgeon, who was a friend of a friend, was called in at the last moment to fix an intestinal blockage and saved his son.

In the other book, surgeon Atul Gawande described how he almost lost an Emergency Room patient who had crashed her car when he fumbled a tracheotomy only for patient to be saved by another surgeon who successfully got the breathing tube inserted. Gawande also has a chapter on doctors’ errors. His point, documented by a paper in the New England Journal of Medicine (1991) and subsequent reports  is that nearly all physicians err.

If nearly all doctors make mistakes, do they talk about them? Privately  with people they trust, yes. In public, that is, with other doctors in academic hospitals, the answer is also yes. There is an institutional mechanism where hospital doctors meet weekly called Morbidity and Mortality Conferences (M & M for short) where, in Gawande’s words, doctors “gather behind closed doors to review the mistakes, untoward events, and deaths that occurred on their watch, determine responsibility, and figure out what to do differently (p. 58).” He describes an M & M (pp.58-64) at his hospital and concludes: “The M & M sees avoiding error as largely a matter of will–staying sufficiently informed and alert to anticipate the myriad ways that things can go wrong and then trying to head off each potential problem before it happens” (p. 62). Protected by law, physicians air their mistakes without fear of malpractice suits.

Nothing like that for teachers in U.S. schools. Sure, privately, teachers tell one another how they goofed with a student, misfired on a lesson, realized that they had provided the wrong information, or fumbled the teaching of a concept in a class. Of course,  there are scattered, well-crafted professional learning communities in elementary and secondary schools where teachers feel it is OK to admit they make mistakes and not fear retaliation. They can admit error and learn to do better the next time. In the vast majority of schools, however, no analogous M & M exists (at least as far as I know).

Of course, there are substantial differences between doctors and teachers. For physicians, the consequences of their mistakes might be lethal or life-threatening. Not so, in most instances, for teachers. But also consider other differences:

*Doctors see patients one-on-one; teachers teach groups of 20 to 35 students four to five hours a day.

*Most U.S. doctors get paid on a fee-for-service basis; nearly all full-time public school teachers are salaried.

*Evidenced-based practice of medicine in diagnosing and caring for patients is more fully developed and used by doctors than the science of teaching accessed by teachers.

While these differences are substantial in challenging comparisons, there are basic commonalities that bind teachers to physicians. First, both are helping professions that seek human improvement. Second, like practitioners in other sciences and crafts, both make mistakes. These commonalities make comparisons credible even with so many differences between the occupations.

Helping professions.

From teachers to psychotherapists to doctors to social workers to nurses, these professionals use their expertise to transform minds, develop skills, deepen insights, cope with feelings and mend bodily ills. In doing so, these helping professions share similar predicaments.

*Expertise is never enough. For surgeons, cutting out a tumor from the colon will not rid the body of cancer; successive treatments of chemotherapy are necessary and even then, the cancer may return.

Some high school teachers of science with advanced degrees in biology, chemistry, and physics believe that lessons should be inquiry driven and filled with hands-on experiences while other colleagues, also with advanced degrees, differ. They argue that naïve and uninformed students must absorb the basic principles of biology, chemistry, and physics through rigorous study before they do any “real world” work in class.

In one case, there is insufficient know-how to rid the body of different cancers and, in the other instance, highly knowledgeable teachers split over how students can best learn science. As important as expertise is to professionals dedicated to helping people, it falls short—and here is another shared predicament–not only for the reasons stated above but also because professionals seeking human improvement need their clients, patients, and students to engage in the actual work of learning and becoming knowledgeable, healthier people.

*Helping professionals are dependent upon their clients’ cooperation. Physician autonomy, anchored in expertise and clinical experience, to make decisions unencumbered by internal or external bureaucracies is both treasured and defended by the medical profession. Yet physicians depend upon patients for successful diagnoses and treatments. If expertise is never enough in the helping professions, patients not only constrain physician autonomy but also influence their effectiveness.

While doctors can affect a patient’s motivation, if that patient is emotionally depressed, is resistant to recommended treatments, or uncommitted to getting healthy by ignoring prescribed medications the physician is stuck. Autonomy to make decisions for the welfare of the patient and ultimate health is irrelevant when patients cannot or do not enter into the process of healing.

For K-12 teachers who face captive audiences among whom are some students unwilling to participate in lessons or who defy the teacher’s authority or are uncommitted to learning what the teacher is teaching, then teachers have to figure out what to do in the face of students’ passivity or active resistance.

Failure and error occur in both medical and teaching practices.
Both doctors and teachers, from time to time, err in what they do with patients and students. Patients can bring malpractice suits to get damages for errors. But that occurs sometimes years after the mistake. What hospital-based physicians do have, however, is an institutionalized way of learning (Mortality and Morbidity conferences) from their mistakes so that they do not occur again. So far, among teachers there are no public ways of admitting mistakes and learning from them (privately, amid trusted colleagues, such admissions occur). For teachers, admitting error publicly can lead directly to job loss).

So while doctors, nurses, and other medical staff have M & M conferences to correct mistakes, most teachers lack such collaborative and public ways of correcting mistakes (one exception might be in special education where various staff come together weekly or monthly to go over individual students’ progress).

Books and articles have been written often about how learning from failure can lead to success. Admitting error without fear of punishment is the essential condition for such learning to occur. There is no sin in being wrong or making mistakes, but in the practice of schooling children and youth today, one would never know that.

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* Dr. Joel Merenstein and I have been close friends since boyhood in Pittsburgh (PA)

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Best Practices and Bad Habits (Part 2)

Transfer of learning appears to be a simple concept. What you learn in the family or learn in school  can be applied in different situations outside of the family and the classroom. Learning Spanish, for example, helps later in learning Italian. Learning to get along with an older brother or sister helps in learning how to get along with others later in life. Learning math in middle school helps one in high school physics. It doesn’t always work that way, however.

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In Part 1,  I described how I taught a two-week unit on specific critical thinking skills useful to understand history and use in daily life in the early 1960s. My theory was that teaching these thinking skills directly one after the other at the very beginning of the semester would lead to students applying them when I began teaching units on the American Revolution, Immigration, Sectionalism and the Civil War, and the Industrial Revolution.

The response of students to the stories and subsequent discussions and debates almost made me swoon. I was energized by students’ enthusiasm as we went from one specific skill to another using contemporary stories drawn from newspapers,  student lives, and Glenville high school. The two week unit was from all indications a success with student engagement high and even scores on the unit test were higher than I had expected.

Then, when I began my U.S. history units on the American Revolution through World War I, the skills I believed that I had taught my students weeks earlier were missing in action. Root canal work was easier than getting students to distinguish between a biased source and one less so or explain why certain statements were opinions, not facts. I was puzzled.  What had happened?

Years later, I discovered from reading psychologists a great deal about the ins-and-outs of transfer of learning (see, for example, here). Teaching specific critical thinking skills and expecting students to apply what they learned to different situations depended upon many conditions that were, I learned later, missing in my lessons. Even the concept of teaching these skills isolated from the historical content–as I did–undermines the very goal I wanted to achieve (see CritThink).

Nonetheless, puzzled as I was by the absence of students applying what they had learned in the later history units I taught, for the next few years I continued to teach that two week unit on critical thinking at the beginning of the semester, marching through the lessons one skill after another. I repeated again and again this unit because the students were engaged, loved to apply what they learned to their daily lives, and I felt good after each of the five periods I taught. An uncommon experience for a veteran teacher.

Even had a colleague I trusted grabbed me by the shoulders then and told me how I was way off in thinking that my students would transfer the skills they learned in the two-week unit to subsequent history units, I would not have believed that colleague.  I would have continued with what I considered a “best practice” that, in reality, had become a “bad” habit.

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Like Dr. Danielle Ofra, I would have given reasons to myself why what I was doing helped students. As I look back, I kept doing the same unit year after year and ignored the signs–the mysterious tug I felt every semester seeing repeatedly that students failed to apply the skills in subsequent history units that they had supposedly learned weeks earlier. I persisted even in light of the evidence of little transfer of learning.

Such “bad” habits, of course are common. From over-eating to smoking to excessive Internet surfing to watching far too much television, “bad” habits–destructive to one’s health and well-being–persist among substantial numbers of youth and adults.

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Such habits are like ruts in road that get deeper and deeper through repetition of the behavior. It is hard to get out of the well worn groove. Yet people do break “bad” habits by replacing them with “good” habits that begin a new groove, and get practiced over and over again. It can be done and does occur.

As for me, my “bad” habit of ignoring evidence of my students not applying what they learned in that two-week thinking skills unit, eventually changed. The baffling lack of application got me to read more and talk to colleagues about what occurred in my teaching. I stumbled into new knowledge about transfer of learning. I made many attempts, some failed badly, to build new units in history where these thinking skills were embedded in the historical content. Eventually, I got into a new groove and created different units and taught them (e.g., Colonization, American Revolution, Causes of the Civil War, The Industrial Revolution, The Kennedy Assassination). See here.

But understanding transfer of learning was a hard road to travel in getting out of that rut I had made for myself as a history teacher many years ago.

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Best Practices and Bad Habits in Practicing Medicine and Teaching Students

Listen to Danielle Ofri lamenting a fact she discovered about her work in New York City’s Bellevue hospital as a physician: “we often ignore good advice when it conflicts with what we’ve always done.”

Ofri was referring to the latest clinical guideline issued by the Society of General Internal Medicine that recommended against annual physical exams for healthy adults. The scientific evidence shows “the harm of annual visits — overdiagnosis, overtreatment, excess costs — can outweigh the benefits.”  These guidelines become  “best practices” for physicians to follow with patients; they are based upon analysis of many clinical studies.

Keep in mind that the body of evidence producing clinical guidelines for how doctors should practice is based on cumulative research and meta-analyses often involving tens of thousands of patients in control and experimental studies. “Evidence-based medicine”–even with all of the criticism of reversals in the advice doctors receive-is a reality at the fingertips of every doctor tapping keys and watching the computer screen as they take a patient’s history and conduct an annual exam.

Yet Ofri continues to have her patients return every year for an annual exam. How come?

She says: After the research was initially published last year, I grappled with the evidence, or lack thereof, reaching a conclusion that I mainly still supported the annual visit, if only because it establishes a solid doctor-patient relationship. But seeing these new, strongly worded recommendations, I may have to re-evaluate. At the very least, I should take a moment to think before I reflexively recommend the annual visit. But I know that I might still end up doing the same thing, despite the evidence.

She concludes: Humans are creatures of habit. Our default is to continue on the path we’ve always trod.

For some physicians, habit trumps evidence or what was once a “good” habit–annual exams for all of her patients–becomes a “bad” habit. True as well for K-12 teachers.

No such clinical research base, however, exists for recommending “best practices” in teaching reading, math, science, or history. Sure there are single studies, even groups of studies that point in a direction that teachers might consider in teaching long division or teaching six year-olds how to parse vowels and consonants. But for most teachers, “best practices” is a meld of what researchers say practitioners ought to do, what “experts” say should be done in classrooms, lessons learned from personal experiences in teaching, deeply-ingrained beliefs–call it ideology–about how best to teach and how students learn, and, yes, you guessed it: habit.

All of these ways of defining “best practice” for teachers came into play when I taught history to high school students many years ago. Let me explain.

In the fifth year of my teaching at Cleveland’s Glenville high school–it was the early 1960s–I had already introduced materials to my classes on what was then called “Negro history” (see here and here). I then began experimenting with the direct teaching of critical thinking skills. I believed that such skills were crucial in negotiating one’s way through life and understanding history. I wanted my students to acquire and use these skills every day. So I began teaching my U.S. history courses with a two-week unit on thinking skills. My theory was that the students learning these skills at the very beginning of the semester would then apply them when I began teaching units on the American Revolution, Immigration, Sectionalism and the Civil War, and the Industrial Revolution.

In the two-week unit, I selected skills I believed were important for understanding the past such as: figuring out the difference between a fact and opinion, making a hunch about what happened and sorting evidence that would support or contradict the hunch, judging how reliable a source of information is, distinguishing between relevant and irrelevant information in reaching a conclusion.

For each of these, I would go over the specific skill with the class and they and I would give examples from our daily lives, school events, and family happenings. Then,  I chose a contemporary event–a criminal case in the local newspaper, a national scandal that was on television, and occurrences in the school–and wrote out a one-page story that would require each student to apply the particular skill we were discussing such as making an informed guess, collecting evidence to support their hunch, and reaching a judgment. I also gave the class additional sources from which they could (or could not because of biases) select information to support their conclusion.

For the two weeks, each period–I was teaching five classes a day at the time–was filled with engaged students participating in flurries of discussion, debates over evidence, student questioning of each others’ conclusions, and similar excitement. I was elated by the apparent success of my critical thinking skills unit.

After the two weeks of direct instruction of skills, I plunged into the Coming of the American Revolution and subsequent history material. From time to time, over the course of the semester, I would ask questions that I felt would prompt use of those thinking skills we had worked on earlier in the year. Blank stares from most students with occasional “Oh yeah” from others. I designed homework that explicitly called for use of these thinking skills; few students applied what they had presumably learned.    I was thoroughly puzzled.

Which brings me to the concept of transfer. Why did students taught discrete thinking skills directly with a high degree of engagement and apparent learning for two weeks have a difficult time transferring those very same skills to history lessons later in the semester? I take up this issue and my “bad” habit in the next post. 

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Links and Lessons for K-12 Schools and Hospitals (Jeff Bowen)

Dr. Jeffrey Bowen has served as superintendent of the Yorkshire Pioneer Central School District in western New York, research director for the New York State School Boards Association, and supervisor of on-the-job training in an Air Force hospital.  He is a founding member and vice president of the Healthy Community Alliance in Gowanda, New York.  

Since 2000, hospital bills have increased at an annual average rate of 10 percent.  Surveys show most Americans think that health care costs seriously threaten the economy.  Issues of access and quality complicate the picture.  Health care is gobbling up 20 percent of the Gross Domestic Product (GDP).

Meanwhile, funding cutbacks are distressing K-12 schools.  More than half the states are spending less per student this year compared to last.  As thousands of teachers are laid off, school boards and superintendents are reverting to bare-bones core academic programs and nervously depleting fund balances..

Schools and hospitals have many similarities.  These include for profit and nonprofit types, boards of directors and CEO’s, differentiated patient or pupil treatments, stringent confidentiality of records, specialized and licensed staff, extensive professional development, substantial physical plants and technology, and diverse business functions.  Schools and hospitals are communities as well as bureaucracies.

Hospitals depend on individual plans for each patient.  They keep detailed records regarding what intervention has been tried, which ones have succeeded or failed and for what length of time.  They must measure change carefully because lives depend on it.. At least for nondisabled children, Schools are less conscientious about individual plans for children .

Schools should take the cue from hospitals and strive toward complete, flexible individual plans for all students.  Thereby, interventions can be applied consistently and for the right length of time.  Special education has helped schools build bridges between themselves and the medical world.  Like medical professionals, school staffs have adopted the use of Response to Intervention (RTI).  Teachers vary the time, frequency and duration of an intervention to meet individual needs, assess and compare data regarding its effects, and then if necessary utilize an alternative intervention. RTI gets at problems before the child fails dismally and has to be remediated.   Educators should expand and refine this model, along with other medical inspirations like brain-based learning, doing group rounds, action research, scientifically valid practices (a federal Race To The Top program priority), referrals and preventive counseling.

Teachers hope to be publicly respected like doctors.   This will not happen unless school boards empower teachers to exercise more discretion to generate students’ individual plans.  Joint accountability for results would be a must, but teachers and children would benefit from more responsive and tailored support.

 Teachers and doctors alike are grappling with an explosion of internet-based information and new technology.  Educators are encouraged to coach or guide students to self-directed learning, while doctors and other medical staff are exploring telemedicine to facilitate prevention, diagnosis, treatment, and rehabilitation in home settings.  The key is to use technology more creatively, not as a convenient substitute for the status quo.

A warning: as technology redefines relationships, shoddy education or physical damage can occur as individuals self-diagnose or take intellectual shortcuts over the Internet.  Technology must reinforce rather than substitute for licensed professional expertise, solid thinking and good judgment.

 The intersection of medicine and education could be called health.  Public schools struggle to combine core academic subjects with learning about mental, emotional and physical health.  By the same token, hospitals and doctors are challenged to reach out to their surrounding communities in ways that could definitely strengthen health services

By promoting healthy communities, schools and hospitals could better serve the public at lower cost.

For many years I have served on the board of a nonprofit network called the Healthy Community Alliance (HCA) in rural western New York.  Largely state grant-funded with six full-time employees, the network  provides or coordinates programs that address chronic disease awareness and prevention, youth mental health, parent education and management including physical activity and nutrition.

The Alliance takes advantage of emerging health and lifestyle priorities for both young and older populations.  It maintains an impressive list of partnerships and affiliations, but relationships with both hospitals and school districts are hampered by apathy or uneasiness because silo thinking lingers.  School and hospital executives should prioritize alliances with regional health networks to close community service gaps more efficiently and cost effectively.

Funding is a minefield for both schools and hospitals.  However, public schools operate in a comparatively controlled fiscal environment.  Elected school boards, annual public budget or tax rate referenda, property tax caps, and mandated reporting requirements keep schools more accountable to their constituencies than most hospitals are accountable to theirs.

Hospital charges depend on a confusing combination of costs derived from different sources.  Hospitals do not publicize standardized fees for specific services.  Usually patients are not in any position to make informed choices.

In a recent Time Magazine special report, Stephen Brill urges significantly lowering the eligibility age for Medicare to 40 so that insurance limits can be extended on certain expensive tests, drugs, and services. Medicare controls costs by reimbursement based on certain standards for treatment.  The standards are published, specific, measurable, and reasonably scientific.  Connecting performance standards to cost reimbursements seems to hold promise not just for medicine, but as well for schools where politics often override educational performance. Medicare may have big flaws, but it also saves big money.   

Everyone wants measurable results to assure performance quality and bang for the buckSchool and hospital leaders should make time to discuss their commonalities.  By climbing out of their boxes, these two institutions could reconnect cost with quality and multiply productivity.

  References

Anderson, G. (Johns Hopkins University) as cited in Babcock, C.R. (2013, March 12). Americans without insurance face escalating hospital bills. The Buffalo News. Buffalo, New York.

Brill, S. (2013, March 6). Bitter Pill: How outrageous pricing and egregious profits are destroying our health care. Time Magazine.

CBS News/New York Times. (2009, June 20). The Debate Over Health Care. National Poll Conducted by CBS News/New York Times.

Healthy Community Alliance, Inc. (2012).  Community Value Report. Gowanda, New York: Author.

Mellard, D.F., and Johnson, E. (2008). RTI: A Practitioner’s Guide to Implementing Response to Intervention. Thousand Oaks, CA: Corwin Press.

Oliff, P., Mai, C, and Leachman, M. (2012, September 4). New School Year Brings More Cuts in State Funding For Schools.  Center on Budget and Policy Priorities. Washington, D.C.

Richardson, W. (2013, March). Students First, Not Stuff. Educational Leadership, 7 (6), 10-14.

USDOE. (2012). The Condition of Education. Washington, D.C.: Author.

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Money Spurs Use of New Technologies in Medical Practice: Schools Also?

Physicians have steadily adopted new technologies from the early 19th century stethoscope to the X-ray decades later to late-20th century computer-tomography scans. Such rapid adoption of new technologies has been (and is) common in medicine. What is uncommon is that medical technology spurred by new ways of funding in the past half-century has come to dominate clinical practice among specialty doctors (but less so among primary care physicians whose revenue is largely generated by office visits). How come? [i]

Public and private insurers pay doctors not only for visits to offices, clinics, and hospitals but also for the diagnostic tests they order such as blood work, sonograms, X-rays, scans, and the treatments they deem best in light of an emerging diagnosis. They also prescribe medications and screen healthy patients for possible diseases including more tests since this system of payments–called fee-for-service–encourage such practices. Fee-for-service payments from private and public insurers depend upon counting patient visits, diagnostic tests, and treatments.

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Surveys of physicians, in part, support this view of doctors ordering additional tests beyond what may be necessary for the patient. Consider “aggressive care.” In a recent survey of primary care physicians, 28 percent said they ordered more tests or referred patients to specialists—their operational definition of “aggressive care.”  When asked why, physicians responded that they feared malpractice litigation, had to meet clinical performance measures set by insurers, and had insufficient time with patients. Recently a group of nine medical groups of specialists laid out recommendations that would reduce diagnostic tests (e.g., imaging tests for many cases of lower back pain).

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To see how fee-for-service infiltrates daily clinical practice, do the following thought experiment. Suppose you want to build a house for your family. You will need experts, expensive equipment, and materials and have to coordinate all of these. Instead of hiring a general contractor to oversee brick masons, carpenters, electricians, plumbers, and other specialists, you paid electricians for every outlet they recommended, carpenters for cabinets they thought you needed, plumbers for faucets they wanted to install, and brick masons for sidewalks they thought you should have. As an owner of the house, you would have hundreds of outlets, scores of cabinets and faucets and sidewalk after sidewalk winding around your house. The expense would be astronomical and the house would be in dire trouble a few years later.

Physicians, researchers, and policymakers say that lack of coordination and mindfulness in building such a house is what has occurred with fee-for-service dominating private and public payments to most physicians. One doctor pointed out that in the analogy the “general contractor” is what primary care physicians do in coordinating health care for patients. But family medicine and primary care practitioners are shrinking in numbers. Economic incentives through fee-for-service, however, nudge specialists to order diagnostic tests and prescribe treatments using the latest technologies.[ii]

When specialists form groups or hospitals invest in the latest equipment (e.g., imaging machines) and procedures (e.g., arterial stents), incentives to use both often multiply. For cardiologists inserting stents (cost: $30-50 thousand per procedure) to keep arteries open is a huge money-maker. As one medical researcher said: “In many hospitals, the cardiac service line [stent] generates 40 percent of the total hospital revenue, so there’s incredible pressure to do more procedures.”

Financial incentives do reshape clinical practice especially when the federal government puts its fiscal muscle behind certain medical technologies. For example, in the 1960s, a machine was invented to cleanse blood of impurities because of kidney failure. This invention saved lives but was so expensive that only the wealthy could afford it. In 1973, The U.S. Congress amended Medicare to cover full costs for dialysis of patients who would otherwise die.

Uses of technological tests for diagnosis and treatment in medical practice is, in part, a function of financial incentives–the market at work–put in place by private and public systems of funding. Whether it makes a difference in caring for patients–either in healing or extending lives–remains unclear.

Now, switch from doctors using new technologies to diagnose and treat patients to teachers and principals working in classrooms and schools. Think about school reformers who press administrators and teachers to use online instruction, blended learning, iPads, etc., etc., etc. What, if anything, can be learned from the impact of fee-for-service funding spurring greater use of high-tech tests in medical practice and how market incentives can be applied to schools and classrooms?


[i] Stanley Reiser, Medicine and the Reign of Technology (New York: Cambridge University Press, 1978). To be clear, when I refer to medical technology I mean the equipment, devices, drugs, procedures, and processes used to deliver diagnoses and treatments to patients.

[ii] Joel Merenstein, MD. suggested this to me. For shrinking number of primary care physicians, see Thomas Bodenheimer, MD, “Primary Care-Will It Survive?” New England Journal of Medicine, 2006, 355, pp. 861-864.

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Trusting Teaching and Doctors

When was the last time you heard an elected policymaker tell lawmakers the following about state and federal mandates for curriculum standards, accountability, and testing?

The laws that are in fashion demand tightly constrained curricula and reams of accountability data. All the better if it requires quiz-bits of information, regurgitated at regular intervals and stored in vast computers. Performance metrics, of course, are invoked like talismans. Distant authorities crack the whip, demanding quantitative measures and a stark, single number to encapsulate the precise achievement level of every child.

We seem to think that education is a thing—like a vaccine—that can be designed from afar and simply injected into our children. But as the Irish poet, William Butler Yeats said, “Education is not the filling of a pail but the lighting of a fire.”

This year, as you consider new education laws, I ask you to consider the principle of Subsidiarity. Subsidiarity is the idea that a central authority should only perform those tasks which cannot be performed at a more immediate or local level. In other words, higher or more remote levels of government, like the state, should render assistance to local school districts, but always respect their primary jurisdiction and the dignity and freedom of teachers and students.

Subsidiarity is offended when distant authorities prescribe in minute detail what is taught, how it is taught and how it is to be measured. I would prefer to trust our teachers who are in the classroom each day, doing the real work – lighting fires in young minds.

Those words come from Governor of California, Jerry Brown, where 300,000 teachers teach six million children in his State of the State address to the Legislature on January 24, 2013.

Re-read that last sentence. “Trust our teachers.”

That is a stunner given the reform-inflated air we breathe filled by federal, state, and district officials eager to evaluate teachers on the basis of student test scores, implement pay-for-performance plans, and get teachers to prepare lessons for state-adopted Common Core standards in reading and math.

On the heels of a statewide referendum that increased taxes—yes, increased taxes for seven years–Jerry Brown is no novice bellowing the latest school reform slogan. He is a 75 year-old veteran of school reform having served eight years as governor before and after Proposition 13 (1978). He is a hard-driving, practical political leader who knows the ins-and-outs of both local and state politics (e.g. mayor of Oakland, 1999-2007, state Attorney General, 2007-2011). When he says “trust our teachers” he means have confidence in teachers to do the right thing and continually work to improve their performance. That is good news for the state and nation.

Does that mean that the reform tide has turned and teachers will no longer be blamed for mediocre schooling and ignored in policy circles? Hardly. For all I know, Governor Jerry Brown may be an outlier and not the vanguard of a movement to restore trust in teachers by shrinking mandates telling them what to teach and how what is taught will be measured. But it is a welcome sign that has been missing for many years.

Less welcome has been the news for doctors who are hip-deep in pay-4-performance plans across the country. There is a national movement afoot to raise the quality of patient care and contain ever-escalating costs by launching plans that measure how well doctors treat their patients. In New York City public hospitals, for example,  doctors’ annual raises will depend upon performance metrics that include:

“how well patients say their doctors communicate with them, how many patients with heart failure and pneumonia are readmitted within 30 days, how quickly emergency room patients go from triage to beds, whether doctors get to the operating room on time and how quickly patients are discharged.”

The evidence over the past century has been clear that when policymakers and managers concoct high-stakes incentives to measure job effectiveness, award dollar bonuses, or fire employees, professionals and non-professionals learn to game the metrics. Incentives corrupt measures time and again.  There is a history in finance, the military, government, education, and other sectors of how metrics get gamed that policymakers ignore repeatedly. What’s worse, of course, is that doctors, like teachers, become the target rather than the political and socioeconomic structures within which they labor. In doing so, their loyalty to the helping profession in which they serve,  erodes.

Thus, over time, teachers and doctors come to see the “quality” measures used to evaluate and pay them as perverse destroying bonds they have to their students and patients, the institutions, and the very process of teaching and healing. Perhaps, the oath that medical school graduates take upon receiving the M.D. degree should also be taken by policymakers eager for pay-for-performance: Do no harm.

One top policymaker, Governor Jerry Brown, understands that admonition. Not trusting teachers (or not trusting doctors’ professionalism) and making rules that attempt to control performance will ultimately do harm.  I do not know whether you are an outlier or a sign of an emerging sensibility but I thank you Governor Brown for your recent words.

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Reshaping Teaching through Managerial Use of Student Test Scores

The path of educational progress more closely resembles the flight of a butterfly than the flight of a bullet.  Philip Jackson, 1968

Top governmental policymakers and private insurance companies, deeply concerned over ever-rising health care costs and unwilling to rely upon doctors to restrain expenditures, have built structures over the past quarter-century to hold physicians accountable for their actions in diagnosing and treating patients. These structures leaned heavily upon a research base built up over decades from clinical trials on screening procedures to the effects of drugs on an array of diseases. Combining evidence-based medicine with incentives and sanctions, public and private insurers have measured, reported, and rewarded doctors’ performance in hospitals, clinics, and office practices.
In copying outcome-driven corporations, these medical policymakers and insurers relied upon performance-based metrics. They assumed that creating economic incentives for individuals and organizations would increase innovation, lower costs, and improve patient care. They identified numerous measures, confirmed in large part by results from randomized clinical trials embedded in evidence-based medicine, and implemented those measures in hospitals, clinics, and doctors’ offices. Physician “report cards” and pay-for-performance plans, however, have yet to yield promised innovations, high quality care, and reduced costs.

Educational policymakers have made a similar set of assumptions in constructing accountability structures and using metrics for managing how teachers are to be evaluated and paid. In doing so, however, these decision-makers lack the knowledge base in educational research that physicians have had available in evidence-based medicine.

While social scientists and educational researchers have used randomized control group studies to uncover what caused phenomena in schools and classrooms, such studies have been the exception, not the rule. Ethical considerations, cost, and the complexity of schools, teaching, and learning reduce experimental-control research designs.

Qualitative research studies using surveys, interviews, case studies, and ethnographies are not designed to draw causal inferences; moreover, they cannot, given the questions asked, the samples drawn, and methodologies used. Qualitative studies ask different questions and provide rich data for exploring other issues that are missing from experimental-control designs.

As a consequence, unlike physicians who can draw from a literature of randomized control trials and use results for diagnosis and treatment of common and uncommon illnesses (e.g., Cochrane Collaborative), only a small and emerging body of knowledge drawn from randomized clinical trials about teaching, learning, and effective schools yet exists that policymakers and practitioners can tap (e.g., U.S Department of Education, “What Works Clearinghouse,” and Campbell Collaborative).[i]

That slim database, however, has not lessened the current passion among educational policymakers and politicians for using test scores to evaluate teacher performance (and pay higher salaries). The current “science” of value-added measures (VAM) leans heavily upon the work of William Sanders. Smart researchers and officials are determined to re-engineer teaching to make it closer to the “flight of a bullet” rather than the “flight of a “butterfly.” In seeking the Holy Grail, they have ignored the long march that researchers and policymakers have slogged through in the past century to make teaching scientific.[ii]

Not many contemporary reformers can recall Franklin Bobbitt in the 1920s, Ralph Tyler and Benjamin Bloom in the 1950s, Nathaniel Gage in the 1970s and 1980s, and many other researchers who worked hard to create a science of curriculum and instruction.  These scholars rejected the notion that teaching can be unpredictable and uncertain–”the flight of a butterfly.” They believed that teaching could be rational and predictable through scientifically engineering classrooms.

In How To Make a Curriculum (1924), Franklin Bobbitt listed 160 “educational objectives” that teachers should pursue in teaching children such as “the ability to use language …required for proper and effective participation in community life.” Colleagues in math listed 300 for teachers in grades 1-6 and nearly 900 for social studies. This scientific movement to graft “educational objectives” onto daily classroom lessons collapsed of its own weight by the 1940s, and was largely ignored by teachers.[iii]

By the early 1960s, another generation of social scientists had advanced the idea that teachers should use “behavioral objectives” to guide lessons. Ralph Tyler, Benjamin Bloom and others created taxonomies that provided teachers with “prescriptions for the formulation of educational objectives.” Teachers generally ignored these scientific prescriptions in their daily lessons.[iv]

In the 1970s and 1980s, Nathaniel Gage and others sought to establish “ a scientific basis for the art of teaching.” They focused on teaching behaviors (how teachers asked questions, which students are called upon, etc.)–the process of teaching leading to the products of effective teaching, student scores on standardized tests. This line of research called “process-product” continued the behavioral tradition from an earlier generation committed to a science of teaching. Using experimental methods to identify teaching behaviors that were correlated to student gains in test scores on standardized tests, Gage and others came up with “teacher should” statements that were associated with improved student achievement.[v]

The limitations of establishing a set of scientifically prescribed teaching behaviors soon became apparent as critics pointed out how many other factors (e.g., teacher knowledge and beliefs, the content of the lesson, students themselves, the classroom environment, the school) come into play when teachers teach students. Again, teachers generally ignored the results from “process-product” studies.[vi]

And here in 2013, re-engineering teaching through science again seeks “the flight of the bullet.” Evaluating and paying teachers on the basis of student test scores through value-added measures dominates policy talk and action.

In establishing new accountability structures that used squishy metrics and attached high-stakes rewards (e.g., cash bonuses for individual teachers) and sanctions (e.g., no diploma for failing high school students; teachers fired for being ineffective) educational policymakers have plunged into a highly contested arena where the search for teacher effectiveness—“the flight of the bullet”—has generated anger, fear, and lowered morale among those who work daily in classrooms. And, at the same time, generated political gains for elected policymakers.

Recall that under President George W. Bush, the Teacher Incentive Fund made grants to districts for overhauling their teacher evaluation systems. After Barack Obama became President in 2009, the U.S. Department of Education launched Race to the Top, a multi-billion dollar competition among states during a recession when school budgets were cut. To win, states had to meet certain conditions to collect federal dollars. One of those conditions was that states had to create new systems of teacher evaluation that included student test scores. Furthermore, in another federal initiative to turn around failing schools, the U.S. Secretary of Education dispensed School Improvement Grants to districts to overhaul schools with persistent low academic achievement. One of the strategies to turn around such schools included using student test scores to evaluate teachers.[vii]

Philanthropists have pursued similar policies. The Bill and Melinda Gates Foundation awarded grants to six districts to create and establish “fair and reliable measures of effective teaching” including the use of student test scores.  Yet even with all this federal and private money being spent the question remains whether these structures and metrics have reshaped classroom practices.[viii]


[i] Michael Feuer, Lisa Towne, and Richard Shavelson, “Scientific Culture and Educational Research, Educational Researcher, 2002, 31(8), pp. 4-14; for a direct comparison between EBM and EBE see: John Willinsky, “Extending the prospects of evidence-based education. In: Insight, Vol. 1, No. 1, pp. 23-41. For the Cochrane Collaborative, see http://www.cochrane.org/ ; for Campbell Collaborative, see: http://www.campbellcollaboration.org/ ; for What Works Clearinghouse, see: http://ies.ed.gov/ncee/wwc/ .

[ii] Quote comes from: Philip Jackson, Life in Classrooms,  (New York: Holt,Rinehart, and Winston,1968, pp. 166-167. William Sanders and Sandra Horn, “The Tennessee Value-Added Assessment System (TVAAS): Mixed Model Methodology in Educational Assessment,” Journal of Personnel Evaluation in Education, 1994, 8(3), pp. 299-311; Daniel McCaffrey, et. al., “Models for Value-Added Modeling of Teacher Effects,”  Journal of Educational Behavioral Statistics, 2004,  29(1), pp. 67-101.

[iii] Elliot Eisner, “Educational Objectives: Help or Hindrance?” The School Review, 1967, 75, pp. 250-260.

[iv] Ibid.

[v] N.L. Gage, The Scientific Basis for the Art of Teaching (New York: Teachers College Press, 1978).

[vi] Walter Doyle, “Paradigms for Research on Teacher Effectiveness,” Review of Research in Education, 1977, 5, pp. 163-198; N.L. Gage and Margaret Needels, “Process-Product Research on Teaching: A Review of Criticisms,” The Elementary School Journal, 1989, 89(3), pp. 253-300.

[vii] Sarah Garland, “Federal teacher evaluation requirement has wide impact,” http://hechingerreport.org/content/federal-teacher-evaluation-requirement-has-wide-impact_8360/ .

[viii] Bill and Melinda Gates Foundation, “Working with Teachers to Develop Fair and Reliable Measures of Effective Teaching: The MET Project,” 2010. The MetLife Survey of The American Teacher: Teachers, Parents, and the Economy, 2011 (Report published, March 2012), pp. 6-7;  See Scholastic, Inc. and Bill & Melinda Gates Foundation, Primary Sources: 2012: America’s Teachers on the Teaching Profession, pp. 27-29.

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Evaluating Doctors on Their Performance with Patients

The Centers for Medicare and Medicaid Systems (CMS) and private insurers have identified numerous pay-for-performance measures, confirmed in large part by evidence-based medicine, and implemented them in hospitals, clinics, and doctors’ offices.

For example, there are process measures for hypertension and heart disease where, for example, periodic readings of patient’ blood pressure and blood sugar levels are reported. But testing does not tell you whether the patient is bringing these diseases under control. So intermediate outcome measures that focus on patients’ actual blood pressure and blood sugar levels are noted to indicate whether the patient is improving, stable, or deteriorating.

Then there are final outcome metrics that demonstrate what happened to patients who received treatment in hospitals, went to another facility, or returned home. Complications after surgery such as infections, strong reactions to chemotherapy that requires re-admission into hospitals for further treatment, or death are examples of such outcome measures.  CMS and private insurers identified scores of such measures as a basis for allocating or withholding payments to hospitals, groups of physicians, and individual doctors ( pay for performance of doctors)

As one would expect when attaching high stakes to metrics in a helping profession such as medicine where there are many stakeholders (e.g., insurers, employers, doctors, medical staff, patients) views on pay-for-performance measures diverge, especially since insurers have published “report cards” displaying rankings, percentages, and results of these different measures for organizations and individual doctors. Divergent views of performance measures and “report cards” are inevitable when one examines the complex terrain that physicians inhabit and the predicaments they inherently face: expertise is never enough, making decisions amid uncertainty is common, and dependence upon the patient for improvement is essential. No surprise, then, these metrics and their outcomes, thus far, have generated mixed reactions. See here, here, and here.

Many policy makers, administrators, and doctors are satisfied that the measures are consistent with findings derived from evidence-based medicine and their experiences with patients. They welcome efforts to raise the quality of care and reduce costs. While many primary care doctors do agree with the policy initiative, they still question the measures because they know that these metrics—even when evidence-based medicine endorse the measures–seldom pick up individual differences among patients who have breast cancer, heart disease, or diabetes.

Consider a pediatrician whose practice includes adolescent girls. He tells the story of what happened to him when one of his insurer’s measures of quality care is a requirement to test all sexually active girls for chlamydia, a sexually transmitted disease. Since insurers do not and cannot read every single medical chart, they use a proxy measure to determine whether a girl is sexually active. They check to see if patients take birth control pills. That proxy complicates matters greatly because the pediatrician’s patients don’t take those pills for contraception, but for acne and menstrual pain.

The pediatrician asks a colleague: “So do I skip the testing for Chlamydia and fail my quality standards?” he asked. “Or do I order a test that the patient doesn’t need and that will probably not be covered by her insurance?” He ended his story by saying: “I’m all for quality. I just don’t think this is quality.”

For another primary care physician who has been highly ranked in the past on these measures from the local health insurer, her current “report card” left her dismayed.

“The quarterly “report card” sits on my desk. Only 33% of my patients with diabetes have glycated hemoglobin levels that are at goal. Only 44% have cholesterol levels at goal. All my grades are well below my institution’s targets. It’s hard not to feel like a failure when the numbers are so abysmal.”

She pondered the report card and told a colleague: “[They] focus on diabetes in pristine isolation [when] my patients inconveniently carry at least five other diagnoses and routinely have medication lists in the double digits.”

Moreover, according to the doctor, one of her patients has diabetes that can be controlled but has failed to come into the office regularly even though staff had contacted her many times. The doctor told her colleague that the patient “just can’t afford to take that much time off from work.”  “Does that,” the physician asked the colleague, “make me a worse doctor?”

These recent policy efforts to create accountability through establishing performance measures and dispensing monetary rewards to those who reach the benchmarks end up steering clinical practice toward standardization. These physicians I described are caught in multiple predicaments. They are involved, unknowingly, in the  struggle that has gone back and forth in medical circles for decades over the worth of doctors’ intuitive judgments vs. empirical evidence when uncertainty reigns and the abiding quandary of being dependent upon patients for success when the metrics make the doctor wholly responsible for outcomes. And now there is a full-court press that policymakers, saturated with data, have mobilized to standardize medical decision-making to increase efficiency and effectiveness.


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