"Lies, damned lies and statistics" often is attributed to former British Prime Minister Benjamin Disraeli. (Ironically, it appears that such attribution might be a lie itself.1) The pursuit of numbers in private practice, while not a lie per se, nevertheless has moral implications.Many practice-management companies rant and rave about PVA (patient visit average) or total number of patients seen in a day.
I was forwarded an e-mail wherein someone touted the ignominious achievement of one doctor having adjusted 830 patients in one day. Some readers might think this was just advertising hyperbole. I hear that often when I bring this up in ethics postgraduate classes. However, in one recent ethics seminar, a doctor told everyone he had been to that practice-management doctor's office and actually had observed the doctor treat 750 patients in one day!
Let's do the math: A 10-hour workday = 43 seconds per patient; a 12-hour workday = 52 seconds per patient; and a 16-hour workday = 69 seconds per patient. Now, if one believes the adjustment is akin to a sacrament in a religion, then seeing hundreds of patients in one day is as laudable as it appears it is for those pastors who have built mega-churches by saving so many souls.
A friend of mine told me a story about a man he had met in chiropractic college. The man, upon hearing that my friend was a chiropractic student, reported he had seen multiple chiropractors for his low back pain. He said he sees a great doctor now. In fact, he reported that he loved this particular chiropractor so much that he would go daily if he had the time and money. My friend then asked the man about the status of his low back pain. The man said it hadn't changed at all. It turns out this doctor at the time had a CA whose job was to stand outside the treatment room to warn the doctor if he had spent more than 30 seconds with a patient.
I've heard people say this is a good doctor because obviously he is giving the patients something they are looking for. I say he's creating doctor dependency. Our job isn't to make the patient love us enough to pay to see us even if we don't help their chief complaint. We aren't supposed to turn them into our annuity. Our job is to help them with the suffering that brings them to us.2 If we can't, we need to help them find someone who can. One could argue that maintenance care might be justified, but only to maintain the patient's health after they've achieved it! This particular patient had not achieved health, since his low back pain was unchanged, even after the care of this doctor he "loved."
I'm on a mailing list that results in my getting audio CDs from a company that is going to make me a rich doctor. Of course, I've got to get my daily volume up to the stratosphere and have patients prepay for long-term care, and I need to believe in one particular religion. I'm not sure how my religious beliefs matter, but as in war, it seems one particular sect has its god's blessing to be profitable in practice (or victorious in war3). I've been to a practice-management seminar at which we were told to do management by statistics - that is, to pay our staff more money as we drove up our PVA or some other statistic that reflected quantity, not quality, of care.
From where does this reliance on statistics come? I see three distinct situations ingrained into so many chiropractors that success can be measured by the number of patients one sees. First, there is the indebtedness of chiropractic students. Too much debt makes the quest for money supersede the primacy of our duties to the patient. Antiphanes, an ancient Greek dramatist, wrote: "The quest for riches darkens the sense of right and wrong." That darkened sense of right and wrong can lead one to delude oneself that a high volume of patients shows that one is a good doctor. Many practice-management firms reinforce this delusion by giving an escalating level of awards for greater patient volumes.
Another situation that makes many in the profession so enamored by the number of office visits are chiropractic college graduation requirements. There are ethical lessons taught in college that are part of what is called the "hidden curriculum." These are lessons learned but not consciously taught. The pursuit of numbers (i.e., the minimum requirement of number of adjustments, X-rays, physical exams) needed to graduate from chiropractic college might be a part of the hidden curriculum. Here's what a student wrote me: "My classmates will take the attitude of 'patients as numbers' and 'retain them as a number,' rather than care for them according to all the evidence-based, case-management, patient-centered, outcome-measured ways we have been taught." Thus, their situation (the hidden curriculum) teaches that the numbers matter more than competency or quality and may be a result of the law of unintended consequences the CCE standards have created.
Finally, a situation pushing the importance of numbers is the shrinking reimbursement from managed care organizations. In any business in which the profit margin shrinks, the only way to maintain or increase one's income is to increase volume. Thus, another result of the law of unintended consequences is that managed care organizations may be squeezing doctors to the point that quality care is not profitable, and only low-quality, high-volume care is profitable. Then people will try to deceive themselves that high volume also is high quality4 so they can feel good about their reduced quality of care. Concentrating on the quantity of care and not the quality might just be the lie that statistics (PVA, graduation requirements or reduced reimbursement) made.
- Lee PM. "Lies, Damned Lies and Statistics." www.york.ac.uk/depts/maths/histstat/lies.htm.
- Perle SM. "The Eighth Habit: Empower Your Patients." Dynamic Chiropractic, 2007:25(3). www.chiroweb.com/archives/25/03/12.html.
- Bob Dylan. "With God on Our Side," copyright 1963.
- Perle SM. "Scientific Misconduct, Error or Willful Ignorance?" Dynamic Chiropractic, 2003;21(14). www.chiroweb.com/archives/21/14/15.html.
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