Healthcare Quality is Diligence, Thoroughness and Attention to Detail... Learn How to Find It.

This video provides an in-depth exploration of healthcare quality, defining it primarily through the lens of diligence, thoroughness, and attention to detail. Dr. Eric Bricker, the speaker, draws extensively from the wisdom of Dr. William Osler, the founding physician of the Johns Hopkins Department of Medicine over a century ago. Osler famously identified apathy, indifference, and intellectual laziness as the most dangerous shortcomings for doctors, positing that true quality stems from the complete opposite: an unwavering commitment to diligence. Bricker highlights that this philosophy fostered an "Oslerian culture" at Johns Hopkins, where diligence was a universal expectation among all healthcare professionals, contrasting this with the more "spotty" presence of diligence he observed in other healthcare settings.

The presentation further delves into the critical distinction between measuring healthcare quality by outcomes versus by the process of diligence. Dr. Bricker argues that focusing solely on outcomes can incentivize "cherry-picking" easy patients and "lemon-dropping" complex or non-adherent ones, thereby distorting true quality assessment. Instead, he advocates for evaluating the diligence applied to the care process itself. This leads to a discussion on how compensation structures should be designed to promote diligence. He critiques the prevalent fee-for-service model in America for inadvertently promoting rushing and higher patient volume, which directly undermines the thoroughness required for quality care, as doctors are financially rewarded for seeing more patients in less time.

To illustrate the appropriate application of diligence, Dr. Bricker introduces a 2x2 matrix that stratifies care based on clinical complexity (high or low) and required diligence (high or low). The ideal scenario is high diligence applied to high clinical complexity situations, such as major surgery, cancer, cardiovascular disease, or high-risk obstetrics. Conversely, low diligence in highly complex cases is deemed unacceptable. He also points out the inefficiency of applying high diligence to low-complexity situations (e.g., the "worried well"), as this represents an opportunity cost where highly skilled resources are not optimally utilized. The video concludes with practical advice for patients on how to identify diligent doctors, emphasizing the value of primary care physician referrals, healthcare navigation services, and personal observations of a doctor's listening skills, explanatory abilities, and adherence to basic hygiene like handwashing.

Key Takeaways:

• Defining Healthcare Quality: True healthcare quality is fundamentally rooted in diligence, thoroughness, and attention to detail, a concept championed by Dr. William Osler over a century ago. It is a commitment to the process of care, not just the outcome.
• The Foe of Apathy: Osler identified apathy, indifference, carelessness, and intellectual laziness as the most dangerous traits in a physician, emphasizing that these undermine the very essence of quality care.
• Cultivating Diligence: Institutions like Johns Hopkins historically fostered an "Oslerian culture" where diligence was a pervasive and expected standard among all healthcare providers, creating an environment where slacking off was culturally unacceptable.
• Process Over Outcomes: Measuring healthcare quality solely by patient outcomes can be misleading, as it can incentivize providers to "cherry-pick" easy cases and avoid complex ones, rather than focusing on the quality of care delivered regardless of patient prognosis.
• Compensation Structure Impact: Compensation models should be intentionally designed to promote diligence. The prevailing fee-for-service model is criticized for incentivizing rushing and high patient volume, which often compromises the thoroughness essential for quality care.
• Strategic Resource Allocation: A 2x2 matrix framework helps match clinical complexity (high/low) with the appropriate level of diligence (high/low). High complexity situations (e.g., major surgery, cancer) demand a high degree of diligence.
• Avoiding Mismatches: It is crucial to avoid scenarios where high clinical complexity is met with low diligence. Conversely, applying excessive diligence to low-complexity cases can be an inefficient use of valuable resources, leading to opportunity costs.
• Leveraging Primary Care Physicians: Patients can utilize their primary care physician's referral expertise to identify diligent specialists within their local network, as PCPs often have a better understanding of other providers' quality.
• Healthcare Navigation Services: Specialized services, such as the former Compass Professional Health Services, play a vital role in helping patients, especially those with complex diagnoses like cancer, identify highly diligent and appropriate medical providers.
• Patient Self-Assessment (The Three Don'ts): Patients can personally assess a doctor's diligence by observing three key behaviors: whether the doctor listens well, explains things clearly and thoroughly, and washes their hands in front of the patient.
• Actionable Patient Empowerment: If a doctor consistently fails to meet these "three don'ts" (poor listening, inadequate explanation, lack of handwashing), patients are advised to "vote with their feet" and seek care from another provider who demonstrates greater diligence.
• Systemic Importance of Diligence: The concept of diligence extends beyond individual practitioners to the entire healthcare system, influencing how resources are allocated and how quality standards are maintained across various departments and roles.

Tools/Resources Mentioned:

• "The Quotable Osler": A book compiling quotes from Dr. William Osler, foundational physician at Johns Hopkins.
• Compass Professional Health Services: A healthcare navigation service (mentioned as a past employer) that focused on identifying highly diligent physicians for members.
• AHealthcareZ video on "Mismatch Between Disease Complexity and Physician Skill": Another video by Dr. Bricker that delves deeper into the appropriate matching of provider expertise with patient needs.
• "16 Lessons in the Business of Healing": Dr. Eric Bricker's book.

Key Concepts:

• Diligence in Healthcare: Defined as thoroughness, attention to detail, and a complete lack of apathy, serving as the cornerstone of high-quality medical service.
• Oslerian Culture: A pervasive organizational culture, exemplified by Johns Hopkins, where diligence is a universal expectation and standard for all healthcare professionals.
• Fee-for-Service: A common healthcare compensation model where providers are paid for each service rendered, criticized in the video for potentially incentivizing volume over the diligence required for quality.
• 2x2 Matrix for Clinical Complexity and Diligence: A framework used to visualize and strategize the appropriate allocation of diligence based on the seriousness and complexity of a patient's medical condition.
• Healthcare Navigation: Services designed to guide patients through the healthcare system, helping them identify and access appropriate, high-quality providers for their specific needs.
• The "Three Don'ts": Practical, patient-observable indicators (doctor not listening, not explaining well, not washing hands) that suggest a lack of diligence in a healthcare provider.