Disclosure- I am married to a physician who is in an academic medicine practice.

I sit on the nexus between two worlds- that of the normal, every day patient, and that of someone who practices medicine every day. It’s often an odd place to be, especially in these days of debate over health care reform. It’s so very clear that medicine has to start keeping up better with the changing ways of communication. Yet, it is hamstrung by a world where health information can be used as leverage against someone for their employment, where disclosure of information and security are at a premium, and where litigation and taking things out of context abound.

A friend of ours said to me the other day that the best piece of advice they ever got was that “You have to be treating patients, not practicing medicine.”  In a nutshell, that means patient-centered care should always be the rule, and the institution of medicine needs to make sure the rules, regulations, procedures, and even science do not lose sight of what’s most important here- making people well, or keeping them from getting sick in the first place.

That said, the markers doctors use to judge the quality of care and those used by patients could not be more different.

As in any business, the people inside the field know who they can trust. If a doctor needs to see one himself, they ask other doctors for their advice if they don’t know someone in that specialty themselves, or ask their nursing staff what they think of the doctor in question. Just like a secretary knowing more about her boss than any customer ever will, the same goes for nurses and doctors.

Doctors, especially in academic medical centers, know how current and up to date the practitioners are in the area. (Or better yet, ask a nurse, since they work more closely with a doctor than most other doctors do.)

They know who is Board Certified in their sub specialty, and who is not, as well as those who had trouble passing their Boards. (This means the Doctor passed some lengthy exams requiring them to pass a written exam as well as an oral exam before a group of doctors, examining the patient cases they treated during training, questioning what decisions they made and why, good and bad.)

While there are plenty of caring physicians who haven’t been able to pass their Boards, many of the more prestigious hospitals don’t allow those doctors to practice there because they aren’t certified. If you are in a rural area, or have a small community hospital, there’s a pretty good chance not every doctor practicing there will be Board Certified in their sub specialty, in contrast to hsopitals in larger, more competitive markets.

As the wife of a physician, I know the back room gossip of who’s good, who’s okay and who is starting to lose some of their sharpest surgical skills. It may not be something we talk about in public, but everyone knows who is not always on their “A” Game at work, and medicine is no different from any other job in that respect. I know I’d rather be treated by someone who has a good combination of clinical skills, surgical skills when needed and who is doing some research or otherwise engaged in teaching or the latest treatments.

We certainly have a bias towards academic research hospitals for that reason. Even when you might be seen by a resident, the chances are you are getting better and more consistent care than in some of the other practices around. This means I often sit next to medicare patients while waiting in the office, since these doctors treat anyone regardless of their insurance status. Being in the office of a doctor who treats the wealthiest and most prestigious people in the community is far less important to me than being treated by the doctor who knows the most.

I worry that being a lawyer and a doctor’s wife gives me a very skewed picture of what quality of care looks like. I know when I show up at the office or even in the Emergency Room with a kid with a broken arm, we get some favors, some “professional courtesy”, like not having to wait as long before being seen.  (It’s one of the few perks that helps compensate for the huge number of hours each week my husband spends at the hospital and on call.)

But at the heart of it, quality of care to physicians is based first and foremost on the science, who is best trained and who keeps up with the latest advances.  From a patient’s perspective, we often don’t have the all the knowledge necessary to make the best health care decisions.  We don’t ask if our doctors are board-certified.  We don’t know if they are practicing rountinely within the standard of care.  Most likely we’ve chosen them because they take our insurance, they aren’t too far from home or work, or we like them personally.  We judge a lot of the quality of health care by how we are treated emotionally- Do I like the receptionist and the nurses?  Is the lobby and waiting area nice?

None of that has anything to do, however, with the quality of our care, but it has everything to do with our perception of being cared for.

One of the things we’re going to have to sort out in health care reform is how much of the reform needs to be based on allowing doctors more time to really see their patients and get to know them- one on one care that takes time, and is not an assembly line.  If we want an efficient system, the first thing that gets factored out is the more personal attention- just like “making schools more efficient” has meant factoring out smaller classrooms and things like art for the sake of cramming as much knowledge as possible into the heads of outr kids in each school day.

But in both cases, the efficiency has detracted from the perception of quality, andwe have factored out the “quality of life” factor which is so essential both to great education and great healtcare.  These are not services that can be effectively mechanized like an assembly line- the human touch does really matter, and we have to accept that quality and efficiency are not always going to be 100% compatible metrics where humans are concerned.