The Real Quality Chasm: Differences in Perceptions Between Doctors & Consumers

Sue Bergeson Health Guide
  • I'm writing after seeing my doctor and just being tired of the lack of quality I'm seeing ... and what I've seen when I've been to other doctors as well. 


    A few years ago, the prestigious Institute of Medicine (IOM) created quite a stir when it released something called the Quality Chasm Report which indicated a huge gap between best practices and current treatment of many of the nation's most prevalent illnesses.  Depression was, I think, number one or two on the list. This led to a flurry of other papers and conferences—doctors all looked at the problem and agreed that SOMETHING MUST BE DONE. This led to other meetings where people gathered and wrote instructions and guidelines about what should be done.

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    Lots of conversation. Lots of writing. But not much actually implemented yet.


    While I was an active participant in many of those meetings and still hold hope that they'll make a difference in the future, I think the real quality chasm is very different and is something to be wrestled with before any changes can occur within our system. I think the real chasm is the difference between how doctors perceive their care/treatment and how their patients perceive it.


    I was recently asked to speak to a very prestigious groups of individuals who were examining quality measures. I shared with them the following survey results that indicate what consumers want from doctors:


    According to one survey we did with over 2,000 people responding, our number one request of our doctors was this: "Give me hope; make me feel hopeful about my future." This response was confirmed by another meeting attendee, a doctor who has made a name for himself in quality measurement in mental health. He said that while no one's able to quantify this yet, providing hope will not "go away" as a key indicator of what we consumers consider quality.


    Other things we want from our doctors in a quality practice?

    • Let me make decisions and have some input into my treatment/care.
    • Focus on my wellness, not my illness.
    • Act in a way that shows you believe that I can recover.
    • Listen to what I need instead of telling me what I need.


    Notice that we didn't say we wanted doctors who had more degrees or board certifications, cleaner offices, better office hours or a fax machine. We wanted hope, empowerment, recovery orientation and responsiveness.


    In another survey DBSA did with NAMI, we asked what the hallmarks of a good professional were. There were about 900 people who responded. What did we most want? "Please listen to me," was the number one response. Did you know studies show that a consumer will speak for less than 20 seconds before a doctor will interrupt them?


    What else did we want?

    • Communicate with me (i.e., speak in ways I can understand).
    • Be compassionate.
    • Be knowledgeable.
    • Have decent interpersonal skills.


    Notice that only one thing on both lists I've shared so far is taught in medical school.


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    Now, compare these things to what the professional guilds define as quality. (A guild is a society or association that advances or protects the members of that profession.) When you look up a list of providers on the American Psychiatric Association (APA) website, for example, you can find out where the practice is, how long the practice has been in existence and what degrees and certifications the doctor has. Board certification is supposed to be the highest indicator of quality. But what does the degree or certification have to do with how good doctors are from a consumer (their patient's) perspective? They may be smart, or at least able to pass an examination, but does that translate into good patient care? Most consumers would be highly doubtful that the one has much to do with the other.


    Take, for example, another survey DBSA did of 500 doctors and 2,000 of their patients. We asked doctors what kind of decision making was best, and they all agreed that joint decision making—involving the consumer in selecting a treatment—was the best practice. Seventy-nine percent (79%) of physicians said this is the way they make decisions in their practice.  But only 39% of their patients agreed that this is how decisions are actually made in their practices. 


    That's a pretty big chasm.


    Did the doctors lie about their practice? Did the consumers exaggerate how bad things were? Or was it more a matter of having different languages, different experiences and different expectations?


    It's my opinion that we need to look long and hard at the quality chasm that exists between doctors' perceptions of care and consumers' experiences of care. Unless we work on closing that gap, that quality chasm, nothing else is going to get much better.


    Do you have any suggestions or ideas for how we at DBSA—and how you in your community—can work to eliminate this gap?


Published On: May 30, 2008