What Does Good Look Like?

Raoul S. Concepcion, MD

Editor-in-Chief of

Urologists in Cancer Care

Director of Clinical Research Urologic Surgeon Urology Associates, PC Nashville, TN

When I first entered practice in 1990, I was fortunate to have senior partners and colleagues who offered sage advice, much of it based on retrospective analysis of their own successes and failures over time.

Two of the most memorable really struck a chord:

1.Take time to watch your children grow up.

2.The only thing of value that you have and the government cannot tax is your free time.

Using that as my modus operandi, from day one of my new career I tried to take Thursday afternoons and be true to those core statements. It did allow me precious time with both my children during those formative years before they started school. Once they were enrolled, I was able to engage with friends and peers, often walking the golf course at our local club. Both have provided great memories that I will always cherish and never regret. One particular sweltering Thursday in the dead of summer, I was walking the number 3 fairway with a friend in the investment industry. He inquired if I was taking new patients, as he would like to make an appointment for a urologic issue. My response at the time was yes, I will always see new patients, but what did he know about me as a urologist? He promptly stated that I had taken care of many of our friends, as well as his mother, who actually had staghorn calculus in a solitary kidney (one of my partners and I did an anatrophic pyelolithotomy….oh, the good old days!). That was true, but what data did he have that justified his trust in me, besides my reputation? I said that if I were going to invest my money with him, I would like to know what his returns were over time, irrespective of our friendship; why did physicians not have to worry about providing outcome data, just like the rest of the world? (I did, by the way, end up doing his vasectomy.)

If you think about the mechanism by which patients have historically ended up in our offices, it has been due to relationships that we have forged over time. We may have overlapped with our referring physicians in medical school, residency, the golf course, the neighborhood, or our children’s school. They refer their patients and, to the best of our ability, we try to provide optimal care. The end result, we hope, is that more patients are referred, and that we establish reputations as caring and “good” physicians. I still believe in that fundamental. However, we are coming into a time where we will have to show that we are better, not just by reputation, but by providing outcome data that differentiate us from others. Otherwise, the ever-growing number of narrow networks, ACOs, etc, despite our perceived reputations, may not allow their insured to grace our offices.

So, what does good look like? I guess the simple answer is: It depends. If you ask that question to a payer or insurance company, it relates to how much, or little, money they have to pay out in claims. If you ask that to a government bureaucrat, their response may be one that actually measures a process, and compliance.

Did the patient get his or her beta blocker or antibiotic at the appropriate time during surgery? What is the patient’s cholesterol level or hemoglobin A1C? Was incentive spirometry ordered postoperatively? Did you ask the Medicare female patient that you are seeing in the office for a renal mass about incontinence? Easy to measure and get a number, but is that really the measure of quality? What IS good?

The real answer should be: Good is what is important to the patient. Do I live longer because you have treated my muscle invasive bladder cancer by removing my bladder? If so, what will be my quality of life? Will my continence or erectile function be maintained after this robotic-assisted prostatectomy? How long can I expect to stay dry and not wear pads after this sling procedure? How quickly can I return to work after surgery? Right now, we do not have the answers to any of these questions as individual surgeons, and we will not agree on what are the right questions to answer. We can cite population-based data, but very few of us know exactly how well we are doing across disease states.

Our concerns up to now have been about volume and profitability of services. Moving forward as payment reform shifts, we need to transform to a value-driven system that focuses on maximizing outcomes for our patients. In order to get there, however, we need to define the outcomes and know what our true costs are to achieve those endpoints. If we have better outcomes, the costs will ultimately decrease. That will make us more attractive to payers and our volumes will increase, as will our market share. We need to begin this process and not let an outside agency determine what the metrics are going to be. If we acknowledge that maximizing value for the patient is the new fundamental strategy, we as physicians are vital to the most important relationship that exists, and that is between us and our patients.

As I write this, I feel a little bit like Tom Cruise in the opening minutes of the movie “Jerry Maguire,” where, in a business of “more is better,” he was advocating quality, personal attention, and personal relationship. That movie was in 1996. We are only 20 years behind, but I hope that we can experience the same ending and be the Ambassadors of Kwan.