I got my report card the other week, and I must say I didn’t do very well. I’m pulling around a B, better than average but not by much. My parents would be appalled.
I am graded these days not by test performance or classroom participation, but by my success in getting patients to do well. Not necessarily to feel well or to be well, mind you, but to perform well on their own tests. They do well, I do well. They do badly, I flunk.
Gone are the days when anyone paid attention to my peer interactions, effort, improvement, or to the difficulty of the assigned material. Most of those variables are now impossible to assess — and as for the medical equivalent of the essay question, forget it. No one has the stamina to plow through my notes.
Rather, “continuous quality improvement,” as we call the process of getting doctors to be their very best selves, requires something snappy and easy to track.
So, every set of doctors marches to its own numbers. Surgeons are assessed by their complication rates, internists by what fraction of their diabetic patients are well controlled and have seen the proper specialists, and by how many other patients are persuaded to accept recommended medications and vaccines.
In an H.I.V. clinic, the obvious number to track is the one that consumes our attention: the H.I.V. viral load. This measurement of viral RNA circulating in a patient’s blood generally correlates with disease activity. Successful drug combinations will reduce it so much that it cannot be detected with standard assays, and at that “undetectable” level most of the bad things about H.I.V. infection melt away, including its inexorable downhill progression and its transmissibility.
Undetectable is good for the patient, good for the community — and now good for the doctor, as we are scored on how many of our patients achieve this benchmark.
Nationwide, about 70 percent of H.I.V.-infected patients receiving medical care are undetectable. In New York State, the numberranges from 79 to 90 percent, depending on how you define medical care.
The number on my report card was 88 percent, not so bad, not so good. I also received a list of my failures by name (not that I wasn’t aware of them already, thanks very much) and a few generic suggestions for improvement.
After I brought home a 67 on that history test back in seventh grade, a painful post-mortem with my mother ensued, a slow, defensive slog through question after question. I still say we didn’t get to Caligula in class.
Were anyone to take the interest, I could provide a similar set of annotations to my current grade.
Take Patient A, a big failure for yours truly with 11,000 copies of H.I.V. RNA per milliliter of blood. Frankly, Patient A is actually one of my big recent successes. He is a sad, sick loner who trusts nobody and nothing, let alone people in white coats and pills in amber bottles.
He and I struggled alone together far too long, until I had the sense to enlist one of our clinic’s wonderful care coordinators who work with patients as a combination of friend and social worker. Patient A has thrived with her help: His viral load has plunged from several million to, yes, 11,000. He has gained 20 pounds, and he is actually planning to see a dentist. Not my idea of a failure.
Take Patient B, another black mark on my record with a viral load of 8,000. She is a middle-aged woman with the gullet of a very small child. She absolutely cannot swallow pills, especially the giant ones used to treat H.I.V. Even the one-pill-a-day combination options are impossible for her to choke down; crushed tablets and all of the pediatric syrups and chewables make her gag.
A couple of capsules seem to be keeping her infection in check, at least until something better comes along. Patient B is my big challenge (and I am her personal mixologist); we have grown quite close over all these years of experimentation. Somehow “failure” doesn’t seem like the right word there.
And Patient C, oh yes, I should have put my foot down with him. Patient C was having gothic difficulties with his prescription insurance; medications that were delivered monthly suddenly stopped showing up, and by the time it was all untangled he had been off treatment for months. He came in and announced he wanted to check his blood work.
I suspect he needed the proof that it wasn’t all a giant technical error, that he was still infected, that no miracle had occurred. Perhaps I should have argued, but I didn’t. And indeed there was no miracle: His viral load was 100,000, another giant ding for Dr. Zuger, and back on meds he went.
I have things to say about Patients D, E and all the others, too — long shaggy-dog stories, explanations, rationalizations, narratives about life and health, exactly the hangdog commentary you’d expect from a straight-A student gone bad. You could say it’s all so much embroidery. Or you could say that the numbers don’t tell the whole story.