3 truths about making tough decisions

Decision-making is exhausting. Whether partnering with patients to make medical choices or making business decisions for your practice, the best answer is rarely obvious. There are almost always tradeoffs to evaluate; risks to calculate; and hopes, goals and leaps of faith that defy computation.

When doctors face their own medical decisions, it isn't necessarily any easier for them to know what to do, as a recent piece from the Washington Post illustrates. And while business strategy is not directly a matter of life or death, lives and livelihoods can certainly be affected, thus taking even the wisest of practice leaders through an arduous path of, "Do we or don't we?" and "How do we get from A to B?"

I recently spoke with several practices about their decision to become certified--or perhaps more dauntingly, recertified--as a patient-centered medical home (PCMH). At least for this particular endeavor, knowing what they were getting into didn't do much to ease practices' anxiety about moving forward. (I recall similar misgivings leading up to delivering my second child, though there wasn't exactly any turning back.)

At any rate, learning about people's decision-making processes yields some interesting insights.These takeaways might not make your own decisions (or assisting with patients') any simpler, but may offer some comfort, validation or helpful reminders:

Money is a starting point

Using the PCMH example, an obvious factor to weigh is how accreditation from the National Committee for Quality Assurance (NCQA) or other body may impact reimbursement. Almost everyone I talk to about this subject brings up the financial factor first (when asked how they recommend other practices approach the decision), but not one person has said dollars are what the decision ultimately came down to. The following quote from Sal Volpe, M.D., a solo practitioner in New York, is a representative example of practices' actual reasoning: "Look at what your reimbursement would be like if you were a PCMH. Will you make additional money? Will you break even? Will you lose money? At our practice, we said okay [even with no extra reimbursement] because it's the way I was trained and it's what I wanted to do. If you can afford it, it's definitely the thing to do."

Of course, this advice may not work for every practice. It's an opinion. But it's worth noting that unless financial restrictions make a given choice impossible, I've observed that money rarely drives final decisions as powerfully as other factors.

You can't sugar-coat a tough call

Simply acknowledging that a choice is difficult might make it somewhat less overwhelming. Consider, for example, what internal medicine physician Bill Clark, M.D., told the Washington Post about how he would have liked his doctors to talk with him about addressing an infected hip replacement:

"I wished what had happened was that both of these doctors had said to me, 'Well, what's more important to you? Either you can have surgery to wash out the hip but then be left with risk of recurrent infection. Or you can have surgery to remove the prosthesis, with 100 percent certainty of infection cure but not having normal walking for many weeks, followed by surgical placement of another prosthesis.' I wish they had said clearly, 'This is a tough decision and these are the options.' "

'If everything is important, nothing is important'

In a recent conversation with Ed McBride, M.D., vice president of clinical services at Summit Medical Group in Knoxville, Tennessee, we touched upon the difficulty practices face when working on numerous quality measures at once (as a PCMH or not). "It's hard to focus on 50 things," he said. "If everything is important, nothing is important."

For McBride and his team at Summit, measures that give the group the opportunity to make the greatest influence in patient care get the highest priority. These aren't necessarily the metrics the practice is "good at," he noted.

Every practice needs to have its own guiding star, so to speak, but identifying it is critical regardless of practice size.

"No matter how big you are, you still have limited time, energy, resources and dollars that you can dedicate to any particular initiative or group of initiatives," McBride, who works for one of the biggest practices in Tennessee, told me. Once you figure out what it is that matters most—the key places to push yourself—you can align your efforts accordingly. - Deb (@PracticeMgt)