Quality Equals Goodness ?

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Columns - From the Addiction Physician

Written by Stuart Gitlow

Wednesday, 30 March 2011 11:32

The definition of "quality" should not be mistaken for that of a value judgment. Quality is simply a characteristic, perhaps inherent or essential, but neither necessarily positive nor negative. A “quality measure,” therefore, should not be presumed to measure the degree of the target’s goodness.

I might, for example, develop a set of quality measures about a car tire. Those quality measures could include the hardness of the rubber. Tire A could have a score of 90, whereas Tire B has one of 70, indicating the rubber in Tire B is softer than that of Tire B. An individual looking only at the quality measure scores might conclude incorrectly that Tire A is better at this parameter. That, of course, depends. Rubber hardness has something to do with the rate at which a tire wears while in use. The softer the tire, the faster it wears out; however, the softer the tire, the better its grip. The driver more interested in cutting costs than in driving comfort would turn to Tire A. The driver more interested in better response and improved control would pick Tire B.

Here is where things get interesting. Staying with the tire analogy for a moment more, note that from a public safety standpoint, one might argue that all drivers should use Tire A. Drivers, the argument would go, would be less likely to speed around turns, weave in and out of traffic, or push their cars beyond the drivers’ limits if they are restrained by Tire A’s qualities. The Green argument also would apply – fewer tires would require disposal if we all use Tire A. Insurers also would support this idea, since sidewall damage to Tire A would be less likely and, therefore, insurance payments would be less frequent. The only people who would want Tire B would be the individual drivers.

Quality is simply a characteristic, perhaps inherent or essential, but neither necessarily positive nor negative

Imagine that we are to create quality measures of addiction training. The quality measures would be achieved through the development of a training curriculum and through the concurrent testing of the efficacy of that curriculum. One measure might be: “Fellows will gain an understanding of the DSM-IV’s definitions of substance use disorders.” The score on the measure would be based in part upon whether DSM definitions are taught within the classroom curriculum portion of the fellowship, and in part, upon how fellows do on a test of their understanding of such definitions. Is this a good quality or a bad quality? Again, it depends.

From a third-party vantage point, we would say there are advantages to having all physicians define addictive disease using the same terminology and approach. Surely, this holds true from a research perspective as well; but the DSM definitions may be lacking, in which case we have lost the opportunity to have clinicians develop a definition of disease and approach to treatment, based upon their observations as keen scientists working within the epidemic. The whole point of a pre-medical curriculum is to ensure that those students attending medical school represent our finest young scientific minds. The medical curriculum itself is based around gaining an understanding of the natural human condition and the development of abnormal pathology. If we then constrain these trainees once they have completed their eight years of training to a simple regurgitation of previously developed definitions, the eight years will have been wasted.

An improved measure of goodness, if you will, would therefore be: “Fellows will gain an understanding of the DSM-IV’s definitions of substance use disorders and demonstrate the extent to which such definitions do or do not fit the disease model.” A further measure would be: “Fellows, following one year of work with hundreds of patients with addictive disease, will develop a definition of such disease. They will demonstrate their understanding of their model by comparing their definition with other definitions that have been developed over the years by various groups and committees.” I would, as a mentor to such students, expect their definition to include reference to family history, social environment of upbringing, relationship with parents and siblings, initial subjective experience with addictive substances and other critically relevant points missed in the DSM rubric. Research has demonstrated, and history-taking with patients supports, that patients with opioid dependence have an experience when using opioids that differs from the experience garnered by those without opioid dependence. Asking questions about this experience does not currently assist with a finding of opioid dependence when using strict DSM-IV criteria, but is a critical point that will assist new trainees in gaining an understanding and recognition of the disease.

Most definitions of substance use disorders focus on the substance use itself – the marker of the disorder – rather than on the underlying pathology. Realize that if we take an addict and remove him to an environment where no substances are available, the addictive disease remains present. Only when our definition of the disease still allows for a positive identification of that addict even while in such an environment will our definition be sensitive and specific. Until then, we are doing little more than identifying behavior; and that’s why so many clinicians eventually get to the point where they diagnose a substance use disorder purely on the basis of quantity of intake, something that’s not in even the DSM-IV criteria.

We badly need our new physicians to be more than accurate readers of a previously developed and generally inadequate criteria set. We need them to recognize and understand the disease– its pathology, course, development and features. We need them to develop their own approach to treatment because so much of treating this disease is based upon the rapport developed between two individuals; given that no two individuals are alike, the approach utilized by any one clinician must differ from that of another. We therefore cannot afford to enforce a quality measure unless and until we have demonstrated a superior set of outcomes with any given individual clinician using such an approach. In the end, this column could be summarized as: Patients and clinicians are not widgets; they therefore should not be treated as such.

Stuart Gitlow, MD, MPH, MBA, a psychiatrist, is a member of the American Medical Association’s Council on Science & Public Health, and an officer of the American Society of Addiction Medicine. This column represents his personal opinion and does not imply any position or policy taken by either the AMA or ASAM.

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