Back to the Future: Clinical Vignettes and the Measurement of Physician Performance

The past 2 decades have seen many efforts to improve the quality of health care. These efforts have relied on a series of methods devised by workers in the field of quality management science and, in some cases, used successfully in industry for more than 50 years (1, 2).

Measuring performance is central to the quality management sciences. The principal measures in health care are patient outcomes and the process of care that physicians provide in practice. These measures identify areas that need improvement, signal the accomplishment of goals, and respond to the need for accountability (3). Unfortunately, methods of assessing physicians' practice performance are in their infancy, and they face unresolved logistic and psychometric challenges. For instance, comparing physicians on the basis of their daily work is difficult because they see patients who have different conditions (case mix) and, even when the conditions are the same, patients' severity of illness and comorbid conditions differ. Furthermore, attributing patient outcomes solely to individual physicians may be inappropriate because care is often rendered by teams (4).

In this issue, Peabody and colleagues (5) test the quality of practice by using clinical vignettes. Since all physicians take the same vignettes under secure conditions, problems of case mix, severity of illness, and attribution are eliminated (5). This elegant, multisite study compared physician performance by using 3 sources of data on physicians' actions and decisions: …