More on Medicine
Responding to the post below, my friend Jennifer George points me to this terrific Atul Gawande article in The New Yorker on the questions raised, for doctors and patients, by tracking and reporting the different outcomes from different medical centers. By definition, not everyone can be the best. What happens to doctors who are in the middle of the bell curve? How would their otherwise satisfied patients react to knowing their physicians' results are merely normal?The article focuses on cystic fibrosis treatments. Here are a few excerpts, but it deserves a full read:
Like most medical clinics, the Minnesota Cystic Fibrosis Center has several physicians and many more staff members. Warwick established a weekly meeting to review everyone's care for their patients, and he insists on a degree of uniformity that clinicians usually find intolerable. Some chafe. He can have, as one of the doctors put it, "somewhat of an absence of, um, collegial respect for different care plans." And although he stepped down as director of the center in 1999, to let a protege, Carlos Milla, take over, he remains its guiding spirit. He and his colleagues aren't content if their patients' lung function is eighty per cent of normal, or even ninety per cent. They aim for a hundred per cent--or better. Almost ten per cent of the children at his center get supplemental feedings through a latex tube surgically inserted into their stomachs, simply because, by Warwick's standards, they were not gaining enough weight. There's no published research showing that you need to do this. But not a single child or teen-ager at the center has died in years. Its oldest patient is now sixty-four....
We are used to thinking that a doctor's ability depends mainly on science and skill. The lesson from Minneapolis is that these may be the easiest parts of care. Even doctors with great knowledge and technical skill can have mediocre results; more nebulous factors like aggressiveness and consistency and ingenuity can matter enormously. In Cincinnati and in Minneapolis, the doctors are equally capable and well versed in the data on CF. But if Annie Page--who has had no breathing problems or major setbacks--were in Minneapolis she would almost certainly have had a feeding tube in her stomach and Warwick's team hounding her to figure out ways to make her breathing even better than normal.
Don Berwick believes that the subtleties of medical decision-making can be identified and learned. The lessons are hidden. But if we open the book on physicians' results, the lessons will be exposed. And if we are genuinely curious about how the best achieve their results, he believes they will spread.
The Cincinnati CF team has already begun tracking the nutrition and lung function of individual patients the way Warwick does, and is getting more aggressive in improving the results in these areas, too. Yet you have to wonder whether it is possible to replicate people like Warwick, with their intense drive and constant experimenting. In the two years since the Cystic Fibrosis Foundation began bringing together centers willing to share their data, certain patterns have begun to emerge, according to Bruce Marshall, the head of quality improvement for the foundation. All the centers appear to have made significant progress. None, however, have progressed more than centers like Fairview.
"You look at the rates of improvement in different quartiles, and it's the centers in the top quartile that are improving fastest," Marshall says. "They are at risk of breaking away." What the best may have, above all, is a capacity to learn and adapt--and to do so faster than everyone else.
Once we acknowledge that, no matter how much we improve our average, the bell curve isn't going away, we're left with all sorts of questions. Will being in the bottom half be used against doctors in lawsuits? Will we be expected to tell our patient how we score? Will our patients leave us? Will those at the bottom be paid less than those at the top? The answer to all these questions is likely yes....
The hardest question for anyone who takes responsibility for what he or she does is, What if I turn out to be average? If we took all the surgeons at my level of experience, compared our results, and found that I am one of the worst, the answer would be easy: I'd turn in my scalpel. But what if I were a C? Working as I do in a city that's mobbed with surgeons, how could I justify putting patients under the knife? I could tell myself, Someone's got to be average. If the bell curve is a fact, then so is the reality that most doctors are going to be average. There is no shame in being one of them, right?
Except, of course, there is. Somehow, what troubles people isn't so much being average as settling for it. Everyone knows that averageness is, for most of us, our fate. And in certain matters--looks, money, tennis--we would do well to accept this. But in your surgeon, your child's pediatrician, your police department, your local high school? When the stakes are our lives and the lives of our children, we expect averageness to be resisted. And so I push to make myself the best. If I'm not the best already, I believe wholeheartedly that I will be. And you expect that of me, too. Whatever the next round of numbers may say.
Read the whole article here.