Wednesday, December 08, 2004

The Measuring Stick...
Courtesy of Book of Joe a New Yorker piece by the good Dr. Atul Gawande: THE BELL CURVE. In which Dr. Gawande examines a hospital's soul-baring honesty, and its' struggle to improve. It begins with the diagnosis of cystic fibrosis (CF) in the child that lives near Cincinnati:
The one overwhelming thought in the minds of Honor and Don Page was: We need to get to Children's. Cincinnati Children's Hospital is among the most respected pediatric hospitals in the country. It was where Albert Sabin invented the oral polio vaccine. The chapter on cystic fibrosis in the 'Nelson Textbook of Pediatrics"-the bible of the specialty-was written by one of the hospital's pediatricians. The Pages called and were given an appointment for the next morning.
The Page family then goes through an intense ordeal with physicians, respiratory therapists and nutritionists. They feel that they are getting the best care possible for their child, but are they?
The one thing that the clinicians failed to tell them, however, was that Cincinnati Children's was not, as the Pages supposed, among the country's best centers for children with cystic fibrosis. According to data from that year, it was, at best, an average program. This was no small matter. In 1997, patients at an average center were living to be just over thirty years old; patients at the top center typically lived to be forty-six. By some measures, Cincinnati was well below average. The best predictor of a CF patient's life expectancy is his or her lung function. At Cincinnati, lung function for patients under the age of twelve-children like Annie-was in the bottom twenty-five per cent of the country's CF patients. And the doctors there knew it.
Dr. Gawande then discusses the sparse information about physician outcomes and compares it to the evolution of the CF reporting system that ranks the country's CF treatment centers. What he learns is that clinical pathways and evidence-based protocols do not always a superstar make:
What makes the situation especially puzzling is that our system for CF care is far more sophisticated than that for most diseases. The hundred and seventeen CF centers across the country are all ultra-specialized, undergo a rigorous certification process, and have lots of experience in caring for people with CF. They all follow the same detailed guidelines for CF treatment. They all participate in research trials to figure out new and better treatments. You would think, therefore, that their results would be much the same. Yet the differences are enormous. Patients have not known this. So what happens when they find out?
Dr. Gawande then visits the center at Cincinnati Children's, and after some wrangling, visits one of the best, Fairview-University Children's Hospital. What Dr. Gawande finds is that sometimes the vision of one person makes all the difference:
The director of Fairview-University Children's Hospital's cystic-fibrosis center for almost forty years has been none other than Warren Warwick, the pediatrician who had conducted the study of LeRoy Matthews's suspiciously high success rate. Ever since then, Warwick has made a study of what it takes to do better than everyone else. The secret, he insists, is simple, and he learned it from Matthews: you do whatever you can to keep your patients' lungs as open as possible. Patients with CF at Fairview got the same things that patients everywhere did-some nebulized treatments to loosen secretions and unclog passageways (a kind of mist tent in a mouth pipe), antibiotics, and a good thumping on their chests every day. Yet, somehow, everything he did was different
Dr. Warick, while accomplishing this, has little regard for "evidence based medicine"
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.

The buzzword for clinicians these days is "evidence-based practice"-good doctors are supposed to follow research findings rather than their own intuition or ad-hoc experimentation. Yet Warwick is almost contemptuous of established findings. National clinical guidelines for care are, he says, "a record of the past, and little more-they should have an expiration date.'
Moving along:
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.
So how do we teach physicians to be like Dr. Warick in an environment that treats medicine as a volume business? Dr. Warick is somewhat of a "maverick" and is willing to try new and different therapies to enhance care. Will physicians locked in to "evidence based" protocols have the ability to "think outside the box"? Since the "technical" aspects of CF care are widely known, if a program can become more aggressive about their care the gap should narrow, shouldn't it? Maybe not:
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.
Not exactly a skill that can be taught. So the bell curve is maintained, just shifted to the right. What implications does this have for the rest of us?
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 patients 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.
There are always going to be "average" physicians because that's the way that statistics work. The goal of all physicians should be to shrink the distance between "average" and "excellent" to as narrow a range as possible. This is the practical solution since the number of "centers of excellence" may be small, and some conditions are so common, like appendicitis in children that the 13 centers that give the best results would be overwhelmed. Sometimes the difference between "average" and "excellent" is small. And remember, these are statistics, and even "excellent" places have bad outcomes. Some patients, even those with "good insurance" may not have the means to travel to a MD Anderson or Sloan-Kettering. What about them? To sum up:
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.
Should we resign ourselves to being "average"? We should strive to improve ourselves, to narrow the gap between "average" and "excellent" so that is insignificant.
Back to online Christmas shopping.
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