January, 2005
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| Vol. 4, No. 1 |
January, 2005 |
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Jerry Bylander, Editor jerryby@cableone.net |
| The Director's Column |
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| Next Meeting |
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Date and Time: Tuesday,
January 18, 2005 6:30 pm - Social Hour 7:00 pm - Program Sponsored by: US Too!
Texoma
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| Last Meeting |
| Date & Time: | Tuesday, September 21, 2004, 7:00 PM |
| Place: | Wilson N. Jones, North Campus |
| Attendance: | approximately 25 attendees |
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Topic: " Do you plan radiation therapy in place of surgery?”
The meeting adjourned about 9 PM. Henri Plunkett, Program Chair/by the Editor |
| Other Important Events |
| Your organization's meetings listed here. Contact the Editor at jerryby@cableone.net |
| Editor's Notes |
The Bell Curve Revisited--A doctor looks at where his practice fits on the physician's bell curve. From and article by A. Gawande, Asst. Prof., Department of Health Policy and Management, Harvard School of Public Health, Boston.
Earlier I wrote a column about the practice of medicine based on a distribution of patient's responses to treatment which falls on a bell curve (Gaussian) distribution. The average patient's response (C grade) falls at the top of the bell and others may fall on the right or left. If you are a "C", then pass go and collect $200, but if you fall above or below your therapist must work out through informed trials what therapy will work for you.
In a similar way, writing in the Dec. 6, 2004, New Yorker, Dr. Atwul Gawande wonders where his practice falls on the bell curve for his profession. Before summarizing his article, let me observe that physician's skill don't fall on a Gaussian curve, instead the curve will more closely resemble a Poisson distribution. That is, it will be a bell curve that is sharply cut off below the C+ level. The medical profession does an excellent job, for the most part, of selecting out the lesser qualified students. Further, Dr. Gawande doesn't seem to recognize, that for a given practitioner, s/he may be an A in his/her specialty, only a B or C+ in other areas outside their primary expertise. With these caveats out of the way lets visit Dr. Gawande's discussion of medical practice where overall patient outcomes are found to not be primarily a function of a doctor's skill.
He starts by comparing outcomes for cystic fibrosis patients at various hospitals. (I once had a technician who had daughter with cystic fibrosis (CS), and my wife and I often went over to help pat the daughter on the back for 30 minutes to break up the congestion. The girl lived in a tent over her crib with a vaporizer. I think she died in her teens.) Anyway the patient Dr. G. uses as an example went to Cincinnati Children's Hospital, which is one of the most respected hospitals in the country and is where Dr. Sabin invented the oral polio vaccine. "The chapter on CS in Nelson Textbook of Pediatrics - the bible of the specialty -was written by one of the their pediatricians". However it is not the best CS hospital, it is only a C.
Dr. G. argues that for a long time the various hospitals were distributed according to a Poisson curve (or "shark fin" curve). But not now, instead there are "a handful of teams with disturbingly poor outcomes...a handful with remarkably good results, and a great undistinguished middle." He then tells us the curve for recurrence after a hernia procedure is 1 in 10 for D's, 1 in 20 for C's and 1 in 500 for A+'s. Treatable colon cancer ten year survival rates were 63% for A surgeons and 20% for D surgeons. Death rates for heart bypass patients in New York hospitals with wide experience are 5% for D's and below 1% for A's. "It is distressing for Doctor's to ...acknowledge the bell curve...I am a surgeon in a department that is, our members like to believe, one of the best in the country. But...we have...no evidence...whether we are as good as we think we are."
He then takes on the federal government's "death list", but it turns out that rankings here were useless because of the variety of patients at one hospital versus those at another. Young patient survival is not a good metric, because most die from metastatic cancer. He then notes that recovery time for an appendectomy or the rate of complications from a cancerous thyroidectomy are not good indicators of location on the bell curve. Finally it is difficult to quantify relative location on the curve, since good records don't seem to be kept except in the case of VA hospitals. However CS records are far ahead of others.
He then describes how Warren Warwick of the University of Minnesota kept his patients alive longer that other hospitals as the survival age advanced from 18 years in 1972 to 33% by 2003. But "at the best center it was more than 47" years. Why? The reasons involve a long list of proactive techniques used by the best, as well as careful follow up (see the article for details). He does point out that "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 greatest knowledge and technical skill can have mediocre results: more nebulous factors like aggressiveness and consistency and ingenuity can matter enormously."
Dr. G. asks, once patients know about the variations: "Once we acknowledge that, no matter how much we improve our average, the bell curve isn't going away...will being in the bottom half be used against doctors in lawsuits." Likely yes. "Will we be expected to tell our patients how we score?" Likely yes. "Will our patients leave us?" Probably. "Will those at the bottom be paid less than those at the top?" Likely.
He then asks in a city where there are so many surgeons, what is wrong with being average? He concludes we must resist being average and push for being the best.