Wednesday, November 09, 2005

The medical bell curve

Atul Gawande recently wrote in the New Yorker about standards of medical care, in an article entitled the Bell Curve. I couldn't find the article on line, but here is some Q&A about it.

The thrust of the article is grappling with the issue that some doctors and care centres are better than others. If we can identify which doctors or surgeons are below average in survival rates, standards of care, etc. what should we do about it? First of all, should we tell people, and then if we do, what do we do about it when nobody wants to be cared for by the below average physician?

At the heart of this problem, to me, is the tension between individual and group needs. The group as a whole is better off if the below average physician continues to practice. Because below average care is better than no care at all. But the individual, of course, will want the best possible care. It's possible that the only way to continue to have all those below average physicians practicing is not to tell their patients that they are below average.

At some point, the below average care becomes medical malpractice. But where is that point? And if you draw that line too high, then poor care, which is better than no care at all, becomes unavailable.

It's easy for me to pontificate on this. I'm healthy. But I do have some experience. I've had two caesareans in my life. I strongly believe that the second one (a locum) would qualify as below average. I had much poorer recovery, and a much worse scar. But, even given that, I would prefer to have had the caesarean than to have had to wait another two weeks with increasingly high blood pressure and eventual pre-eclampsia for my regular doctor to return from holidays. (let's pretend that there weren't other intermediate options). In this case, poor care was definitely much better than no care at all.

4 Comments:

At 5:14 pm, Anonymous elsewhere said...

It's an article from last year's NY (I've got it somewhere). There was a forerunner of this article in the now defunct HQ a couple of years ago and Gawande's written a book called Complications.

I work for an Aboriginal health service, so we have an interest in equitable standards of health care & access. We reckon that surgeons etc should have to show their batting averages publically, tho with some contextual detail (e.g. if it's a procedure with a high rate of complications, tho this should be benchmarkable against other surgeon's performances of same op). Personally, I would think that word of mouth recommendation from someone within the medical professional whom you trust is possibly your best bet, tho this is not practicable in an emergency situation.

The thing about transparency is that it may be a way of forcing the mean up (and the practices of the hospital system & the college of surgeons not just the surgeon should be taken into account here). From memory, one of the interesting things about the Gawande article was the level of public ownership and participation in producing better-than-average outcomes for the patients on the cystic fibrosis program in the hospital that features -- i.e. the patients and their families collaborated with the practitioners to up the ante.

 
At 9:12 pm, Blogger Jennifer said...

Thanks for the comment. I used to believe unambiguously in transparency (it really annoyed me that a colleague who worked for a medical insurer could actually find out which doctors to avoid), until I read that article, and wondered what would happen in our current litigious society to the below average doctors.

But in most other workplaces, publishing performance tends to improve performance, because of our competitive natures, so you may be right than transparency would lead to more improvement than otherwise.

 
At 9:42 pm, Blogger Tjilpi said...

My first time here Jennifer. I've enjoyed what I have read so far. I'm a GP in Alice Springs. I have never come face to face with El(sewhere) but we email and blog to each other. Love your statistical analyses. I graduated MBBS from Qld in 1978. Not a single bit of statistics taught in that course. I did do some stats in Psych in a BA I did prior to starting medicine and followed up with a whole year of stats in an MPH I completed in 2001. That gave me some tools to look more critically at drug company advertising statistics. I'm not sure if Stats is being taught in undergraduate Med courses at present but it ought to be. Anyway, I really fired up Blogger comments to say that it is a Caesarean, despite the statistically increasing spelling as Caesarian!!

Cheers, Greg

 
At 10:12 pm, Blogger Jennifer said...

Thanks - I hadn't realised until you pointed out how statistical this blog is so far. It'll probably stay that way, given my propensities. I've had an amateur interest in management of health care for ages, so I may come back to this topic!

 

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