Medical Kaizen, Cont'd
For those who can't get enough of the Gawande debate, biologist Jim Hu has several interesting blog posts. (Jim's lab also has a blog that illustrates how you can use blogging for organizational coordination.) And Oren Grad, with whom I've corresponded about medical outcomes research for years, writes:
Thanks for posting the link to Atul Gawande's interesting article in the New Yorker. I do think Gawande, who in general is quite good at writing about medical topics for general audiences, went astray this time in hanging the article on the implications of the bell curve.
Another way of looking at the objective of Berwick and his followers is to think of it as pushing the entire performance curve up and reducing its spread so that even performers who are, in a mathematical sense, below average nonetheless deliver a level of quality that is entirely satisfactory in a substantive sense. If they succeed, then why should anybody care who is below average?
Of course, there will be some lumps and bumps along the way from here to there, as low performers have their consciousness raised by being publicly "named and shamed". But the response Gawande describes in Cincinnati is consistent with much else in the literature in supporting an optimistic view of the impact on patients' attitides of the candor and good faith effort that Berwick preaches.
There may be a very few domains of medical practice, perhaps especially in certain areas of high-risk surgery that require truly virtuosic manual dexterity, where there just can't be enough high-quality practice to go around. But it's not obvious that this is true, or if it is that it can't be solved in time with computer-guided mechanical assistance - and it's anyway doubtful that this is the rule more broadly. In the meantime, there's so much low-hanging fruit still to be picked in health care quality improvement that it doesn't make sense to waste too much of one's energy worrying about theoretical extreme cases.
The really hard, really interesting issues, and many, many fascinating stories, lie elsewhere. How do we know what constitutes best practice, anyway? Berwick drew his own inspiration from the pioneering quality improvement work of Deming and his colleagues. But the application of these methods to health care is not without controversy. There's a very nice point-counterpoint on this in JAMA in 2002 (full references below, in case you're interested). The competing position in the JAMA debate, the reigning dogma that true knowledge is derived from controlled clinical studies, also has its problems when you dig deeply enough into its conceptual foundations.
Despite the vogue for "report cards" and the genuine benefits that can be achieved through their careful use, assessment of health care outcomes, or more particularly reliable attribution of cause and effect, remains a huge problem. Our ability to adjust outcome measures for pre-existing risk, and thus draw attributions from purely observational data, is still fairly primitive on the whole. This is something that Gawande does acknowledge in a nice passage, but dismisses a little too easily in his rush to lay on the psychological dilemmas of being graded on a curve.
How physicians manage to grope their way forward through this epistemological fog and make real, tangible improvements in health outcomes, and how to arrange things so that they can see more clearly and make more rapid progress against the inertia of existing institutions and practices and vested interests, is one of the great, ongoing stories of our time, for much more interesting reasons than this article allows.
We can certainly use more writers who can figure out how to explain this stuff with sufficient clarity to the general public so that they understand what the issues really are, and how to demand better in an intelligent way. In fairness, Gawande's writings as a whole are a valuable contribution to public understanding - it's just a pity he stumbled a bit this time.
Sources:
"What Practices Will Most Improve Safety? Evidence-Based Medicine Meets Patient Safety, Leape LL, Berwick DM, Bates DW, JAMA 2002 July 24;288:501-7
"Safe But Sound: Patient Safety Meets Evidence-Based Medicine," Shojania KG, Duncan BW, McDonald KM, Wachter RM, JAMA 2002 July 24;288:508-13
On Oren's point, one of the reasons CF is a good candidate for spreading best practices is that there are established, measurable indicators, such as lung-function, that can be tracked.