Are You Average?
Are you average? Most of us are, pretty much, in at least some important aspects of our lives. We come to terms with these patches of mediocrity in ourselves. It's not that big a deal. Most of us are better at things we care about. Not the best, maybe, but quite obviously not everybody can be the best.
What about your doctor? You want her to be average or the best? How do you know how good she is? Think she is going to tell you if she's just average?
Fact is, at least insofar as she compares with other doctors in her field, she probably doesn't even know herself how good, or average, or lousy she is. She has her own self-analysis of her skills, of course, which is likely skewed. She has the analysis of her medical partners and colleagues, which is likely skewed. She has the analysis of her patients, which is likely skewed. In most cases, the only objective data there is to look at is whether your doctor has ever been disciplined, or even suspended for practicing really bad medicine. I think you would be safe under those circumstance assuming your doctor could be doing better.
There's a bell curve, you know, and your doctor is somewhere on it. I'll bet you'd like to know where.
One small field in medicine has been far ahead of most others in measuring the performance of its practitioners: cystic-fibrosis care. For forty years, the Cystic Fibrosis Foundation has gathered detailed data from the country’s cystic-fibrosis treatment centers. It did not begin doing so because it was more enlightened than everyone else. It did so because, in the nineteen-sixties, a pediatrician from Cleveland named LeRoy Matthews was driving people in the field crazy.
That's from an article by writer and practicing surgeon Atul Gawande in the current New Yorker. The article is called "The Bell Curve: What happens when patients find out how good their doctors really are?"
Matthews had started a cystic-fibrosis treatment program as a young pulmonary specialist at Babies and Children’s Hospital, in Cleveland, in 1957, and within a few years was claiming to have an annual mortality rate that was less than two per cent. To anyone treating CF at the time, it was a preposterous assertion. National mortality rates for the disease were estimated to be higher than twenty per cent a year, and the average patient died by the age of three. Yet here was Matthews saying that he and his colleagues could stop the disease from doing serious harm for years. “How long [our patients] will live remains to be seen, but I expect most of them to come to my funeral,” he told one conference of physicians.
In 1964, the Cystic Fibrosis Foundation gave a University of Minnesota pediatrician named Warren Warwick a budget of ten thousand dollars to collect reports on every patient treated at the thirty-one CF centers in the United States that year—data that would test Matthews’s claim. Several months later, he had the results: the median estimated age at death for patients in Matthews’s center was twenty-one years, seven times the age of patients treated elsewhere. He had not had a single death among patients younger than six in at least five years.
I'll leave it to you to read the article and find out for yourself what was going on. In the meantime, I will drag in another interesting character: Don Berwick.
Berwick runs a small, nonprofit organization in Boston called the Institute for Healthcare Improvement. The institute provided multimillion-dollar grants to hospitals that were willing to try his ideas for improving medicine. Cincinnati’s CF program won one of the grants. And among Berwick’s key stipulations was that recipients had to open up their information to their patients—to “go naked,” as one doctor put it.
To fix medicine, Berwick maintained, we need to do two things: measure ourselves and be more open about what we are doing. This meant routinely comparing the performance of doctors and hospitals, looking at everything from complication rates to how often a drug ordered for a patient is delivered correctly and on time. And, he insisted, hospitals should give patients total access to the information. “‘No secrets’ is the new rule in my escape fire,” he said.
Dr. Gawande takes us on a journey to an institution that has, by far, the best record in helping Cystic Fibrosis patients of any other institution in the country. Their oldest living CF patient right now is 64 years old. If you know anything about CF, that's just stunning.
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.
And yet there is this Bell Curve, and it maps a pretty wide variation in the successful treatment of Cystic Fibrosis. Why? It's an interesting and enlightening story, not just for health care professionals.
And one last thing. Maybe you want to know where your doctor falls on that curve, but does she?
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.
I'm wid' you, Doc.