Monday, April 30, 2012

Pushing Standards

Overall, I found Better one of the, well, better assigned books of this class. What really stood out to me was the chapter on The Bell Curve. Gawande’s concluding remarks on accepting that there is a bell curve that describes all aspects of human behavior were somewhat disheartening. My impression is he accepts the bell curve as a given and there being nothing an individual can really do to improve his performance. He even questions what individuals should do given their realization that they are average, or, gasp, below average. He states:

             “What if I turn out to be average? If we took all the surgeons at my level of experience, compared our results, and discovered that I am one of the worst, the answer would be easy: I’d turn in my scalpel. But what if I were / a B-? 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? . . . What is troubling is not just being average but settling for it. . . . When the stakes are our lives and the lives of our children, we want no one to settle for average” (Gawande, 229-230).

He, of course, has a point, we do not want our physicians to settle for average. But to me, realizing where a physician is along the bell curve has important implications for improving the standard of care. What’s important is not settling per se, but constantly trying to improve. It’s raising the bar for what average is. Of course there will always be a handful of physicians that will be top notch, but what matters is the variance among them. He says that he would turn in his scalpel if he realized he was the worst, but what if he could improve? What if he could study the behavior of individuals with the best performance and become average? More importantly, what if it were possible to apply the behavior of the top performers to the entire curve and improve those who are average or worst? If the difference between the top and average is negligible, then settling is not really settling, it’s merely improving the definition of what average is.

I can certainly understand the uncertainty in grading physicians not only from a patients’ perspective but also from the graded individuals’ perspective. People typically do not want to be thought of as average. Patients do not want to go to an average doctor, they want to go the best doctor. This of course can only be created if individuals and patients are aware of the grades. But if the grades aren’t available, is it possible to improve? The article  Grading Docs With Electronic Medical Records seems to agree with this point by describing doctors who were able to improve their care once they were aware of what areas they needed to improve.

1 comment:

  1. I was also very intrigued by this chapter. Gawande states,

    “We in medicine are not the only ones being graded nowadays. Firemen, C.E.O.s, and salesmen are. Even teachers are being graded, and, in some places, being paid accordingly. Yet we all feel uneasy about being judged by such grades. They never seem to measure the right things. They don’t take into account circumstances beyond our control. They are misused; they are unfair. Still, the simple facts remain: there is a bell curve in all human activities, and the differences you measure usually matter” (228).

    The question of how doctors can be graded is a very complex one, and the development of proper grading systems is an issue for a variety of professions. As Gawande explains, getting data that can be used to develop a grading system is extremely difficult in the medical field. It is easy to find death rates for a certain institution, but concepts such as recovery time or the number of resulting complications are not as easy to measure and collect. I agree that a grading system can help to improve patient outcomes, the difficult lies in creating a system that allows for a comparison between doctors regarding certain topics that may not be easy to measure.