June 12, 2007

Qualities Leading to High Performance in Medicine

Dr. Atul Gawande has an insatiable curiousity that leads him to ask some fascinating questions about what it means to be a doctor. Today, Atul Gawande is a professor of surgery at Harvard Medical School, columnist in the New Yorker and recently was the guest columnist for a month in the New York Times. In 2006, he received a MacArthur's Fellowship (known as the Genius award) in recognition for his research, writings and innovative as well as practical approaches to improving surgery.

I'd written about Dr. Gawande here when he was looking at how you might find solutions to the problem of leaving sponges in a patient after surgery. For Dr. Gawande, the problem is not bad doctors doing bad things, it is good doctors making mistakes that could be prevented. What he wants to find out is what can be done to reduce the mistakes and to improve outcomes.


Recently he talked at the Commonweal Club of California about his latest book and area of interest. Better: A Surgeon's Notes on Performance explores what allows some doctors to deliver outstanding results, especially in the light that as human beings doctors are fallible. Dr. Gawande asks, "What does it mean to be good at something in which failure is effortless?"

He asserts that understanding what it means to perform in medicine is even more complex than trying to understand how top athletes achieve their top performance and thus a good subject for exploring this topic. And it would not be hard to assert that achieving high quality medical results can be even harder than building high quality software (something I spend time trying to do) because some of the dimensions that affect this discipline are so audacious. Here's Dr. Gawande's description of those dimensions.

First, because lives are at stake. That's because you are taking people as your responsibility, and that makes it moral in nature.

The second dimension is because medicine in dauntingly ambitious. We're proposing that we will try to provide the knowledge of science and skill that has been developed over centuries and make it available on an individual basis to every single person in the country, and indeed, every person in the world is our ideal.

We also have a further dimension which is that in this work it is not just an individual trying to carry it out. It's not enough that a doctor be good at technical treatment and diagnosis, you have to have sometimes hundreds of people involved in the care of an individual person. And so for example, you need all the nurses on the shifts coming though taking care of the person who is in the hospital for a few days. You have to have the engineer whose responsibility to have the oxygen flow coming into the tubing going to her nose, is actually getting there, pure oxygen. You want to have even the people bringing the lunch trays making sure that they know that they aren't giving the tray that has concentrated sugars in it to someone with diabetes. All the way down to the doctors.

And then there's a further demand. Not only must you do this work consistently, reliably, with lots of people working together somehow, you have to do it with humaneness, with gentleness, and concern.

Well, it's clearly not just the stakes, but the complexity of medicine that makes it intriging and also a little bit disturbing when you get down into the details.

There is a sign of how hard performance is in medicine and that is the fact we have a bell-curve. We have a wide gap between those who are great at what they do and those who are at the bottom of the curve. And furthermore that most of us are grouped in that broad, mediocre middle.

He goes on to demonstrate the bell-curve with several different examples where the results are dramatically different. A simple example is comparing the percentage of hernias that will come back after having an operation to fix it. In one hospital devoted to only hernias, the doctors perform 700-1000 per year, more than most doctors will ever perform in their lifetime. People who have a hernia operation there have a one in thousand chance that the hernia will come back. The national average is one in twenty and at the low end, the likeihood a hernia will come back is 15-20% or even higher.

Then he talked about how performance affects outcomes in an incurable disease: cystic fibrosis. The average age of death for someone with cystic fibrosis is 33 years. Yet at one hospital specializing in cystic fibrosis, the average lifespan for patients treated there had been extended to 47 years. What could explain this difference in outcomes especially since this is an area where the practitioners follow detailed guidelines, share best practices and are diligent in clinical trials? Dr. Gawande said he really didn't figure out what was the difference until he had time to spend in one of the best clinics watching what really happened in the individual patient care. What he found was the hospital tracked the lung function every week and if it changed for the worse, they dug into the reasons it might have changed and what to do about it. It was the careful attention to detail, not letting anything slip, that contributed to making this one clinic outstanding.

Dr. Gawande enumerated the qualities that truly affect the quality of results:

  • Attention to detail and a capacity for diligence
  • Careful surveillance - tracking results
  • Not letting obstacles interfer with doing the right thing
  • Ingenuity at the bedside
  • Spread this attitude across the entire team

Towards the end of the lecture, Dr Gawande told about how his study became more than just a study for him.

When you start seeing that the implications of how performance using the knowledge we already have out there can change what our results actually are, you start to see deeper implications. But I hadn't realized it in the course of writing the book until I had a conversation in the operating room. I was doing a case that was going extremely well. It was routine enough that I had the iPod on, playing some music and I started chatting across the drapes with the anesthesiologist, and the anesthesiologist at that moment was a second year anesthesiologist by the name of Mark Simon, a second year resident, 29 years old. And we just started chatting about, well I mentioned this whole thing about cystic fibrosis thing, the bell curve, and how variable the care was, and my puzzling over it. Asking him, what do you think this could be, what do you think could account for all of this, why some places were better than another?

And he was distinctly uncomfortable with this whole line of discussion. And then he confessed that he has cystic fibrosis. I was floored. I had no idea. I had operated with him before and I had never known. And then he described to me what it had been like. He had done well in undergraduate, in his undergraduate years in college. He did well in most of medical school, and then in his fourth year he got a pneumonia, a bad exacerbation of his cystic fibrosis, and it landed him in the hospital for a month. The next year, in his first year of residency, he spent six weeks in the hospital. This was now the second half of his second year and he had already spent a month in the hospital. And at the age of 29, he had become all too acutely aware that the average of survival of cystic fibrosis is 33 years.

So our discussion shifted. What we began to talk about was how do we save his life? How do we make it possible for him to see... for him to be a geriatric patient? Well, our answer would normally be that he needs a cure. And the Cystic Fibrosis Foundation has also bet in that direction. It put most of its investment in scientists trying to find a cure for cystic fibrosis. It's what the National Institute of Health has done. It's what the US Government does for health problems that we don't seemingly have solutions to. And in 1989, when the gene for cystic fibrosis was discovered, it was thought that it was paid off. Because surely a cure would be only a few years away. But here we are, it's almost 2 decades later and we don't have a cure on the horizon.

So where Mark has put his bet is that we already have the wisdom out there to help him live that long. Because, yes, the average survival is 33 years. But there is that one place out there in Minnesota that has used the knowledge we already have and somehow have made it so people can live to 47 years. And if collectively we could take the knowledge that was strewn through all the different centers, perhaps we could see it be even longer.

One of the reasons I find Dr. Gawande so remarkable is precisely that type of insight. Putting all the money and time into searching for a cure can blind us to the potential of making real progress in keeping the disease managable so that a person can live a full life. Today, doctors know that the terrible damage that is experienced by someone with juvenile diabetes can be prevented if the blood sugars are rigorously managed so that there are no extremes and they know how to help patients learn to keep them in control. Sometimes just doing something a lot better is enough.

Dr. Gawande believes that we can improve medicine by understanding what the very best doctors do, and by sharing the knowledge and best practices in an open and transparent manner.

He is a graceful and gifted speaker and an eloquent and moving writer who will make you think about the subject for a long time. You can listen to the lecture here and I've attached the transcript here.

[Note the last section I quoted was not in the transcript attached, but it is in the audio. Any errors in the transcription are mine.]

Posted by Mary at June 12, 2007 06:27 AM | Health/Medicine/Health Care | Technorati links |

The second dimension is because medicine in dauntingly ambitious. We're proposing that we will try to provide the knowledge of science and skill that has been developed over centuries and make it available on an individual basis to every single person in the country, and indeed, every person in the world is our ideal.

And yet, insurance companies are in business to try to make sure that this doesn't happen unless *they* get a cut. I am old enough to remember a world without medical insurance.

It was very different. I suspect that things will not improve until that is, once again, the case.

Posted by: Scorpio at June 12, 2007 01:19 PM