House and Other Doctors
Colby Cosh has a couple of nice posts on the new TV show, "House M.D.," and now he has linked to an article about evaluating doctors that really ties some thoughts together.
The article by Atul Gawande in the Dec. 6 New Yorker argues that if doctors are evaluated rigorously, they always end up on a bell curve. A few achieve exceptional outcomes; another few are terrible; many, even if they are hard-working and have excellent credentials, end up somewhere in the mediocre middle.
Such studies are still new, but the bell curve seems to keep emerging in many fields. Gawande is a surgeon, but he looks specifically at treatment for Cystic Fibrosis. Breakthroughs have been made in the life expectancy of patients with CF--mostly by being very aggressive with fairly pedestrian treatments that quickly get boring for patients--especially teenage ones. Patients are supposed to submit to "chest percussions" on many points of their body, and inhaling medications, several times a day. Everyone in the field knows that teenagers, especially, will slack off on this.
Gawande visits a doctor whose centre has a mediocre record. The teenage patient is slacking off, but things don't look too bad, the doctor gives the speech to exhort vigilance that must be given millions of times a year, and that's about it. (A few follow-up appointments with various people are arranged).
Then Gawande visits a doctor at the Number 1 centre in the U.S. A teenager's results aren't all that bad--but they were much better only recently; in fact, this kid's lung capacity was not just normal, but above normal. This elite centre always asks the question: why not the best? The doctor asks if the young woman is doing all her treatments. "Yes, of course," she replies.
Ah hah. As Dr. House would predict, she is lying. Because of her new boyfriend, and the scene at school, she doesn't find it cool to schedule the treatments she knows she needs. Her doctor doesn't immediately accuse her of lying--he simply puts some numbers on the board--something, again, that is done millions of times. If you skip treatments for a week, that probably only lowers your life expectancy an infinitesimal amount; and teenagers like to gamble and experiment with danger and their bodies. But keeping up a bad habit for a year can be a disaster, and it gets worse after that.
The doctor gives the young woman a kind of concentrated, personal version of the "exhorting" speech: why exactly have you done so poorly this time, if you are doing your treatments? Do we need to change the treatments, or admit you to hospital, or what? What the "mediocre" doctor accepted as part of life with these patients, this elite doctor treats as totally unacceptable. The young woman fesses up. Her doctor has some creative suggestions to enjoy boyfriend, school and life (carrying meds without telling the nurse--breaking the rules!) while getting all the treatments. She starts to feel that she is off the hook, and he says: you're going to spend one night in hospital. She's visibly disappointed. He quietly says: we failed this time, and we have to take responsibility for our failures. She cries, and agrees.
This is great stuff. As Gawande makes clear, many excellent, ethical doctors, who want the very best for their patients, simply wouldn't do all this--it's too personal, too hard on the doctor as well as the patient. But what is the approach that so many good people would reject? Excellence--cutting through b.s., insisting on the truth, insisting on the best. These kids can actually have the same lung capacity as the rest of us, and they are now approaching (at the best centres) normal life expectancy. So why isn't that the literally unrelenting goal of every patient, and every person who works with the patients?
House would say: patients lie, and highly trained professionals settle for second best. Incredibly, the teenager who got the full treatment--successfully--at Minneapolis was showing better results at the time of the appointment than the one who got kind of a kiss-off at Cincinnati.
House got an unfriendly review from a doctor on Slate. The doctor suggested that modern patients and hospitals would refuse to put up with House's rudeness. Maybe. But the rudeness is always along the lines of: you've done something dumb or careless to get here; or you're lying about your history; or other doctors have been careless in diagnosing. An overall troubling message is that doctors still don't know that much about diagnosing illness. Obviously great strides have been made, but I remember reading there is still a lot to be said for an autopsy as a way to find out--too late--what a poor s.o.b. actually had. House, I think, really tries to distinguish things he knows from things he doesn't--and he doesn't hide the latter from patients.
UPDATE: The New Yorker again (Dec. 13): mammograms don't reveal as much as they seem to; they sometimes reveal too much, in a way that is misleading/causes unnecessary treatment; and generally are relied on more than they should be. A trained doctors hands can gather much more information than the eyes, even with modern scans; yet intuitively we trust the eyes more.
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