Thursday, January 8, 2009

Physician Outliers and Their Role in Health Outcomes Variation

The shortness of breath was returning. She suspected her long standing asthma was responsible, but the inhalers were to no avail. See finally saw the doctor, expecting another short course of glucocorticosteroids. The doctor examined her and arranged for an echocardiogram. It showed a dilated cardiomyopathy, i.e., chronic heart failure.

In addition to chronic obstructive pulmonary disease, high blood pressure and having had a stroke, he had had a cardiac pacemaker placed. He felt best when his blood pressure remained high at 170/90. His regular doctor didn’t change a thing.

Even family wondered why the doctors could never really find anything to help her myriad complaints that included dizziness, chest pains and intestinal complaints. As the years went by, she eventually developed diabetes mellitus. Her doctor, a fan of disease management, told her to not answer the nurses when they phoned her.

As regular readers may have discerned, the Disease Management Care Blog is delighting in Malcom Gladewell’s bestselling book Outliers. In it, he shows that human accomplishment is not just a function of innate ability but timing, social support and practice. When it comes to developing world class expertise in intellectually difficult tasks, that level of necessary practice is prodigious: 10,000 hours. That translates to three to fours a day for approximately ten years.

What does this have to do with the care of populations with chronic illness? In yesterday’s post, the DMCB pointed out that supporting ‘patient centered medical care’ (where the patient is ultimately responsible for selecting a course of treatment) can result in variations in clinical outcomes that are arguably ‘good.’ In today’s post, it argues that high physician expertise can also lead to variation.

Patients and healthcare professionals are well aware of the physician who can glance at the x-ray and spot the tumor that no one else will see, the other physician who can spend minutes with a patient and immediately discern the diagnosis or the surgeon who can perform an extraordinarily difficult procedure and cure the problem. The DMCB thinks medical school, post-graduate training and the additional years in practice easily exceed 10,000 hours. For the right individuals under the right circumstances, that level of practice results in far more than ‘art’ or ‘science,’ but Gladwellesque expertise. That’s the kind of ‘outlier’ ability that innately knows a patient’s shortness of breath is not run-of-the-mill asthma, that persons with pacemaker syndrome may ‘need’ high blood pressure and that a somatoform disorder is one area where the less that is said about disease, the better. Because they are outliers, they find outliers. Outliers are statistical anomalies. It's not art, it's not science, it's exceptionalism. As physicians, they find exceptions. They lead to variation.

True, the national guidelines that tout treatment of asthma, heart failure, hypertension and diabetes always caution they are no substitute for a physician’s judgment. It is also true that most of the problem with docs' inability to adequately recognize or treat asthma, heart failure, hypertension and diabetes can result from less than 10,000 hours of training or failure to use their 10,000 hours to maximum effect. As a result, too many patients fail to receive a sufficient level of quality care.

However, for those world-class level experts who understand the guidelines, the DMCB doubts they’ll achieve 100% compliance with nationally recognized guideline-based standards. There’s no science or peer review literature on this, but more likely they’ll be achieving 80-90% compliance because somewhere between 1 to 20% [?] of patients have an outlier reason to not receive standard treatment. The DMCB asks: which would YOU rather have: a doc with 100% compliance or a doc with 90% compliance?

Given the importance of 10,000 hours of 'practice,' perhaps being called a ‘practitioner’ is not such a bad thing after all.

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