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To Vary Is Human …


 

Just a few years ago, if I had been asked to comment on variation in healthcare, I would have said it needed a fundraising event for awareness, or even a respected celebrity patron—maybe Sandra Bullock decrying unnecessary variation on Oprah. Fortunately, more socially influential forces evolved. In a relatively short (from a cultural perspective) span of time, variation has emerged to become standard water-cooler talk amongst physicians and politicians alike.

Although the first analysis of medical variation surfaced in 1938, it wasn’t until Wennberg and Gittelsohn’s seminal paper that our collective medical consciousness emerged.1 Wennberg noted that if his children had simply gone to school in the neighboring district of Stowe, Vt., they would have had a 70% chance of having a tonsillectomy, as opposed to a 20% chance in their chosen district of Waterbury. Decades later, that work is the foundation of the Dartmouth Atlas project, which has turned its lenses toward unexplained variation in the costs of healthcare.

Meanwhile, in a parallel—nonmedical—universe, two engineer-statisticians were busy refining quality-control theory in the late 1930s. Shewhart developed the PDCA (plan-do-check-act) cycle, and Deming took it to Japan, revolutionizing that country’s manufacturing industry. They recognized that unwarranted variations were key quality constraints in any process, and that sustained improvements in outcomes could be attained only through careful analysis and control of this variation.

Growth and learning do not occur in isolation. A team-based approach, in the setting of standardization and measurement, will accelerate the pace of our evolution..

Hospital Variation and Application

Following the Institute of Medicine’s landmark report a decade ago, these fields of study explicitly converged, and variation began to emerge as a key player in healthcare quality discussions. Sprinkle in a few more ingredients—such as the looming cliff that is Medicare insolvency, a failing economy, and Atul Gawande’s uncloaking of McAllen, Texas—and the transformation of the Kool-Aid is now complete.

A fortunate (or unfortunate, depending on your perspective) byproduct of these analyses has been that physicians are at the sharp end of the most important yet variable decisions in medicine. Why are doctors so different in their practices? The short answer is that we’re human; the long answer is that, well, we’re human.

In complex settings, the literature on medical decision-making tells us that we humans simply are not wired to process more than three to five different options at any one time. Even rocket scientists might disagree if they regularly encountered large boluses of clinical data in the face of an ever-exploding body of knowledge. When we dissect the more straightforward daily decisions, the complexity of the human persona then becomes an overlay with as much variability and heterogeneity as our own genetic makeup.

The Simple Life

The late John Eisenberg, in a book titled Doctors’ Decisions and the Cost of Medical Care, lists a dizzying array of reasons behind physician decision-making: experience, risk tolerance, practice style, incentives, and concept of social good, to name a few.2 Each of these domains could be a unique area of study—just for each individual human practitioner. In an era of genomic medicine, the strongest predictor of the phenotypic quality of care might simply be the genotype of the physician.

This is not a revelation for anyone who has ever questioned another physician’s care. My guess is that it’s been less than a week for most of us. After all, we’re hospitalists, perfectly perched as second-tier providers to judge other physicians’ care. We are air-traffic control for doctors’ decisions, and it’s quite a scene: thousands of independent physicians practicing on isolated islands. Like “outside EDs,” some of these habitats appear quite a bit more aboriginal and remote than others. Now, I will admit that I’ve often dreamed of practicing on an isolated, single-palm-tree island. Armed with only a coconut (my patient) and evidence-based medicine, this would be an overdue retreat from the chaotic morass of illogical (i.e., different from my own) medical decisions.

But it is exactly this reaction that provides clues to our current state. No one prepared us for the fact that healthcare delivery is a social science, so frustration and avoidance are merely natural reflections of our immaturity. If we did receive any coaching, it tended to be of the Monday-morning-quarterback school, autocratic and self-serving in nature. We were trained to critique only the finer details of scientific “fact,” not humans in context. How, then, are we to improve our care when we can barely handle the variation?

Advanced Concepts

Adapting a Darwinian perspective, we might hunt out the highly developed and advanced tribes in our midst. One such tribe is pediatric oncology. For decades, almost all variation in pediatric oncology has been controlled through treatment protocols tailored to the particular risk factors of the patient, not the physician. Although this ostensibly improves quality of care, it has had an even greater impact on learning and eventual outcomes.

For this reason and this reason alone, if your 18-year-old child develops leukemia, you probably want to send them to a pediatric oncologist rather than an adult oncologist.7 Survival rates are better because pediatric oncologists have been able to rapidly learn from the enrollment of almost all patients into trials with standardized treatment protocols. By collecting data on a limited number of options and sharing information across practices, true rapid-cycle improvement has materialized.

The key here is not the degree of standardization or the creation of large-scale research networks. It is the extent to which independent practitioners are able to sacrifice their individual beliefs in order to partner for the greater good. Growth and learning do not occur in isolation. A team-based approach, in the setting of standardization and measurement, will accelerate the pace of our evolution. Think about this the next time you feel like throwing a coconut at the infectious-disease consultant who dares cross your island of practice. For if it is human to vary, then only through collaboration may we truly divine. TH

Dr. Shen is The Hospitalist’s pediatric editor. Read his monthly review of pediatric research in our “In the Literature” section (see p. 16).

References

  1. Wennberg J, Gittelsohn. Small area variations in health care delivery. Science. 1973:182(117):1102-1108.
  2. Eisenberg JM. Doctors’ Decisions and the Cost of Medical Care: The Reasons for Doctor’s Practice Patterns and Ways to Change Them. Chicago: Health Administration Press; 1986.

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