We hospitalists are scientifically minded. We understand basic statistics, including percentages, percentiles, numerators, denominators (see Figure 1, right). In healthcare, we see a lot of patients we call denominators; these denominators are generally the types of patients to whom not much happens. They come in “pre-” and they leave “post-.” They generally pass through our walls, and our lives, according to plan, without leaving an impenetrable memory of who they were or what they experienced.
The numerators, on the other hand, do have something happen to them—something unexpected, untoward, unanticipated, unlikely. Sometimes we describe numerators as “noncompliant” or “medically complicated” or “refractory to treatment.” We often find ways to rationalize and explain how the patient turned from a denominator into a numerator—something they did, or didn’t do, to nudge them above the line. They smoked, they ate too much, they didn’t take their medications “as prescribed.” Often there is a less robust discussion about what we could have done to reduce the nudge: understand their background, their literacy, their finances, their physical/cognitive limitations, their understanding of risks and benefits.
I read a powerful piece about “numerators” written by Kerry O’Connell. In this piece, she describes what it was like to cross over the line into being a numerator after acquiring a hospital-acquired infection:
Five years ago this summer while under deep anesthesia for arm surgery number 3, I drifted above the line and joined the group called Numerators. … Numerators have lost a lot to join this group; many have lost organs, and some have lost all their limbs, all have many kinds of scars from their journey. It was not our choice to leave the world of Denominators … and many will struggle the rest of their lives to understand why...
There are lots of silly rules for not counting some infected souls, as if by not counting us we might not exist. Numerators that are identified are then divided by the Denominators to create a nameless, faceless, mysteriously small number called infection rates. “Rates,” like their cousin “odds,” claim to portray hope while predicting doom for some of us. Denominators are in love with rates, for no matter how many Numerators they have sired, someone else has sired more. Rates soothe the Denominator conscious and allow them to sleep peacefully at night ...
Numerators don’t ask for much from the world. We ask that Denominators look behind the numbers to see the people, to love us, count us, respect our suffering, and help keep us out of bankruptcy, for once we were Denominators just like you. Our greatest dream is that you find the daily strength to truly care. To care enough to follow the checklists, to care enough to wash your hands, to care enough to only use virgin needles, for the saddest day for all Numerators is when another unsuspecting Denominator rises above the line to join our group.1
Now think of all the numerators you have met. I am going to repeat that phrase. Think of all the numerators you have met. I have met quite a few. Now I am going to tell you about my most memorable numerator.
CB was a 36-year-old white female admitted to the hospital with a recent diagnosis of ulcerative colitis. She had a protracted hospital course on various immunosuppressant drugs, none of which relieved her symptoms. During her hospital stay, her family, including her 2-year-old twins, visited every single day. After several weeks with no improvement, the decision was made to proceed to a colectomy. The surgical procedure itself was uncomplicated, a true denominator.
Then, on post-op Day 5, the day of her anticipated discharge, a pulmonary embolus thrust her into the numerator position. A preventable, eventually fatal numerator—a numerator who “just would not keep her compression devices on” and whom the staff tried to get out of bed, “but she just wouldn’t do it.” A numerator who just so happened to be my sister.
Every year on April 2, when I call my niece and nephew to wish them a happy birthday, I think about numerators. And I think about how incredibly different life would be for those 10-year-old twins, had their mom just stayed a denominator. And every day, when I sit in conference rooms and hear from countless people about how difficult it is to prevent this and reduce that, and how zero is not feasible, I think about numerators. I don’t look at their bar chart, or their run chart, or their red line, or their blue line, or whether their line is within the control limits, or what their P-value is. I think about who represents that black dot, and about how we are going to actually convince ourselves to “First, do no harm.”
When I find myself amongst a crowd quibbling about finances, lunch breaks, workflows, accountability, and about who is going to check the box or fill out the form, I think about the numerators, and how we are truly wasting their time, their livelihood, and their ability to stay below the line.
And someday, when my niece and nephew are old enough to understand, I will try to help them tolerate and accept the fact that “preventable” and “prevented” are not interchangeable. At least not in the medical industry. At least not yet.
In memory of Colleen Conlin Bowen, May 14, 2004
Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at email@example.com.