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HM12 Session Analysis: Variation in Medical Practice


All hospitalists have seen the phenomenon of "surgical signature," when different surgeons appear to have different rates of surgical intervention. Residents know different physicians often treat a single condition in varying ways. The losers in practice variation are the patients, learners, and the overall healthcare system.

Mark Shen, MD, the pediatric editor for The Hospitalist and presenter of this Tuesday afternoon session at HM12, said he has gone through the five stages of grief in the past when dealing with different care plans in a hospital setting, finally settling on acceptance. Now, he said it is important to move past acceptance and recognize variations in physician practice. Further, it's critical to understand the unintended consequences of unwarranted variation.

There are many factors in variation, said Dr. Shen. Examples include preference-sensitive care, in which a physician has a particular model that she or he follows that is specific to that physician, and supply-sensitive care, the trend where certain procedures are more frequently utilized when they are more readily available. A specific example of variation is the rate of tonsillectomy between surgeons.

Variation arises easily in medicine because of inherent uncertainty in medicine. Uncertainty arises because of the challenges of defining disease, making a diagnosis, selecting a procedure, observing outcomes, and assessing preferences.

Variation can be mitigated by formal protocols individualized to each patient. An example of successful protocols is modern pediatric oncology, which has dramatically improved patient outcomes.


  • Hospitalists must recognize variation in care.
  • Addressing variation improves patient care and offers improved utilization of limited healthcare resources.
  • There are several approaches to mitigate variation, including practice guidelines.
  • Shared decision making with the patient and family will also improve individual patient care.

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