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Commentary

The Bell Curve
Atul Gawande, The New Yorker, 12-11-04

This article is a must-read for anyone interested in personalized medicine, consumer-driven health care, and the practice of medicine in general. The classic “bell curve” dictates that for any given performance measurement there will be a balanced distribution of outcomes: about 20% at the low end, 60% in the middle, and 20% at the high end. When it comes to medicine, this means that there will be (for heart disease, cancer, cystic fibrosis) “a handful of teams with disturbingly poor outcomes for their patients, a handful with remarkably good results, and a great undistinguished middle.”

For instance, Gawande tells us, “a Scottish study of patients with treatable colon cancer found that the ten-year survival rate ranged from a high of sixty-three percent to a low of twenty percent, depending on the surgeon.” The question, then, is which doctor would you want to treat yourself and your loved ones: an average doctor or an excellent one?

The answer is obvious but getting to the point where medical care is driven by the outlying high-performers is another story entirely.

For most of medicine’s history, doctors have operated (literally and figuratively) behind a veil of ignorance separating practitioners from patients, with the patient assuming that they were getting state of the art care. However, as we collect more and more data on risk-adjusted patient outcomes, the illusion of omnicompetence that surrounds doctors and hospitals is evaporating – and generating plenty of angst in the profession as well.

Not everyone is greeting the change with apprehension. Donald Berwick, the head of a nonprofit organization called the Institute for Healthcare Improvement, is looking for better and better ways to improve patient care – and is focused on making more information available to the public. He calls it “going naked.” Berwick believes that “to fix medicine”, “we need to do two things: measure ourselves and be more open about what we are doing.” He believes that “openness would drive improvement, if simply through embarrassment.”

This is exactly the argument that advocates of market-driven medicine have been making for years; the only difference is that health care providers have had, until now, few parameters for success and little inclination to expose themselves to outside scrutiny. However, as health care costs rise, consumers and policymakers are demanding that health care providers be paid for performance, not fee-for-service.



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