There's an old joke health care cynics tell:
Q. What do you call the guy who graduated last in his medical school class?
A. Doctor.
We chuckle at this -- albeit nervously -- because it's strange to think of our doctor at the bottom of any class. We like to think that the title "doctor" refers only to mythically gifted savants of healing. We hope that those ornate diplomas and awards in our doctor's waiting room justify entrusting our lives to his or her care.
Alas, it turns out not all physicians make the honor roll, and that has life and death implications for patients. According to a new study out today in the New England Journal of Medicine (NEJM) by John Birkmeyer and colleagues, surgeons vary in their skill levels. The skills variation doesn't have much to do with the credentials hanging on the wall; it extends to all surgeons whether they practice in an academic medical center or a community hospital. And the differences are not subtle. Patients of surgeons on the bottom quartile of skill level are two to three times more likely to die, suffer a complication, need a repeat surgery or be readmitted to the hospital later. NEJM subscribers can watch some of the videos of these surgical procedures. Even laypersons like me can see startling differences in physician skill levels.
Breakthrough One: Proof That Surgical Skill Is Linked To Better Patient Outcomes
The study puts the imprimatur of science on something most of us logically assume: Patients of highly skilled surgeons fare better. This has long been self-evident in the medical community. As Danny O. Jacobs, MD, MPH, points out in his commentary on the study, it's been assumed since the origins of modern medicine that surgical ability and patient outcomes are linked: "Despite equal training and equivalent certification, there always appeared to be surgeons who were preferred consultants, who were recognized by their peers as being especially capable and whose patients more often seemed to do best."
Self-evident or not, recording the variation in surgical skill and its link to patient outcomes is a major breakthrough in medical research -- one that can help doctors and hospitals target physicians for quality improvement and make their operating suites safer for patients.
Breakthrough Two: New Way To Rate Doctors Or Hospitals
The study pioneers a promising new method for rating provider performance, which could have significant implications for employers and policymakers trying to create more competition for quality.
The method is not complicated, and indeed its very simplicity is what makes it a breakthrough. In the study, researchers asked 20 surgeons to submit a single representative videotape of himself or herself performing a laparoscopic gastric bypass. A panel of peer surgeons viewed the tapes (which did not identify the surgeon or patient) and systematically rated aspects of technical skill on a scale of one to five. The peer reviewers tended to agree in their assessments, and the overall ratings correlated strongly with complication rates.
The researchers went to great lengths to validate and retest their methods. They looked at a second videotaped surgery by the same original cadre of surgeons, they performed fresh expert ratings with five out-of-state reviewers, and they controlled for harsher versus easier judges.
The methodology appears to be a good one and means we may finally have the seed of an efficient and reliable new way to compare doctors and hospitals. Currently, ratings rely on complex measures of performance derived at great length, often by teams of researchers. These measures are exceedingly difficult to develop.
An impressive nonprofit called National Quality Forum (NQF) ably promotes this measurement science and builds consensus among stakeholders on which measures are reliable enough to use. Over the past 15 years, NQF succeeded in dramatically advancing our country's ability to rate hospitals and doctors, and they have created a remarkable system for building consensus on these measures among diverse interest groups.
Now Let's Drive A Market
Despite these efforts and others, the whole enterprise of measurement still remains in its infancy. We lack measures on a wide variety of important and common conditions and procedures, as well as measures of providers' ability to protect patients from errors and infections. For instance, there are no endorsed measures of medication errors in hospitals, even though they are the most common mistakes hospitals make, with an estimated one per day per inpatient in the United States.
The study advances us a hundred years in our ability to rate provider performance, by pioneering an alternative to the stifling complexities of creating measures: a structured and informative method for physician peer-review. It offers the potential for a rapidly implemented strategy that will rate and predict outcomes and complications for patients.
Better comparison of providers drives better markets for the highest quality providers, and helps providers themselves improve. For employers and policymakers frustrated by America's embarrassingly poor performance in nearly every known indicator of health care quality, this study offers two breakthrough glimmers of hope.
This piece first appeared on Forbes.com