ranking doctors and quarterbacks

Monday, October 20, 2014

Once upon a time, sports pages reported about the game. Analysis was more than just the numbers. Reporters and columnists wrote about the ebb and flow of the action, along with the turning points that might had led to that one defining moment where victory or defeat was defined. And then came fantasy football. Instead of team, the focus changed to individual player statistics and who won the game was of secondary importance. Welcome to the same reality that has inched itself into grading doctors and hospitals.

Sometimes statistics are helpful in deciding the quality of care provided to a patient and sometimes those numbers can be deceiving. The latest version of www.healthgrades.com went live this week and it advises that there is a “right way to find the right doctor.” And their philosophy and advice is absolutely correct. Being able to assess a physician’s experience, patient satisfaction and the hospital quality all will give guidance, but too often that guidance presumes a level playing field and that is not always the case. Ratings need to be taken with a grain of salt because context is everything.

This week in the NFL, the Panther’s Derek Anderson and the 49ers Blaine Gabbert placed in the top half of quarterback rankings. Both are backups who came into the game after the outcome had been decided. Johnny Hekker of ranked #7 this week for his one pass completion on a fake punt. However, the cream does rise to the top, as Peyton Manning and Aaron Rogers ranked #1 and #2 for the week, but not every team gets to have a superstar.

In medicine, it’s all about context. Hospitals are not necessarily equipped to care for every medical situation. Some have developed programs with special expertise in trauma, heart attack or stroke. Fewer can care for major burn victims or can perform organ transplants. Hospitals are ranked on patient outcomes and many have to do with complications that might occur during or after a patient hospitalization. Post-operative infections, blood clots, wound healing problems and bed sores are a few parameters that are monitored. The problem with blindly comparing hospital data has to do with patient distribution. Some hospitals are not equipped to care for the sickest, most complicated patients and when they present to their doorstep, the patients are transferred to hospitals that have the capability to provide them care. This is the right thing to do for the patient but the sickest patients also have the highest complication rates, even with the best of care.

Similarly, some physicians and their nursing teams take on the most challenging patients, knowing that some are destined to have reportable complications. Patients with diabetes and patients who smoke have high rates of wound infections and may not heal properly. The risk/benefit analysis for some patients skews to the risk side and yet, sometimes, operations are potentially unavoidable because the alternative is death.

Mayo Clinic in Rochester is a world renowned center of medical excellence. Two hospitals care for their patients. Healthgrades has ranked St. Mary’s Hospital with 34 five-star rankings and 15 five-star awards. Methodist, its sister hospital has but 14 five-star rankings and 9 five-star awards. St. Mary’s has worse than average complication rates for a few of the monitored surgical complications while Methodist is ranked above average. With the same physician and nursing staff, it is likely that one hospital is geared to care for the most injured and ill and is to be expected that their complication rate will be higher. The same type of dichotomy is also found at Massachusetts General Hospital in Boston, the flagship for Harvard Medical School, highly ranked and awarded and yet with worse than expected complication rates.

When it comes to patient satisfaction, only in Lake Wobegon can all the physicians be above average. There are times when the physician must answer “no” to a patient or family demand. Having a less than satisfactory interaction with the patient, may cause a Healthgrades rating to decline, regardless of the soundness of the medical decision making.

The question then remains: how should one find a doctor or choose a hospital? It starts with asking people you know and trust.

  • Family and friends are the first resource to recommend a doctor that they trust.
  • Next comes the hard work. Your doctor should be board certified in their specialty, meaning that they have not only graduated medical school, but also completed post graduate training and have passed their exams. http://certificationmatters.org/
  • Now it’s time to check whether any red flags for discipline or malpractice are flying. A very useful link from Consumer Reports

Once the preliminary screening is done, it’s time to decide whether you like that doctor as a person and to see whether you are compatible. You should feel comfortable not only with the science, but also with the communication skills. Bedside manner is important in increasing the likelihood that a patient will follow their doctor’s advice.

And finally make a plan for emergencies. For some, there may be only one hospital in town, but in larger cities, numerous hospitals vie for your business. Knowing which hospital is best for stroke emergencies or heart attack or trauma may be life-saving. Paramedics and EMTs know and are trained to take the patient to the proper facility, even if it means bypassing a hospital that is closer. But when it’s family that’s driving, you need to know where to go.

Statistics are more than looking at the raw numbers. Understanding how a doctor or hospital ranks is sometimes no different than the process needed to understand quarterbacks and wide receivers. No disrespect meant, but Blaine Gabbert may not be a better quarterback than Joe Flacco or Russell Wilson, regardless of what the numbers say.

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concussions and football

Tuesday, September 30, 2014

 

The latest concussion controversy involves Shane Morris, the University of Michigan quarterback  whose head injury was unrecognized by the coaching and medical staff on the sideline and therefore was allowed to continue to play. After a few public relation gaffs, the university admitted that an error was made and instituted new procedures to address the “communication processes”. Athletic director, Dave Brandon, said that Michigan would have an athletic medical professional in the press box or video booth with the ability to talk to the medical personnel on the field and would increase communication between medical and coaching staff as to player availability.

The NCAA has a recently revised policy on concussion that addresses the issues of diagnosis, treatment and return to play. Good for the NCAA and good for Michigan but it is just window dressing for the whole head injury issue. Here are but a few of the issues that make head injuries a significant public health issue.

There is no easy way to make the diagnosis: Depending upon the research you choose to read, somewhere between 30 and 50 percent of head injuries go unrecognized and therefore unreported. The NCAA guidelines suggest that players will hide their concussion because of the invincibility of youth to fear of losing their roster spot. Studies looking at concussion rates in high school and college athletes suggest that the player did not report concussions because they were unaware that their symptoms were associated with head injury. Headache was the most commonly non-reported initial symptom. Those who had an unreported concussion were more likely to be knocked unconscious with a subsequent concussion and also have more severe post-concussion symptoms.

The diagnosis on the field needs to rely on the players and referees on the field: It is nice that Michigan has the resources to place medical personnel in the press box and have communications equipment to talk to the medical and coaching staff on the field. For all the football played in the US, from freshman and JV high school games to the Division II and III college level, virtually none will have a neurologist or head trauma specialist on the field or in the press box. Most won’t have a press box. Coaches on the sideline are too often shielded from all the action and it’s incumbent upon those on the field to be their brother’s keepers. Watching the replay of Shane Morris laying on the field after being hit, slowly getting up, stumbling and having to be supported by another player, it is clear that something is wrong. Yet, after a few seconds, he waves off help and gets into the huddle for the next play. The lineman who helped steady him and the referees on the field need to feel empowered to stop the play and have him removed.

The diagnosis of concussion on the sideline, in the ER or the doctor’s office may be also difficult to make: While it is easy to make the diagnosis of head injury when a player is knocked unconscious or is vomiting on the field or being dazed and having light sensitivity, many of the symptoms can be subtle and take hours to manifest themselves. It could be that irritability, difficulty concentrating, changing sleep patterns or headaches lead to the diagnosis. While guidelines and scoring systems exist, the only diagnosis of concussion is made clinically by symptoms alone. By definition, a minor head injury or concussion, has a normal physical exam.

Treatment of concussion is brain rest, but for how long: the first order of business is to remove the player of the game to prevent further injury. In football, that starts by having the medial staff take away the player’s helmet. There is no missed communication between the trainers and coaches when the player walks the sideline without a helmet on his head or in his hand. There is a six step program endorsed by the NCAA and the 2013 Zurich International Conference on Concussion in Sport that lays out the path for an athlete to return to play. It is interesting that while there is a presumed safe path to the football field, there is no such safe path to return to school or work.

From the NCAA: “There are no standardized guidelines for returning the athlete to school…Returning the student to school, even if the day is shortened, can be considered when the student can tolerate cognitive activity or stimulation for approximately 30 to 45 minutes. This arbitrary cutoff is based on the observation that a good amount of learning takes place in 30- to 45-minute increments… Given that most concussions resolve within three weeks of the injury, adjustments may often be made in the classroom setting without formal written plans.”

Good for Michigan, the NCAA and college football. Players will be watched from on high, yet between one third and one half of concussions will not be recognized. There is no easy way to make the diagnosis. Rest is the only treatment available. Return to play may occur within one week, yet return to the classroom may be limited to less than an hour.

With all this clarity, what direction and information does this give to players and to their parents who want their kids to play ball. It’s a reminder that institutions of higher education, like the University of Michigan, have a hard time applying science to their everyday lives.

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