Wednesday, September 10, 2008

Baseball is entering its final weeks of the regular season just as college and pro football being their marches to crown champions. And while won/lost records are the bottom line, it seems increasingly that statistics drive interest in the game. Hitting and pitching stats are historic markers that try to compare players across generations. And NFL fantasy fans follow every rush, pass and tackle. Medicine is no different. There may be many opportunities to measure different aspects of care but the question becomes what to do with the numbers.

Recently Medicare released performance data as to how hospitals across the country performed in caring for patients with heart disease and pneumonia. The data was unwieldy and difficult for the public to use. Being politically correct, there were no black and white answers; no bottom line saying that one hospital was safer or better than another. Googling “doctor ratings” will provide reams of websites willing to divulge which doc is good and which isn’t so good.

The question remains, what stats matter and what do they mean? Emergency issues are a little easier to measure. Guidelines state that patients who present to emergency rooms with chest pain should get an electrocardiogram (EKG) done within 10 minutes of hitting the door. A patient with stroke symptoms should be seen by a physician within 10 minutes. Antibiotics should be given within 4 hours of a patient presenting with pneumonia. One can measure how often this occurs and perhaps it becomes a measure of how organized a hospital is in delivering care. But those numbers don’t measure the doctor’s ability to interpret an EKG or the ability to read a chest X-ray to find the pneumonia. In baseball, hitting .300 is a big deal, but doesn’t mention whether all the hits happened when the game was already won or lost. One number doesn’t tell the story.

Medicine also has the distinct disadvantage that while patients usually tell the truth, diseases often are elusive. The backbone of diagnosis is the ability to take a history. Ask the right questions and the patient should be able to guide the doctor to get to the right answer. But some diseases don’t read the textbook and can delay getting treatment started.

Heart attacks are a great example. The textbook presentation of a heart attack is chest pain or pressure, described as tightness or heaviness, that may radiate down the arm or into the neck associated with sweating and shortness of breath. Show up complaining of that in your doctor’s office or in the ER and the wheels start turning pretty quickly. The EKG happens, IVs and medications get started and the statistics look pretty good. Unfortunately, heart disease can also present with atypical symptoms. If a heart attack involves the bottom part of the heart, an inferior myocardial infarction, then the symptoms may be indigestion and upper abdominal pain. The initial assessment in ER triage may suggest that the problem lies with the stomach or gallbladder and the time for the EKG to happen may be lengthened. Is it bad care? Consider that up to 1/3 of all heart attacks are silent, meaning they occur with no symptoms. Imagine rushing to your doctor’s office and complaining that you feel fine. Perhaps you’re having a heart attack and need an EKG…stat!

Sport tries to measure and quantify everything; the speed of a tennis serve, the free throw percentage, the number of greens hit in regulation. As each part of an athlete’s performance improves, ideally the chance of winning improves as well. But it’s the opponent is the wild card. The skill of the opponent that day decides who wins a particular game. While the odds will favor the better team, the game still needs to be played.

Medicine is no different except that while wins and losses are replaced with life and death, in the long run, the deck is stacked and death always wins. Measuring statistics may give a guideline as to how prepared a hospital might be to care for the next patient, but who wins depends on the skill of the nurses and doctors and what the patient brings to the game. The patient who smokes, is overweight and drinks to excess will do less well than one who doesn’t. It’s teamwork, the relationship between the docs and the medical personnel that makes the difference.

And the bottom line is that no matter what the statistics predict, the outcome always remains in doubt. That’s why they play the game.

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