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The Bell Curve:  What happens when patients find out how good their doctors really are? by Atul Gawande

Once we acknowledge that, no matter how much we improve our average, the bell curve isn’t going away, we’re left with all sorts of questions. Will being in the bottom half be used against doctors in lawsuits? Will we be expected to tell our patients how we score? Will our patients leave us? Will those at the bottom be paid less than those at the top? The answer to all these questions is likely yes.

Recently, there has been a lot of discussion, for example, about “paying for quality.” (No one ever says “docking for mediocrity,” but it amounts to the same thing.) Congress has discussed the idea in hearings. Insurers like Aetna and the Blue Cross-Blue Shield companies are introducing it across the country. Already, Medicare has decided not to pay surgeons for intestinal transplantation operations unless they achieve a predefined success rate. Not surprisingly, this makes doctors anxious. I recently sat in on a presentation of the concept to an audience of doctors. By the end, some in the crowd were practically shouting with indignation: We’re going to be paid according to our grades? Who is doing the grading? For God’s sake, how?

We in medicine are not the only ones being graded nowadays. Firemen, C.E.O.s, and salesmen are. Even teachers are being graded, and, in some places, being paid accordingly. Yet we all feel uneasy about being judged by such grades. They never seem to measure the right things. They don’t take into account circumstances beyond our control. They are misused; they are unfair. Still, the simple facts remain: there is a bell curve in all human activities, and the differences you measure usually matter.

I asked Honor Page what she would do if, after all her efforts and the efforts of the doctors and nurses at Cincinnati Children’s Hospital to insure that “there was no place better in the world” to receive cystic-fibrosis care, their comparative performance still rated as resoundingly average.

“I can’t believe that’s possible,” she told me. The staff have worked so hard, she said, that she could not imagine they would fail.

After I pressed her, though, she told me, “I don’t think I’d settle for Cincinnati if it remains just average.” Then she thought about it some more. Would she really move Annie away from people who had been so devoted all these years, just because of the numbers? Well, maybe. But, at the same time, she wanted me to understand that their effort counted for more than she was able to express.

I do not have to consider these matters for very long before I start thinking about where I would stand on a bell curve for the operations I do. I have chosen to specialize (in surgery for endocrine tumors), so I would hope that my statistics prove to be better than those of surgeons who only occasionally do the kind of surgery I do. But am I up in Warwickian territory? Do I have to answer this question?

The hardest question for anyone who takes responsibility for what he or she does is, What if I turn out to be average? If we took all the surgeons at my level of experience, compared our results, and found that I am one of the worst, the answer would be easy: I’d turn in my scalpel. But what if I were a C? Working as I do in a city that’s mobbed with surgeons, how could I justify putting patients under the knife? I could tell myself, Someone’s got to be average. If the bell curve is a fact, then so is the reality that most doctors are going to be average. There is no shame in being one of them, right?

Except, of course, there is. Somehow, what troubles people isn’t so much being average as settling for it. Everyone knows that averageness is, for most of us, our fate. And in certain matters—looks, money, tennis—we would do well to accept this. But in your surgeon, your child’s pediatrician, your police department, your local high school? When the stakes are our lives and the lives of our children, we expect averageness to be resisted. And so I push to make myself the best. If I’m not the best already, I believe wholeheartedly that I will be. And you expect that of me, too. Whatever the next round of numbers may say.

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