Pharmacy and Therapeutics - January 2008 - (Page 7) EDITORIAL Better David B. Nash, MD, MBA I have to admit it; I’m a real fan of Atul Gawande, MD, MPH, and his insightful best-sellers. My fascination with his work started in 2002 with the publication of his first book, Complications: A Surgeon’s Notes on an Imperfect Science. This book became a finalist for the 2002 National Book Award. My interest continues with his latest book, Better: A Surgeon’s Notes on Performance, published by Henry Holt and Company. Dr. Gawande is a 2006 MacArthur Fellow, a recipient of one of those national “genius awards” handed out annually to somebody who makes a major difference in our society. He also happens to be a Harvard-trained surgeon, and he is now a Harvard Medical School faculty member (a real low achiever!). What I like about his books, in addition to the incisive writing, is his unflinching willingness to confront many of our most tightly held myths about medical practice. In Better, he confronts these myths head-on, and his message is clearly relevant for every P&T committee member in the nation. For example, my favorite chapter in Better is called “The Bell Curve” (in Part III, “Ingenuity”). Here is a brief excerpt: 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? Will we be expected to tell our patients how we score? Will 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.” with this reality, the better. In an interview with AMA News last summer, the author pointed out the corollary to the bell curve:1 We went from a world where we were mainly artisans, and that meant you simply did what you could. That worked in simple matters, but as medicine became more complex, we had high failure rates. In order to go to the next level where it’s [a] better experience for the patients and we are more likely to deliver good care consistently and have a better experience for us, I think we have to measure how we’re doing. tice, Dr. Gawande has become a nationally sought-after motivational speaker for downtrodden physicians, researchers in the health services, policymakers, and, for that matter, everyone else in our business. If you have not been lucky enough to see him in person, I suggest finding a national conference that he is headlining. In the meantime, be sure to read Complications and Better; I know you will be better off for having done so. The author’s message is basically a manifesto for measuring and improving the quality and safety of health care, but he accomplishes this in such a way that readers do not even realize that they have swallowed the proverbial pill until the effects take hold. I am tempted to buy a copy of Better for every member of our P&T committee, and if I do, I hope Dr. Gawande will give me a break on the price! As always, I am interested in your views. You can reach me at my e-mail address, david.nash@jefferson.edu. REFERENCE 1. Adams D. Searching for more. Author Q&A with Atul Gawande, MD, MPH. AMA News, June 25, 2007, p 11. I I could not have said it any better. In the nearly 60 years of organizational research on quality measurement and safety improvement that has occurred since World War II, we have collectively learned that we improve only processes that we measure. In fact, when we do measure what we do every day, a bell cur ve of per formance emerges. Dr. Gawande has it dead-on right in my opinion, and the sooner we all come to grips All I can say is Amen. Tracking our collective performance means that a bell curve will emerge; it also means that we will improve what we do for our patients and improve the quality of our own professional lives. In Better, Dr. Gawande gives multiple examples. He not only discusses the bell curve of surgical performance; he also deftly points out that only when we examined death rates on the battlefield in Iraq and death rates in various cystic fibrosis (CF) specialty programs in the U.S. were we able to move the mean and improve survival for our soldiers and the quality of life for those with CF. Self-evaluation is a cornerstone of professionalism, and Dr. Gawande cites examples that we have written and read about in this space previously. Today, despite his busy surgical prac- COMING SOON— NEW ELECTRONIC EDITION P&T will soon introduce an electronic edition of the monthly journal using the Nxtbook format that has been tested and proven successful for other forward-looking publications. Print subscribers will be able to view an electronic version that looks just like the print version. Readers can flip the pages, as with the print edition, or they can click in the table of contents to go directly to an article. A search capability allows readers to find any word anywhere in the issue. A full description of this exciting advance will appear in the February issue of P&T. Vol. 33 No. 1 • January 2008 • P&T® 7
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