A Science of Medical Performance

Everybody wants to cure cancer and pioneer gene therapy. This sort of scientific discovery, especially when the discovery could have profound consequences, is a worthy ambition. But does this ambition distract us from less appealing but even more important endeavors? Does searching for the miracle cure come at a cost?

Atul Gawande, in his new book Better, argues that medical research should search for low-tech improvements (like making doctors more diligent about hand-washing) with the same zeal it lavishes on potential drugs and surgical techniques. He uses the treatment of cystic fibrosis as an example:

In 1989, when scientists discovered the gene for cystic fibrosis...a cure was believed to be only a few years away. Dramatic progress, however, has not occurred. Neither Mark [a medical resident with cystic fibrosis] nor I wanted to let go of the hope that a cure will be found. But Mark was not putting any bets on that happening in time to help him. Instead, he said, his hopes were focused on efforts to monitor and improve and transform clinical performance using know-how already in existence. He believed that of all the work being done, this was the work that would save more lives. And I agreed with him.

To be sure, we need innovations to expand our knowledge and therapies, whether for cystic-fibrosis or childhood lymphoma or heart disease or any of the other countless ways in which the human body fails. But we have not effectively used the abilities science has already given us. And we have not made remotely adequate efforts to change that. When we've made a science of performance, however, thousands of lives have been saved. Indeed, the scientific effort to improve performance in medicine - an effort that at present gets only a pitifully miniscule portion of scientific budgets - can arguably save more lives in the next decade than bench science, more lives than research on the genome, stem cell therapy, cancer vaccines, and all the other laboratory work we hear about in the news.

This sort of diligence isn't sexy and it doesn't make you famous or rich but it's absolutely essential. What I don't know is how you get the scientific and medical communities to be interested in a "science of performance". (Such a science will also meet resistance from doctors who aren't up to par: measuring performance inevitably exposes the under-performers.) Our entire funding system has a deep bias for innovation and discovery. We want the next next thing, and we want it now. The media only exaggerates the problem.

Perhaps what we need is a new branch of psychology: the science of medical performance. These specialized psychologists would focus on ways to help doctors perform better. What kinds of visual cues remind doctors to wash their hands? What's the ideal type of surgical team? How many hours should a doctor work? Why is there so much variation among different hospitals? What makes the most effective hospitals so effective? This science of performance would represent the psychological component of evidence-based medicine. It's not enough to know what drugs are effective. We also need to know what kinds of doctors are effective.