Monday, April 4, 2011


I am currently reading John Wennbergs "Tracking Medicine". There are some great insights, and I cannot recommend it enough. One of the most striking pieces I came across relates to the belief, now vanished, that tonsillectomy was critical for a healthy childhood:
"The American Child Health Association’s research design used a random sampling of 1,000 New York City school children. On examination by a school physician, 60% were found to have already had a tonsillectomy, and of the remaining 40%, nearly half were deemed in need of the operation. To make sure that no one in need of a tonsillectomy was left out, the association arranged for the children not selected for tonsillectomy to be reexamined by another group of physicians. The second wave of physicians recommended that 40% of these children have the operation. Still not content that unmet need had been adequately detected, the association arranged for a third examination of the twice-rejected children by another group of physicians. On the third try, the physicians produced recommendations that another 44% should have the operation. By the end of the three-examination process, only 65 children of the original 1,000 emerged from the screening examination without a recommendation for tonsillectomy. If the association had put those 65 children through additional rounds of examination, it seems likely that virtually every last one would have been recommended for surgery, a thought that gives new meaning to the phrase “no child left behind.”
While we may laugh at such a practice, are we really that different? Look at the variation you practice yourself, let alone the variation amongst your colleagues, and then remember that the variation within an institution is far less than variation between hospitals. As Wennberg says,

"Thus regions have characteristic “surgical signatures” and regions with high rates of a surgery in the early 1990s still tend to have high rates today, and the cumulative effect is to expose large numbers of patients to surgical interventions that they may or may not have wanted." 

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