By LEONARD D’AVOLIO
I’m in the waiting room at New England Baptist Hospital. They just took my father to the operating room. It’s strange to be back.
Once upon a time, your medical director, Dr. Scott Tromanhauser, asked me for help. He was interested in improving the outcomes of total knee replacement surgeries. Nearly 20% of all knee replacements do not improve results. The greatest opportunity for improvement is to reduce unnecessary surgeries.
This seems simple enough to the casual reader, but in the upside-down world that is American healthcare, very few surgical centers in this country bother to find out whether their surgeries make things better or worse. Doing anything that threatens to reduce volume is bad for business.
We presented a concept to their board of directors.
“What if,” we proposed, “we could measure the 1-year postoperative outcomes of every total knee replacement? We could share that data with our surgeons and see, for the first time, how our patients fared. With enough data, we could make personalized predictions of outcomes during a preoperative consultation visit. We could give people the information they need to make good medical decisions.”
They supported the idea. Yes, it could lead to fewer surgeries, but these were the surgeries that should not be done. Additionally, it could be an advantage during price negotiations with payers. Beyond that, they competed, it was the right thing to do.
Scott and I celebrated the approval with a walk through Mount Auburn Cemetery to visit the grave of Dr. Ernest Codman. After all, it was his idea.
Dr. Codman was a surgeon at Mass General Hospital in 1905 when he presented his “Final results system.” In it, he proposed that each hospital capture data before and for at least a year after each procedure. It was about knowing if the procedure was a success and if not, asking “why not?” Codman wanted patients to have this information. How else would the results improve? How else would patients make good medical decisions?
Now, more than 100 years later, we would bring his idea to life, a few kilometers from where he presented it.
Under Scott’s leadership, the institution had been collecting outcomes data. We brought all the surgeons together to review it for the first time. We replaced their identities with Surgeon A, B, C, etc., on the slides, but Scott and I knew the names.
Their reactions were fascinating. Despite being blinded to the results, those most skeptical about what they were seeing were among the worst performers. The person most supportive of using outcome data, Dr. Carl Talmo, turned out to have the best postoperative results.
Next, we proposed a pilot to bring Dr. Codman’s concept into the 21st century. We would use past outcomes to predict patients’ future outcomes.
We wrote an iPad app with a validated machine learning model that predicted the probability of each potential patient getting better, the same, or worse, one year after surgery. Patients answered a few questions and when they entered the examination room, their prediction and the factors influencing it were in the hands of the surgeon. The surgeon would guide them through this as part of a joint decision-making process.
Dr. Talmo promised to use it in his clinic. Some people chose not to have surgery after seeing the expected results. Others entered the operating room with more confidence in their decisions. Their results were fed back into the system, making the model even more useful for future patients.
The time had come to invite others to try it.
we made a 2 minute video explaining how it worked and how you can improve results. We wrote an article called “Patients Like You” that was published in the The catalyst for the New England Journal of Medicine. I called surgical clinics all over the United States. We held meetings with other Baptist surgeons and their colleagues at other Boston hospitals.
People thought it was cool. Nobody was interested in using it. Reducing surgical volume is bad business. COVID hit and Bautista asked if we could consider letting them out of the contract. We did it. Everyone had more important things to do.
It was disappointing but not surprising. We were not naive. Simply idealistic. Compared to what happened to Dr. Codman, we got away with it.
When Codman presented his bottom line system to his board of directors, it was rejected. He accused Mass General directors of prioritizing profits over results. He was fired, ostracized, and died penniless. On Codman’s tombstone are the words: “It may be a hundred years before my ideas are accepted.”
120 years have passed. I’m back at Baptist waiting to hear how my dad’s knee replacement went. I’m worried but not worried. I had the advantage of choosing a surgeon based on his results. Unless the numbers have changed since I was last here, you are in good hands with Dr. Talmo.
For a minute I think, “What a shame.” We came very close to ensuring that everyone in this waiting room had the information they need to make life-changing medical decisions.
I wonder if Dr. Codman took it personally. Did he take comfort in the words of his contemporary Upton Sinclair, who said, “It is difficult to get a man to understand something when his salary depends on his not understanding it”?
This is, and always has been, a problem of perverse incentives. But will it always be like this?
I take comfort in knowing that the vast majority of people who choose a career in healthcare want it to be better. People like Drs. Scott Tromanhauser, Carl Talmo and the Baptist board members who took a chance knowing it was a long shot. People like those I work with every day at Blue Circle Health.
There are more of them than you think. They are harder to find because they didn’t join healthcare to make fortunes or headlines. They came together to make a difference. I only hope I’m still there when many of them realize their collective power and use it to create the health care system we all deserve.
Leonardo D’AvolioPhD is assistant. Professor at Harvard Medical School. He can be contacted at ld******@***il.com
