Author: Leonard Davolio
I'm in the waiting room at New England Baptist Hospital. They just wheeled my dad into the operating room. It feels strange to be back.
At one point, their chief medical officer, Dr. Scott Tromanhauser, asked me for help. He is interested in improving the outcomes of total knee replacement surgeries. Nearly 20% of knee replacements do not improve outcomes. The greatest opportunity for improvement is to reduce unnecessary surgeries.
To the average reader, this may seem simple, but in U.S. health care, few surgical centers bother to understand whether their surgeries make things better or worse. Anything that might reduce sales is bad for business.
We pitched a concept to his board.
We asked, “What if we could measure the 1-year postoperative outcomes of every total knee replacement? We could share this data with surgeons and understand, for the first time, how patients are doing. With enough data, we could make personalized predictions of outcomes during preoperative consultation visits. We could give people the information they need to make good medical decisions.”
They support the idea. Yes, this may reduce the number of surgeries – but these surgeries should not be performed. Additionally, this may be an advantage when negotiating prices with payers. Beyond that, they agreed it was the right thing to do.
To celebrate this approval, Scott and I walked through Mount Auburn Cemetery and visited the grave of Dr. Ernest Codman. It was his idea after all.
Dr. Codman introduced his “Final Result System” in 1905, while he was a surgeon at Massachusetts General Hospital. In it, he recommended that every hospital collect data before and for at least a year after each surgery. It's about finding out if the surgery was successful, and if not, asking “Why wasn't it successful?” Codman wants patients to know this information. How else would the results be improved? How else can patients make good medical decisions?
Now, more than 100 years later, we are bringing his idea to life just a few miles from where he came up with it.
Under Scott's leadership, the agency has been collecting outcomes data. For the first time, we brought together all the surgeons for a review. We replaced their identities in the slides with Surgeon A, B, C, etc., but Scott and I knew the names.
Their reactions were interesting. Although they were blind to the results, those who were most skeptical of the results they saw were the worst performers. The person who most supports the use of outcome data, Dr. Carl Talmo, has been shown to have the best postoperative outcomes.
Next, we propose a pilot program to bring Dr. Codman's concepts into the 21st century. We will use past results to predict future outcomes for patients.
We wrote an iPad app that contains a proven machine learning model that predicts the likelihood that each potential patient will get better, the same, or get worse within a year of surgery. Patients answer a few questions, and when they enter the exam room, their predictions and influencing factors are in the hands of the surgeon. As part of a joint decision-making process, the surgeon guides them through the process.
Dr. Talmer signed up to use it in his clinic. Some people choose not to have surgery after seeing the predicted results. Others go into the operating room more confident in their decisions. Their results are fed back into the system, making the model more useful for future patients.
It’s time to invite others to give it a try.
We've created a 2-minute video explaining how it works and how to improve your results. We wrote an article called “Patients Like You,” which was published in the New England Journal of Medicine Catalyst. I visited surgical offices across the United States. We held meetings with other Baptist surgeons and their colleagues at other hospitals in Boston.
People think it's cool. No one is interested in using it. Reducing the amount of surgery is a bad thing. When COVID hit, Baptist asked if we could consider letting them out of their contract. We did it. Everyone has bigger fish to fry.
This is disappointing, but not surprising. We are not naive. It's just idealism. Compared to what happened to Dr. Codman, we had it easy.
When Codman presented his final system to the board, it was rejected. He accused MGH's directors of putting profits over results. He was fired, ostracized, and died penniless. Codman's tombstone is inscribed with the following sentence: “It may take a hundred years for my idea to be accepted.”
120 years later. I returned to Baptist Hospital waiting to find out how my father's knee replacement surgery was going. I'm concerned, but not worried. My advantage is choosing a surgeon based on his results. Unless the numbers have changed since I was last here, Dr. Talmer is taking good care of him.
For a moment I thought, “What a shame.” We are so close to every person in this waiting room that they have the information they need to make life-changing medical decisions.
I wonder if Dr. Codman takes this personally? Did he take solace in the words of contemporary Upton Sinclair, who said: “It is difficult to make a man understand something when his salary depends on his not understanding it.”
It's always a question of perverse incentives. But will it always be that way?
I take comfort in knowing that the vast majority of people who choose healthcare want it to get better. People like dr. Scott Tromanhauser, Carl Talmo and the members of the Baptist Board of Directors knew the opportunity was long and they took it. Like the people I work with every day at Blue Circle Health.
There are more of them than you think. They're harder to find because they don't join the healthcare industry to get rich or make headlines. They join to make a change. I just hope I'm still around when enough people realize their collective power and use it to create the health care system we all deserve.
Dr. Leonard D'Avolio is an associate. Professor at Harvard Medical School. He can be reached via: LD******@***il.com
