“Snake oil” was brought over by the Chinese in the 1800s as a traditional cure. As it turns out, the oil was found to be very effective for the aches and pains associated with doing labor such as, well, building a railroad across America. As this is what the Chinese were doing, they found it very valuable. They also shared it with their non-Chinese counterparts, who found it to be a useful salve as well. Unfortunately for snake oil users, extracting oil from Chinese snakes (or pretty much any snake) in America was tough. Selling snake oil was not. Witness the story of Clark Stanley, aka The Rattlesnake King:
“[Stanley] reached into a sack, plucked out a snake, slit it open and plunged it into boiling water. When the fat rose to the top, he skimmed it off and used it on the spot to create ‘Stanley’s Snake Oil,’ a liniment that was immediately snapped up by the throng that had gathered to watch the spectacle.”
Rattlesnakes, as it turns out, are missing the anti-inflammatory properties of Chinese water snakes. Since Stanley didn’t put any snake in his snake oil, the oil was remarkable ineffective but very lucrative for Stanley.
The evidence based medicine movement, now 20 years old, helped us to focus our efforts on “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” Our attention is now focused on things like “is the patient’s diabetes under control” as opposed to “should I use the latest new drug that the nice rep lady came and told me about.” A blow against snakeless snake oil.
The extension of this movement is focusing us on quality. We are now looking at the quality implications of analyzing large numbers to determine small differences in outcomes. For example, a certain surgeon might have an infection rate of 10% and another of 5%. If this difference is not due to dirtier patients (the surgeon only operates on people who fall in sewers), a patient will likely choose to go to the one with the better outcomes. This data is now becoming available from the federal government from Medicare. For example, hospital outcomes for Medicare patients can be found here. The score care for orthopedic surgeons replacing hips and knees can be found here. These, data, though useful, only paint a partial picture. The hospitals and the surgeons take care of folks other than Medicare so the truth, although likely present in the data, may be difficult to pull out.
For certain types of procedures a more complete picture can be obtained. If only a few places do a procedure, for example, and they keep track of their outcomes, then folks can see how the program performs over time. Such was the case with pediatric heart operation in Florida. Children’s Medical Services, a state agency that pays for the bulk of the services provided to children with congenital defects, had been quietly tracking information and collecting data of years on heart surgeries done to small children as part of a quality initiative. In information obtained by CNN, about 2300 such procedures were done in eight Florida hospitals from 2011 to 2014, with 4 of the hospitals accounting for over 90% of the cases. These procedures can be very lucrative, bringing in over $500,000 for each operation. The reason CNN began looking into this is because St Mary’s hospital in Palm Beach, one of the low volume programs that was trying to build business, had an extraordinarily high death rate. The rate was even higher than it appeared because several dying patients were transferred to other hospitals immediately prior to death, unusual in a center that performs such complex procedures. Also unusual was when a quality panel was called in and made recommendations on how to fix the problem including not operating on some of the more complex cases, the recommendations appeared not to be followed. Lastly, unusual because the hospital’s parent company gave money to the governor and, coincidentally, the quality panel which tried to keep the hospital from doing operations they were bad at (and which the governor had created) was disbanded because it had no statutory authority. The hospital eventually did closed their pediatric cardiac surgery program, the CEO resigned, and the physician is giving depositions while being protected by armed security guards in case you were concerned. Florida’s side of the mess can be found here.
The CNN story begins with a mother whose child has just been paralyzed and, in the elevator, she has the following exchange:
“Do you know a child with a heart problem here?” asked the stranger.
“Yes. My daughter,” McCarthy answered, and explained what had happened to Layla.
“You need to get her out of here,” the stranger warned.
The hospital had not revealed their their pediatric cardiothoracic surgery team’s low volume, complication rate, or inexperience to prospective patients. If patients had looked, they would have found outcomes for the 4 high volume Florida programs posted on the internet (here is the one from Nicklaus Children’s). St Mary’s, rather than posting quality data, posted releases heralding the arrival of “nationally renowned pediatric heart surgeon Dr. Michael Black” with glowing claims such as “smaller incisions — improved self-esteem.”
In this era of complex care, the great doctor has been supplanted by the great team. Great teams keep score. Hiding poor quality as an institution is akin to selling snakeless snake oil. Consumers for elective procedures should demand to know outcomes. Those who insist on keeping their data to themselves should not have the privilege of your business. Et qui vendit pellucidum. Insist on knowing how much snake is in your snake oil.