Wednesday, March 7, 2012

Variety is the spice of confusion and waste

Two months ago, a patient’s wife told me off before his surgery.

In the pre-op area, I was reviewing the planned surgery with them.  I mentioned that he would likely stay 1 or 2 days in the hospital.  Her forehead furrowed.

“Well, which is it,” she demanded, waving an information pamphlet in front of me.  “The nurse told us 2 or 3 days in the hospital.  This pamphlet says 4 or 5 days.  Now you say 1 or 2 days!”

I stood by my estimate, and asked to see the pamphlet.  While the information about the surgery and postoperative care was accurate, the hospital stay quoted reflected a practice that was about 5 years out of date.  I didn’t realize that this information was still being given out, and understood why she would be confused.

After a 2 day (phew!) hospital stay, he went home.  I called him the next week to discuss his pathology report.  After we had finished, I asked to speak with his wife.  I apologized again for the confusion about the length of stay, and told her that our nurse educator had made the necessary changes in the pamphlet.  I was interested to find out why it had bothered her so much.

“I wasn’t upset about how long he was going to stay in the hospital,” she replied.  “I was upset because I thought, if you people at the hospital weren’t talking to each other about a simple matter like how long someone stays in after surgery, maybe you wouldn’t talk to each other about how to look after my husband.  I didn’t know if I could trust you!”

From a minor (I thought…) and easily explained discrepancy, she had concluded that we were not a cohesive system, and was worried that her husband’s health might be in jeopardy because of it.  This small oversight had shaken her confidence in our ability to provide safe care.

I wish I could find fault with her reasoning.


Variation in clinical practice has been on my mind since a discovery several years ago.  My interest was reawakened recently due to our practice’s latest improvement initiative.

About 3 years ago, as part of our Advanced Access/Clinical Practice Redesign work, we found a wide variation in urologist practice regarding patient recall.  This 2008 post explains that, but in a nutshell, we found that the rate of patient recalls (internal demand) varied from almost zero up to 25%.  We realized that some recall visits are helpful, but that they also use capacity that could shorten wait times for new patient consultation.  For that reason, we worked toward reducing unessential recall.

We discovered, through group discussions, that most of the variation between our practices was “just because”.  That is, we recalled patients with certain conditions and at certain intervals because that’s the way we were trained and the way we had always done it.  We had never discussed “appropriate” recall as a group.  Once we recognized the variation, we developed methods (such as follow-up algorithms) to facilitate follow-up by the patient’s primary care provider.  Our recall rates dropped significantly over the 6 months after that initial discovery.

In that case, clinical variation was a marker for waste in our office system.

Our practice’s latest improvement initiative is around improving care for patients with bladder cancer.  Before Christmas, in order to explore what our current system looked like, I asked one of our office managers what she thought we could improve.  She had no hesitation in her reply.

“Get your act together with BCG,” she suggested.

BCG is commonly used chemotherapy treatment to prevent bladder cancer from returning.  Patients receive 6 treatments, started after their bladder surgery.  After that, they have regular endoscopic bladder examinations to detect any tumor recurrence.

That sounded pretty straightforward to me. I didn’t see much variation there.

She corrected my thinking.

“You all have a different way of ordering the treatment.”

She went on to explain that each of the 8 of us used a slightly different BCG protocol.  Each protocol was medically reasonable, but there was variation in the interval between surgery and treatment, between each of the treatments, and between the treatment and follow-up examinations.  Our staff had to keep track of each urologist’s unique habits (which occasionally changed from patient to patient!).

Staff had to be careful when explaining the treatment and follow-up schedule to patients as, if they gave the protocol belonging to the wrong urologist, the patient would be confused.  (And, have their confidence shaken.)

Also, our staff felt that a common protocol would improve patient safety. (Yes, we really do have amazing staff who think this way!)   Keeping track of multiple protocols increases the chance of confusion and the chance that we’ll miss scheduling important follow-up examinations.

Significant clinical variation had once again gone unrecognized.  (Well, unrecognized by me because I don’t see any variation in my own process.  And if my own process does vary, I convince myself that there’s a darn good reason for it.)

We physicians zealously guard our professional autonomy. We may see efforts to reduce clinical variation as a threat to that autonomy.  I agree that some variation is important to preserve, that is, variation related to each patient’s unique disease process, experience, needs and wishes.  But variation related to poor coordination of our healthcare system leads to waste, affects patient safety and erodes trust.

I think that much variation in practice is present not because practitioners are exerting their autonomy, but rather because we simply haven’t yet identified the variation and appreciated its impact on our patients.  If our healthcare system had methods to identify clinical variation, and encouraged clinicians to be curious as to its cause, clinicians would develop their own solutions to reduce it, and thereby improve our patients’ care.


  1. "I wish I could find fault with her reasoning."

    One of the realities in medicine that needs to be more frequently reflected upon that the patient knows very little relative to the professionals. And if they know anything, they know that not all health services are delivered equally. As a result, when they do notice something is wrong / different it is a very strong indicator that other things might be wrong.

    To provide some more common place examples, how much would you trust a a lawyer with spelling mistakes in their email or a mechanic whose door squeaked?

    How much more so if one mechanic says "I need to wait for the engine to cool before I do the work" and another mechanic says "No worries, I can work on it while the engine is hot."

    As you have written before, it may be hard to reach consensus on the Best way to do something but it should be possible to reach consensus on a Very Good way. And of course it bares remembering that no rule or protocol prevents "common sense" from deviating when necessary. But variation without explanation raises a lot of questions.

  2. Hi Kishore
    very interesting story! And while the woman's reaction may have seemed a bit excessive, I say good for her. We need more patients to step up and question inconsistencies and unclear information in the health system. For too long we have been provider centric and not patient centric. True patient engagement is necessary for us to transform the sytem, addressing safety and quality issues.

    I am Vice Chair of a hospital Board in Ontario and recently participated in an Institute for Healthcare Improvement webinar on highly reliable organizations (HRO). That notion of consistency and examining reasons for variation are key to HROs. The move in health care over the last few decades to clinical pathways/caremaps is a step in the right direction but there is much more to do.

    Congratulations on involving your staff and addressing physician variation!

  3. My husband had an experience similiar to that of this women and her husband, only it was in data that NO one told him. I am a RN, so when my husband went for surgery, i was with him every step of the way, to make sure it went well. He met with 4 different people prior to his surgery (major diaphramatic repair), including a pre-op nurse, the anesthetist, his surgeon and the person who check him in for surgery(she never did introduce herself, but i presume she was an RN) As my husband was waiting, right before his surgery, i felt that i better warn him that he might get a catheter, as none of the other health care professionals had once mentioned the possibility of a catheter, and i know for men, this can be a pretty big deal. He was so upset that no one had told him, and he said they had many opportunities(such as: when they told him he couldn't wear underwear into the OR and he asked why). I think this is something we really need to work on, and i applaud you for recognizing this.

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