Regional variations are created by "grand old men"

A message to all physicians from the chair of the AMA Board of Trustees, William G. Plested III, MD.

By William G. Plested III, MDis a thoracic and cardiovascular surgeon from Brentwood, Calif. He served as AMA board chair during 2003-04, and as AMA president during 2006-07. Posted May 3, 2004.

Print  |   Email  |   Respond  |   Reprints  |   Like Facebook  |   Share Twitter  |   Tweet Linkedin

Today it seems like everyone is in a frenzy about the "quality" of medicine in the United States.

In large part this stems from the Institute of Medicine report "To Err is Human" that used decade-old data that were dubious at best. These data were then extrapolated to the nation as a whole, a ploy substantially beneath the dignity of a group that purports to stand at the pinnacle of our profession.

Yet this flawed report planted the idea that the nation's hospitals and physicians are responsible for almost 100,000 deaths a year due to medical errors.

It can be argued that the medical liability crisis is in significant part the sequel to this pitiful report.

The concern about the "quality" of medical care in America has led to an endless supply of self-styled experts ready to tell us how to practice our profession.

This "quality" debate is a huge subject and well beyond the scope of a single, simple essay. But there is one facet that has caused significant consternation among the pundits and critics, and that is the obvious presence of regional variations in the type of care that is recommended and delivered by physicians. This is one part of the quality debate that would appear to have its genesis and its potential solution squarely in our medical education system.

Basic medical school education in the United States is highly regulated and closely monitored. Curriculum requirements are generally standard, and the result is a product of high quality and surprising consistency. This quality, of course, depends upon a conscientious faculty that lives up to its dual responsibility of teaching and evaluating its students.

Lately, our medical schools seem to be interested in abdicating a portion of this basic responsibility by agreeing that the only way to evaluate students is for state medical boards to give a clinical skills exam using amateur actors who describe fake symptoms and signs. However, this is another issue, and I digress!

My point is that the average U.S. medical school graduate has benefited from a uniformly high-quality medical education, one that should produce much more uniform medical care delivery than is generally experienced today.

So, what happens between the conferring of a medical degree and the practice of the average physician that leads to regional variations in care? The answer is obviously the residency training experience.

Here is where we can encounter the enormous and essentially unregulated influence of what I am calling "old men" and "grand old men."

Regardless of the type of residency a new physician chooses, he or she will soon learn that the most venerated individual in the program -- and this is usually, but not invariably, the department chair -- sets the institution's tone or approach for that specialty's patient management.

In many hospitals, including my own training site, such a venerated person was known euphemistically as the "old man" -- which actually was a term of respect and endearment among the resident staff.

What now comes into play is the reality of the intense and competitive world of academic medicine, where survival, advancement and, ultimately, fame depend upon a host of accomplishments, such as an exhaustive bibliography, extensive research and often the development of "breakthrough" treatments or procedures.

Thus the "old man" usually becomes known for doing something in a manner that is at variance with what is generally accepted. This is transmitted to the residents in that specific teaching program and subsequently to others in the area. This inevitably leads to regional differences in recommended treatment and surgical procedures for various problems.

Once an "old man" gains a strong national or international reputation, he transitions to a "grand old man," and is accorded an even greater degree of deference. The extent to which such almost blind deference can reach was exemplified many years ago, when a "grand old man" of general surgery decided to treat gastric ulcers by freezing the patient's stomach. This gastric freezing technique was actually used by some surgeons across the country until widespread scrutiny of the procedure totally discredited it.

The nature of referral center practice, the mobility of patients, the turnover in insurance coverage, and other factors have made careful follow-up of a variety of treatments unusually difficult.

In addition, the complexity of most procedures -- especially innovative surgical procedures and the multiplicity of other treatment modalities that affect the outcomes of an individual patient -- also contributes to regional differences.

New information technology advances will hopefully correct these deficiencies. In the meantime, the responsibility for addressing the regional variation portion of the quality issue rests squarely with our teaching institutions, residency programs and the various boards. In the future, residency review committees will need to focus not only on the numbers of cases that residents treat, but also on whether the treatments or procedures used have widespread acceptance and carefully documented results, or if they, in fact, represent regional variations to standard care. This will involve interesting debates.

I am certain that some of the observations I am making will be met with a bit of indignation. However, the truth should be obvious. Certainly, two things are clear.

One, that the introduction of modern information technology tools to facilitate patient follow-up and outcomes research should result in the reduction of regional variations in care.

Two, the influence of "old men" and "grand old men"will be markedly reduced -- if not because of the difficulties of introducing variations in an era of careful and thorough outcomes evaluation, then simply because of the steady increase in the numbers of women holding professorships and chair positions in our residency programs!

William G. Plested III, MD is a thoracic and cardiovascular surgeon from Brentwood, Calif. He served as AMA board chair during 2003-04, and as AMA president during 2006-07.

Back to top



Read story

Confronting bias against obese patients

Medical educators are starting to raise awareness about how weight-related stigma can impair patient-physician communication and the treatment of obesity. Read story

Read story


American Medical News is ceasing publication after 55 years of serving physicians by keeping them informed of their rapidly changing profession. Read story

Read story

Policing medical practice employees after work

Doctors can try to regulate staff actions outside the office, but they must watch what they try to stamp out and how they do it. Read story

Read story

Diabetes prevention: Set on a course for lifestyle change

The YMCA's evidence-based program is helping prediabetic patients eat right, get active and lose weight. Read story

Read story

Medicaid's muddled preventive care picture

The health system reform law promises no-cost coverage of a lengthy list of screenings and other prevention services, but some beneficiaries still might miss out. Read story

Read story

How to get tax breaks for your medical practice

Federal, state and local governments offer doctors incentives because practices are recognized as economic engines. But physicians must know how and where to find them. Read story

Read story

Advance pay ACOs: A down payment on Medicare's future

Accountable care organizations that pay doctors up-front bring practice improvements, but it's unclear yet if program actuaries will see a return on investment. Read story

Read story

Physician liability: Your team, your legal risk

When health care team members drop the ball, it's often doctors who end up in court. How can physicians improve such care and avoid risks? Read story

  • Stay informed
  • Twitter
  • Facebook
  • RSS
  • LinkedIn