Tuesday, February 18, 2020
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What good comes of giving surgeons grades?

Dr Sandeep Jauhar, a cardiologist and the author of Doctored: The Disillusionment of an American Physician and Intern: A Doctor’s Initiation, opines in the New York Times, speaking from personal experience, that assigning grades to heart surgeons based on patient outcome is a bad idea.

Citing research published in 2003 in the Journal of Political Economy, he writes:

“Mandatory reporting mechanisms,” the authors concluded, “inevitably give providers the incentive to decline to treat more difficult and complicated patients.” Surveys of cardiac surgeons in The New England Journal of Medicine and elsewhere [The Canadian Journal of Cardiology] have confirmed these findings. And studies from 2005 and 2013 have shown that report cards on interventional cardiologists who perform angioplasty procedures are having similar results.

Surgical report cards are a classic example of how a well-meaning program in medicine can have unintended consequences. …

In other words, doctors avoid operating on high-risk patients in order to pump up their scores on the report cards, which are created by non-doctors and made available to the public so people can choose the doctor they think will best meet their needs.

It must be said that neither the public nor the creators of these report cards know the first thing about angioplasty or any other cardiac procedure. But, in fairness to the general public who loves a good report card about anything and everything, the ratings may have the effect, good or bad, of preventing unnecessary or hopeless surgeries near the end of life.

Cardiac surgeons like Dr Jauhar want to do everything they can to save lives where possible, but surgeries have a cost, especially those performed under hopeless conditions with several comorbidity factors, such as diabetes, kidney failure, and others.

In our schools—and I couldn’t help hearing Dr Jauhar talk about something closer to my own world—there are also a myriad of factors analogous to kidney failure in cardiac patients: poverty, a poor family life, hunger or food insecurity, violence at home or in the neighborhood, and the list goes on and on. Just as the presence of kidney failure makes it less likely a cardiac surgeon will perform an angioplasty, so do poverty, a learning disability, behavioral or discipline problems in a child make it less likely teachers whose jobs depend on student outcomes will teach those children or want to accept them into their classrooms.

This leads to an inevitable if unconscionable picture in which schools and teachers turn students away so their scores don’t count against them. And the people who compile those teacher evaluation systems know less about educating a real child than the insurance adjusters and news magazines know about cardiac surgery, which isn’t very much to begin with.

It will also tend to produce mediocre teachers and mediocre kids, instead of accomplishing the same averages with high-performing and low-performing students. In medicine, people die, but in education, kids come out mediocre and apathetic. The world today is not the place for mediocrity. Brilliant flames should not be put out by a bureaucrat who needs to assign a letter grade. Education is not some scientifically controlled field; it is, rather, an artistic endeavor not susceptible to some statistical measurements we have invented and imposed on the discipline.

Paul Katula is the executive editor of the Voxitatis Research Foundation, which publishes this blog. For more information, see the About page.

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