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Agressive treatment, agressive teaching

Atul Gawande wrote an interesting article in the New Yorker a couple months ago on the varying effectiveness of medical centers around the U.S. in treating cystic fibrosis (CF), a genetic disease that reduces lung functioning in children. Apparently, the basic treatment is the same everywhere–keep the kid’s lungs as clear as possible, from an early age–but some hospitals are much better at it than others: “In 2003, life expectancy with CF had risen to thirty-three years nationally, but at the best center it was more than forty-seven.”

I’ll discuss the article and give a long quote from it, then give my thoughts.

Agressive doctors

Gawande goes to an average-performing center (in Cincinnati) and the nuber-one center (in Minneapolis) and inteviews and observes people at both places. The difference, at least in how he reports it, is that in the top center the doctors are super-agressive and really involved with each patient, getting to know them individually and figuring out what it takes to get them on the treatment:

The director of Fairview-University Children’s Hospital’s cystic-fibrosis center for almost forty years has been none other than Warren Warwick, the pediatrician who had conducted the study of LeRoy Matthews’s suspiciously high success rate. Ever since then, Warwick has made a study of what it takes to do better than everyone else. The secret, he insists, is simple, and he learned it from Matthews: you do whatever you can to keep your patients’ lungs as open as possible. Patients with CF at Fairview got the same things that patients everywhere did–some nebulized treatments to loosen secretions and unclog passageways (a kind of mist tent in a mouth pipe), antibiotics, and a good thumping on their chests every day. Yet, somehow, everything he did was different.

In the clinic one afternoon, I joined him as he saw a seventeen-year-old high-school senior named Janelle, who had been diagnosed with CF at the age of six and had been under his care ever since. She had come for her routine three-month checkup. She wore dyed-black hair to her shoulder blades, black Avril Lavigne eyeliner, four earrings in each ear, two more in an eyebrow, and a stud in her tongue. Warwick is seventy-six years old, tall, stooped, and frumpy-looking, with a well-worn tweed jacket, liver spots dotting his skin, wispy gray hair–by all appearances, a doddering, mid-century academic. He stood in front of Janelle for a moment, hands on his hips, looking her over, and then he said, “So, Janelle, what have you been doing to make us the best CF program in the country?”

“It’s not easy, you know,” she said.

They bantered. She was doing fine. School was going well. Warwick pulled out her latest lung-function measurements. There’d been a slight dip, as there was with Alyssa. Three months earlier, Janelle had been at a hundred and nine per cent (she was actually doing better than normal); now she was at around ninety per cent. Ninety per cent was still pretty good, and some ups and downs in the numbers are to be expected. But this was not the way Warwick saw the results.

He knitted his eyebrows. “Why did they go down?” he asked.

Janelle shrugged.

Any cough lately? No. Colds? No. Fevers? No. Was she sure she’d been taking her treatments regularly? Yes, of course. Every day? Yes. Did she ever miss treatments? Sure. Everyone does once in a while. How often is once in a while?

Then, slowly, Warwick got a different story out of her: in the past few months, it turned out, she’d barely been taking her treatments at all.

He pressed on. “Why aren’t you taking your treatments?” He appeared neither surprised nor angry. He seemed genuinely curious, as if he’d never run across this interesting situation before.

“I don’t know.”

He kept pushing. “What keeps you from doing your treatments?”

“I don’t know.”

“Up here”–he pointed at his own head–“what’s going on?”

“I don’t know,” she said.

He paused for a moment. And then he began speaking to me, taking a new tack. “The thing about patients with CF is that they’re good scientists,” he said. “They always experiment. We have to help them interpret what they experience as they experiment. So they stop doing their treatments. And what happens? They don’t get sick. Therefore, they conclude, Dr. Warwick is nuts.”

“Let’s look at the numbers,” he said to me, ignoring Janelle. He went to a little blackboard he had on the wall. It appeared to be well used. “A person’s daily risk of getting a bad lung illness with CF is 0.5 per cent.” He wrote the number down. Janelle rolled her eyes. She began tapping her foot. “The daily risk of getting a bad lung illness with CF plus treatment is 0.05 per cent,” he went on, and he wrote that number down. “So when you experiment you’re looking at the difference between a 99.95-per-cent chance of staying well and a 99.5-per-cent chance of staying well. Seems hardly any difference, right? On any given day, you have basically a one-hundred-per-cent chance of being well. But”–he paused and took a step toward me–“it is a big difference.” He chalked out the calculations. “Sum it up over a year, and it is the difference between an eighty-three-per-cent chance of making it through 2004 without getting sick and only a sixteen-per-cent chance.”

He turned to Janelle. “How do you stay well all your life? How do you become a geriatric patient?” he asked her. Her foot finally stopped tapping. “I can’t promise you anything. I can only tell you the odds.”

In this short speech was the core of Warwick’s world view. He believed that excellence came from seeing, on a daily basis, the difference between being 99.5-per-cent successful and being 99.95-per-cent successful. Many activities are like that, of course: catching fly balls, manufacturing microchips, delivering overnight packages. Medicine’s only distinction is that lives are lost in those slim margins.

And so he went to work on finding that margin for Janelle. Eventually, he figured out that she had a new boyfriend. She had a new job, too, and was working nights. The boyfriend had his own apartment, and she was either there or at a friend’s house most of the time, so she rarely made it home to take her treatments. At school, new rules required her to go to the school nurse for each dose of medicine during the day. So she skipped going. “It’s such a pain,” she said. He learned that there were some medicines she took and some she didn’t. One she took because it was the only thing that she felt actually made a difference. She took her vitamins, too. (“Why your vitamins?” “Because they’re cool.”) The rest she ignored.

Warwick proposed a deal. Janelle would go home for a breathing treatment every day after school, and get her best friend to hold her to it. She’d also keep key medications in her bag or her pocket at school and take them on her own. (“The nurse won’t let me.” “Don’t tell her,” he said, and deftly turned taking care of herself into an act of rebellion.) So far, Janelle was O.K. with this. But there was one other thing, he said: she’d have to come to the hospital for a few days of therapy to recover the lost ground. She stared at him.

“Today?”

“Yes, today.”

“How about tomorrow?”

“We’ve failed, Janelle,” he said. “It’s important to acknowledge when we’ve failed.”

With that, she began to cry.

Warwick’s combination of focus, aggressiveness, and inventiveness is what makes him extraordinary. He thinks hard about his patients, he pushes them, and he does not hesitate to improvise. Twenty years ago, while he was listening to a church choir and mulling over how he might examine his patients better, he came up with a new stethoscope–a stereo-stethoscope, he calls it. It has two bells dangling from it, and, because of a built-in sound delay, transmits lung sounds in stereo. He had an engineer make it for him. Listening to Janelle with the instrument, he put one bell on the right side of her chest and the other on her left side, and insisted that he could systematically localize how individual lobes of her lungs sounded.

He invented a new cough. It wasn’t enough that his patients actively cough up their sputum. He wanted a deeper, better cough, and later, in his office, Warwick made another patient practice his cough. The patient stretched his arms upward, yawned, pinched his nose, bent down as far as he could, let the pressure build up, and then, straightening, blasted everything out. (“Again!” Warwick encouraged him. “Harder!”)

He produced his most far-reaching invention almost two decades ago–a mechanized, chest-thumping vest for patients to wear. The chief difficulty for people with CF is sticking with the laborious daily regimen of care, particularly the manual chest therapy. It requires another person’s help. It requires conscientiousness, making sure to bang on each of the fourteen locations on a patient’s chest. And it requires consistency, doing this twice a day, every day, year after year. Warwick had become fascinated by studies showing that inflating and deflating a blood-pressure cuff around a dog’s chest could mobilize its lung secretions, and in the mid-nineteen-eighties he created what is now known as the Vest. It looks like a black flak jacket with two vacuum hoses coming out of the sides. These are hooked up to a compressor that shoots quick blasts of air in and out of the vest at high frequencies. (I talked to a patient while he had one of these on. He vibrated like a car on a back road.) Studies eventually showed that Warwick’s device was at least as effective as manual chest therapy, and was used far more consistently. Today, forty-five thousand patients with CF and other lung diseases use the technology.

Like most medical clinics, the Minnesota Cystic Fibrosis Center has several physicians and many more staff members. Warwick established a weekly meeting to review everyone’s care for their patients, and he insists on a degree of uniformity that clinicians usually find intolerable. Some chafe. He can have, as one of the doctors put it, “somewhat of an absence of, um, collegial respect for different care plans.” And although he stepped down as director of the center in 1999, to let a protege, Carlos Milla, take over, he remains its guiding spirit. He and his colleagues aren’t content if their patients’ lung function is eighty per cent of normal, or even ninety per cent. They aim for a hundred per cent–or better. Almost ten per cent of the children at his center get supplemental feedings through a latex tube surgically inserted into their stomachs, simply because, by Warwick’s standards, they were not gaining enough weight. There’s no published research showing that you need to do this. But not a single child or teen-ager at the center has died in years. Its oldest patient is now sixty-four.

My thoughts as a statistician

As a statistician, I wonder: could we measure this agressive approach to treatment? That is, not just measure the overall effectiveness (higher life expectancy, better lung functioning, and so forth), but also have a measure of “agressiveness” and see if it correlates with the objective outcome measures. Would this approach work in other hospitals and for other diseases, and if so, how could it be encouraged?

My thoughts as a teacher

As a teacher, I wonder if this agressive strategy could be used for teaching. The number-one challenge for me is getting students to work on their homeworks. Would a serious, all-out attack, pressing students every week on what they know and don’t know, do the job? Would it be an effective tool for someone like me, who knows the material but can’t always motivate students to take that extra step to learn it themselves? Right now, we’re just satistfied with mediocrity in our teaching, and that doesn’t make me happy.

Maybe such teaching practices are out there already and I’m not aware of them. In writing my book about statistics teaching, I read about a lot of studies demonstrating the effectiveness of student-focused teaching. My guess is that, to start with, one would have to have a clearly-defined syllabus, with similar exams and expectations every year. Right now, it can be hard for us to motivate students partly because we don’t know ourselves exactly what will be on the final exam.

Anyway, I’d be interested in doing this, at least with one of my classes, but I think I’d need some help getting it to work. Probably the same is true of the doctors and the medical therapies.

3 Comments

  1. John Pinkerton says:

    We have a kid with CF and so I read the New Yorker article with interest. Your connecting it to school reminded me of another story:

    I had a high school calculus teacher who on the second day gave us a pop quiz. The problems were from the prior night's homework. The next day, he did the same thing. Of course, we quickly caught on that there would be a test every day, and if we did all the homework, it would be easy.

    After about 3 months, the quizes stopped. But, it never occured to me to stop doing all the homework each night.

    This made a huge difference, as math is a subject that builds. If you learn each part thoroughly, the next is much easier.

    I'd say the teacher was the best I ever had. He later won Tulsa's teacher of the year award. As further evidence of the method's success, at my college (Princeton), it was pretty clear I'd learned calculus better than nearly all the other freshmen. Let me know how it turns out if you try something like this.

  2. Boris S. says:

    This was a fantastic article in the New Yorker. I loved reading it, and now I'm reminded again of it.

    I wonder about the disjuncture between the aggressive approacha and teaching. Patients with CF and their parents have very high-powered incentives to stay with a program, even if it's uncomfortable and annoying.

    But many students don't have similarly high-powered incentives. So they might not be responsive (eg, they'll be angry and get their parents to call) to an aggressive teaching strategy.

    Consider undergrads fulfilling some course requirement. If they are the types to abhor less-than-superior grades, they will work hard, as will those who genuinely love the subject matter. But many will be content to slide by, knowing that the worst they can get in our grade-inflated world is a B, and more likely an B+ or A- if they do just a modicum of work.

    So maybe the answer to making an aggressive teaching strategy work is to make incentives stronger, by reducing grade inflation.

  3. Leon Harris says:

    Wednesday, May 04, 2005: day # 10: 80% complete.

    Dr. Warren Warwick

    I am interested in understanding, reviewing, and mastering the individual calculations that you use to convert both the 99.95% probability daily

    treatment into 83% annual probability of staying well: and the 99.5% into the 16%.

    Your guidance and help is very much appreciated.

    leonisraelharris@yahoo.com

    Thank you, Leon Harris

    Dr. Warwick,

    I am also interested in experimenting with your C.F. vest.

    My background:

    age 75. Quad bypass heart surgery Nov 18, 2004.

    plus aortic valve plus pacemaker. never smoked. breathing weak….getting better.

    stiffness in right hand fingers. water in foot below ankle.

    I have a hunch the vest may shake up and bring lung cells to regain their ability to become aerobic. I'd like to try it.

    What's your opinion?

    What do you suggest?

    Where could I get access to a vest?

    Your help would be appreciated.

    Leon Harris

    leonisraelharris@yahoo.com