Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

The Bell Curve


The difference between a 99.5% and 99.95% success rate isn't necessarily in knowledge or training, but in physician attitudes towards adapting and changing to evolving information.

Recent news about Atul Gawande being named CEO of the new health venture created by Amazon, JPMorgan Chase, and Berkshire Hathaway led me to reflect on some of his past writings. In particular, there’s a chapter from his 2007 book Better called “The Bell Curve” that also recalls me to my focus on clinical excellence. A version of the chapter also appeared as a 2004 essay in the New Yorker, and the lessons of that chapter still resonate with me today.



While I encourage you to read Dr. Gawande’s words directly, the chapter discusses the importance of measuring outcomes in medicine and uses the story of cystic fibrosis outcomes as an example—by measuring and sharing outcomes such as mortality and lung function, we can learn as a system more about what best practices are, and can promulgate them through the medical community. In particular, the chapter shares the narratives of LeRoy Matthews and Warren Warwick—positive outliers whose own results over time have been at the upper boundary of the Bell Curve-distribution of observed outcomes.



A particularly compelling story focuses on how, at the level of a single patient who is struggling with reduction in lung function, was found not to be taking her medication regularly. Dr. Warwick emphasizes that avoiding infection with 99.5% daily success rate (without regular treatment) or 99.95% success rate (with daily treatment) may not seem like much. However, when you focus on the 0.5% versus the 0.05% chance of daily infection and extrapolate this over a year, it’s the difference between having only a 16% or an 83% chance to make it through the year without significant sickness.



What have I learned from this parable taken from Dr. Warwick’s cystic fibrosis experience, and how does it apply to CLOSLER’s mission of promoting clinic excellence?


1.) There’s a ‘bell curve’ in medical performance, even if doctors and patients don’t often like to acknowledge it.


2.) Looking for the ‘positive outliers’ can help us to model best care.


3.) Trying to move you and your care team from the middle of the curve to the positive ‘tail’ of the distribution requires constant self-evaluation and the stated desire not to settle for ‘good enough’ but to want to move towards ‘great.’


4.) The difference between 99.5 and 99.95 isn’t necessarily in knowledge or training, but in physician attitudes towards adapting and changing to evolving information.


5.) Moving the needle from 99.5 to 99.95 isn’t up to the physician alone—it’s a goal achieved together with patients. This in turn requires that the physician have a desire to connect with patients, to share with them that goal, and to work with them to get everyone invested in the same shared treatment plan.