Positive Deviance and Health Care
Jerry Sternin was a professor of nutrition at Tufts University who, with his wife, Monique, had spent much of his career trying to reduce hunger and starvation in the world. * For a while, he was the director of a Save the Children program to reduce malnutrition in poor Vietnamese villages. The usual method was to bring in outside experts to analyze the situation and then to bring in food and implement agricultural techniques from elsewhere.
The program, however, had itself become starved—of money. It couldn’t afford the usual approach. The Sternins had to find different solutions with the resources at hand.
So this is what they decided to do. They went to villages in trouble and got the villagers to help them identify who among them had the best-nourished children—who among them had demonstrated what Jerry Sternin termed a “positive deviance” from the norm. The villagers then visited those mothers at home to see exactly what they were doing.
Just that was revolutionary. The villagers discovered that there were well-nourished children among them, despite the poverty, and that those children’s mothers were breaking with the locally accepted wisdom in all sorts of ways—feeding their children even when they had diarrhea; giving them several small feedings each day rather than one or two big ones; adding sweet-potato greens to the children’s rice even though they were considered to be a low-class food. These ideas spread and took hold. The program measured the results and posted them in the villages for all to see. In two years, malnutrition dropped 65 to 85 percent in every village the Sternins had visited. Their program proved in fact more effective than those of the outside experts.
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I tell you this story because we are now that village.
More than that, though, we in medicine have partly contributed to these troubles. Our country’s health care is by far the most expensive in the world. It now consumes more than one of every six dollars we earn. The financial burden has damaged the global competitiveness of American businesses and bankrupted millions of families, even those with insurance. It’s also devouring our government at every level—squeezing out investments in education, infrastructure, energy development, our future.
Like the malnourished villagers, we are in trouble. As President Obama has said, “The greatest threat to America’s fiscal health is not Social Security, though that’s a significant challenge. It’s not the investments that we’ve made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation’s balance sheet is the skyrocketing cost of health care. It’s not even close.” The public doesn’t know what to do about it. The government doesn’t know. The insurance companies don’t know. There are health care experts who, during the course of the debate, have explained that a quarter of our higher costs are from having higherinsurance administration costs than other countries and higher physician and nurse pay, too. The vast majority of extra spending, however, is for the tests, procedures, specialist visits, and treatments we order for our patients. More than anything, the evidence shows, we simply do more expensive stuff for patients than any other country in the world.
So the country is now coming to us who do this work in medicine. And they are asking us, How do they get these costs under control? What can they do to change things for the better?
Health care is not practiced the same way across the country. Annual Medicare spending varies by more than double, for instance—from less than $6,000 per person in some cities to more than $12,000 per person in others. I visited a place recently where Medicare spends more on health care than the average person earns.
You would expect some variation based on labor and living costs and the health of the population. But as you look between cities of similar circumstances—between places like McAllen and El Paso, Texas, just a few hundred miles apart—you will still find up to two-fold cost differences. A recent study of New York and Los Angeles hospitals found that even within cities, Medicare’s costs for patients of identical life expectancy differ by as much as double, depending on which hospital and physicians they use.
Yet studies find that in high-cost places—where doctors order more frequent tests and procedures, more specialist visits, and more hospital admissions than the average—the patients do no better, whether measured in terms of survival, ability to function, or satisfaction with care. If anything, they seem to do worse.
Nothing in medicine is without risks, it turns out. Complications can arise from hospital stays, drugs, procedures, and tests, and when they are of marginal value, the harm can outweigh the benefit. To make matters worse, high-cost communities appear to do the low-cost, low-profit activities andservices—like providing preventive-care measures, hospice for the dying, and ready access to a primary-care doctor—less consistently for their patients. The patients get more stuff, but not necessarily more of what they need.
Fixing this problem can feel dishearteningly complex. Across the country, we have to change skewed incentives that reward quantity over quality and reward narrowly specialized individuals instead of teams that make sure nothing falls between the cracks for patients and that resources are not misused. But how do we do it?
Let us think about this problem the way Jerry Sternin thought about that starving village in Vietnam. Let us look for the positive deviants.
This is an approach we’re actually familiar with in medicine. In surgery, for instance, I know that there is more I can learn in mastering the operations I do. So what does a surgeon like me do? We look to those who are unusually successful—the positive deviants. We watch them operate and learn their tricks, the moves they make that we can take home.
Likewise, when it comes to medical costs and quality, we should look to our positive deviants. They are the low-cost, high-quality institutions like the Mayo Clinic; the Geisinger Health System in rural Pennsylvania; Intermountain Health Care in Salt Lake City. They are in low-cost, high-quality cities like Seattle, Washington; Durham, North Carolina; and Grand Junction, Colorado. Indeed, you can find positive deviants in pockets of most medical communities that are—right now—delivering higher value health care than everyone else.
We know too little about these positive deviants. We need an entire nationwide project to understand how they do what they do, how they make it possible to withstand incentives to either overtreat or undertreat, and spread those lessons elsewhere.
I have visited some of these places and met some of these doctors. And one of their lessons is that, although the solutions to our health-costproblems are hard, there are solutions. They lie in producing creative ways to ensure we serve our patients more than our revenues. And it seems that we in medicine are the ones who have to make this happen.
Here are some specifics I have observed. First, the positive deviants have found ways to resist the tendency built into every financial incentive in our system to see patients as a revenue stream. These are not the doctors who instruct their secretary to have patients calling with follow-up questions schedule an office visit because insurers don’t pay for phone calls. These are not the doctors who direct patients to their side-business doing Botox injections for cash or to the imaging center that they own. They do not focus, the way businesspeople do, on maximizing their high-margin work and minimizing their low-margin work.
Yet the positive deviants do not seem to ignore the money, either. Many physicians do, and I think I am one of them. We try to remain oblivious to the thousands of dollars flowing through our prescription pens. There’s nothing especially awful about that. We keep up with the latest technologies and medications in our specialty. We see our patients. We make our recommendations. We send out our bills. And, as long as the numbers come out all right at the end of each month, we put the money out of our minds. But we do not work to ensure that we and our local medical community are not overtreating or undertreating. We may be fine doctors. But we are not the positive deviants.
Instead, the positive deviants are the ones who pursue this work. And they seem to do so in small ways and large. They join with their colleagues to install electronic health records, look for ways to provide easier phone and e-mail access, or offer expanded hours. They hire an extra nurse to monitor diabetic patients more closely and to make sure that patients don’t miss their mammograms and pap smears or their cancer follow-up. They think about how to create the local structures and incentives to make better, safer, more appropriate care possible.
Along the way, you will sometimes feel worn down, your cynicism taking over. But resist. Look for those in your community who are making health care better, safer, and less costly. Pay attention to them. Learn how they do it. And join with them.
—Atul Gawande
Atul Gawande is a general surgeon at the Brigham and Women’s Hospital in Boston, staff writer for the New Yorker, and assistant professor at Harvard Medical School and the Harvard School of Public Health.