ICU Doctors’ Ability to Save Lives Vary Wildly
They fought for glory with secret calculations. The outcome is rattling the establishment.
STORY AT-A-GLANCE
Research by Dr. Pierre Kory highlights significant variability in ICU doctors’ life-saving skills, challenging traditional metrics like reputation and academic achievements, which often do not correlate with patient outcomes
APACHE scores objectively assess doctors’ performance, revealing that lower observed/expected mortality ratios indicate better life-saving abilities, emphasizing the importance of early and accurate diagnosis
Findings show that ICU doctors who rely less on extensive diagnostic tests and more on bedside diagnostic skills, such as ultrasound, provide equally effective care, questioning the necessity of resource-intensive practices
Research suggests that overuse of medical resources, such as CT scans and echocardiograms, does not necessarily lead to better patient outcomes, advocating for a more minimalist approach in ICU care
Kory’s method of evaluating ICU doctors’ skills offers a new perspective on assessing medical professionals, focusing on empirical evidence to improve patient survival rates and health care quality
In the United States, ICU (intensive care unit) mortality rates range between 8% and 25% depending on various factors,1 such as patient demographics and where the facility is located. These numbers illustrate a critical issue — the survival chances of ICU patients plainly depend on where and how they are treated.
ICU doctors, or intensivists, are at the forefront of these life-and-death situations. Their expertise in advanced life support techniques and sophisticated medical technology is essential for patient survival. For example, administering early mobilization therapy2 is crucial for improving survival rates.
But how can patients assess the ability of their doctors in a hospital setting? Dr. Pierre Kory performed a study using this hypothesis as a guide to help patients get the best care possible.
Assessing ICU Doctors’ Life-Saving Skills — A New Perspective
In Kory’s study, which was posted on his Substack page,3 he explains that doctors should be given a rating similar to NFL (National Football League) quarterbacks. Just as these athletes are rated on their performance using certain criteria, Kory developed a method to assess the life-saving skills of ICU specialists. For background, "the best doctors" are normally measured with imperfect metrics such as:
Reputation — Word of mouth recommendations, which medical school they came from and number of years in practice
Certification — The different specialty certifications a doctor has, etc.
Malpractice history — If they’ve been sued by a previous patient
Post-op wound infection rates — According to Kory, "this is probably the only truly statistical metric you can judge doctors by"
Patient complaints — How many patients have lodged complaints against a particular doctor
Geography and insurance/schedule availability — Some patients will choose the most convenient option for them
To create an objective method for evaluating doctors, Kory’s study used the APACHE (Acute Physiology, Age, Chronic Health Evaluation) score, which predicts patient mortality risk and identifies who is the most effective clinician.
The underlying causes of variability in ICU doctors’ skills are multifaceted. Factors such as the ability to make early and accurate diagnoses, the reliance on bedside diagnostic skills, and the use of advanced techniques like ultrasound play significant roles. Kory’s expertise in ultrasound, for instance, allowed him to reduce the need for additional tests. This approach not only saves resources but also minimizes time wasted, which is important when caring for ICU patients.
Understanding how these factors contribute to patient outcomes is crucial. When doctors rely heavily on extensive testing, it could indicate uncertainty or a lack of confidence in their diagnostic abilities. Conversely, those who use fewer resources, like Kory, often demonstrate a higher level of expertise and efficiency. This is key to improving survival rates, as timely and accurate interventions are essential in critical care settings.
A Revolutionary Way to Analyze an ICU Doctor’s Performance
Before moving further, note that Kory’s study is a personal investigation published on his Substack page. The reason for not publishing this in a medical journal was the fear of generating "discord and controversy (and maybe even embarrassment) amongst the ICU team" that he was leading at the time. Having established the background, he noted a startling variation in the ability of ICU doctors to save lives.4
The study focused on patients admitted to the ICU under the care of this team of doctors previously headed by Kory. By closely monitoring how each physician utilized diagnostic tests and interventions, the research highlighted significant differences in their approaches and effectiveness.5
Again, Kory, being a big football fan, envisioned a system where doctors are evaluated similarly to NFL quarterbacks, assigning each clinician a ‘Quarterback Rating’ (QBR) based on their performance.6 This analogy underscores the substantial disparities in skill levels that exist among ICU specialists.
Disregarding the six "traditional" metrics used to evaluate doctors, Kory employed the APACHE score, a tool used to predict a patient’s risk of dying based on various health indicators.7
By calculating the observed mortality rate of patients for each doctor and comparing it to the expected rate, Kory developed an observed/expected (O/E) mortality ratio.8 Essentially, a lower O/E ratio indicates a better-skilled ICU doctor, while a higher ratio pointed to poorer performance.9
Kory discovered that many of his colleagues were overusing interventions such as invasive catheters, leading to unnecessary procedures that did not improve patient outcomes.10 This excessive use of resources not only increased costs but also indicated a lack of confidence in diagnostic abilities.11
To perform the statistical analysis, Kory used an advanced software called QlikView, which allowed Kory to evaluate the number of tests each doctor ordered, as well as the number of times they consulted other specialists.12 This data-driven approach showed the big picture of each doctor’s abilities, revealing significant variability in their practices.13
Ultimately, Kory’s aim is to challenge the status quo, advocating for a shift towards metrics that genuinely reflect clinical performance and patient outcomes. Such changes will lead to enhanced quality of care and better outcomes for patients.14
Variations in ICU Resource Usage Impacts Patient Survival
The research focused on 17 ICU doctors, each represented by a letter to keep their identities anonymous. Over an 18-month period, each doctor managed an average of 130 patients. The study aimed to understand whether the frequency of ordering tests and consultations influenced the likelihood of patients being discharged alive from the ICU. The results are shown in the table below:
The findings revealed a shocking disparity in resource usage. For instance, Doctor G ordered 19 times as many tests as the least active doctor, Doctor E (which was Kory), who was the lowest in ordering CT scans.15 Surprisingly, this high level of resource use did not correlate with better patient outcomes. In fact, Doctor I, who ordered almost twice as many chest CT scans as the next ranked doctor, was the lowest in terms of discharging patients alive from the ICU.16
Conversely, doctors who adopted a more minimalist approach, using fewer tests and relying on bedside diagnostics like ultrasound, saw better patient survival rates.17 These doctors were able to initiate the correct therapies earlier in the disease process, directly impacting patient recovery positively. For example, Doctor C, the most resource-intensive doctor, used approximately double the resources compared to Doctor E, yet the outcomes did not favor higher resource use.18
"Minimalist" doctors, in Kory’s words, were given a higher score for their conservative approach, and fared better in saving lives. In other words, a higher volume of testing is not equivalent to better care. Conversely, efficient use of resources, focusing on essential diagnostics, enhances patient survival. For the overall scores, see the table below:
As seen in the image above, a minimalist approach to resource use in the ICU, characterized by fewer diagnostic tests and consultations between specialists, leads to better patient outcomes. Overuse of medical resources does not enhance survival rates and may, in some cases, impede timely and effective treatment. According to Kory, contributing reasons include increased radiation exposure to the patient, as well as risks of transporting them within the hospital premises.
Practical Steps to Protect Your Health in a Hospital Setting
While asking for a rank of the best doctors in a hospital is impractical, there are still ways for you to take control of your health in a clinical or inpatient setting to reduce the resources (thus, financial expenses) used. By actively participating in your health decisions, you’re empowering yourself to advocate for the treatments that are truly beneficial for your well-being. Some of my recommendations include:
Choose health care providers who listen and embrace a holistic approach — If you are seeking medical care, prioritize finding health care professionals who listen attentively to your concerns and consider the whole picture of your health.
A doctor who adopts a holistic view will evaluate all aspects of your well-being, rather than focusing solely on isolated symptoms or conditions. They will also develop customized, comprehensive treatment plans. This holistic approach will lead to more accurate diagnoses and effective treatment plans tailored to your current health profile.
Create a "Caregivers and Consent" document — I strongly recommend drafting a "Caregivers and Consent" document to outline your health care preferences and decisions clearly. This document serves as a guide for your receiving medical team and loved ones, ensuring that your wishes are respected, especially during critical moments.
Templates for this document have been created by Laura Bartlett and Greta Crawford of ProtocolKills.com. They developed the documents in response to the medical mistreatment experienced by patients during the COVID-19 pandemic. Having this document in place provides peace of mind and clarity in high-pressure situations. The template is available at the Patients Documents page. Other documents are available for the Medical Power of Attorney.19
Take an active role in managing your health — Staying informed about your health status and actively participating in your treatment will significantly impact your outcomes. Regularly monitor your health biomarkers, ask questions to your doctor and stay committed to your treatment plan. By doing so, you’re effectively collaborating with your health care providers, allowing you to adjust your approach as needed to ensure optimal recovery.
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