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119 Certain quantitative measures are valuable for a patient to consult. The number of cases a surgeon has performed often correlates with his or her expertise. This is because there is a “learning curve” in performing a certain procedure. Similarly, safety data can be very informative, like a hospital’s track record of serious complications; this has been shown accurate in assessing potentially preventable infections that occur when inserting a catheter into a vein. But beyond safety there is great difficulty in assessing “quality care” because of the complexity and severity of many clinical conditions. For example, a cardiologist who chooses to treat only those with mild heart disease will have better outcomes, and a better report card, than another who takes on the difficult, challenging cases. Such complex patients require more of a doctor’s time and incur significantly more costs. Indeed, a study from the Brigham and Women’s Hospital showed that some cardiologists in Boston were avoiding caring for very sick and complicated patients with heart disease because of fear that their report cards would look bad; see Frederick S. Resnic, Frederick G. P. Welt, “The public health hazards of risk avoidance associated with public reporting of risk-adjusted outcomes in coronary intervention,” Journal of the American College of Cardiology 53 (2009), pp. 825–830. And for similar findings in California, see Cheryl L. Damberg et al., “Taking stock of pay-for-performance: A candid assessment from the front lines,” Health Affairs 28 (2009), pp. 517–525. Cost is also a major factor in physician ratings: Cheaper care is often rated more highly. But a study of major California hospitals showed that the more money spent on a patient with heart failure, the more likely he or she was to survive: Michael K. Ong et al., “Looking forward, looking back: Assessing variations in hospital resource use and outcomes for elderly patients with heart failure,” Circulation Cardiovascular Quality and Outcomes 2 (2009), pp. 548–557.

121 The debate about radiation for Julie centered on issues of both quality of life and long-term survival. Before the advent of modern radiation techniques, radiation was routinely recommended for all women undergoing mastectomy who had cancer that had spread to the lymph nodes. Its use declined sharply following many reports of an adverse impact, both side effects with damage to the heart and unclear benefit with regard to survival. The risk to the heart has greatly reduced with ways to more accurately focus the beam and avoid damaging cardiac tissue. This then shifted the debate to how radiation may or may not help women like Julie Brody. Women at high risk for recurrent breast cancer often have the tumor recur locally, at the site of mastectomy and where the lymph nodes were excised. Women with such “local recurrence” not only suffer from the cancer growing on their chest, but also have a higher rate of metastasis appearing in bone, liver, and lung. A clinical trial in British Columbia of women at high risk for return of the breast cancer in the local area where the breast and lymph nodes were removed showed that there was a significant benefit in overall survival when radiation was given after mastectomy. We have seen how such data can be presented to look more impressive, like using a relative reduction in risk that can appear to be very large while in reality it is very minor. So let’s assess for results in detail, looking not at relative benefit but at absolute benefit. The absolute reduction in mortality was 11 percent in women with one to three positive nodes and 7 percent in those with more than four nodes: Joseph Ragaz et al., “Locoregional radiation therapy in patients with high-risk breast cancer receiving adjuvant chemotherapy: 20-year results of the British Columbia randomized trial,” JNCI 97 (2005), p. 116–126. Furthermore, a so-called meta-analysis from the Early Breast Cancer Trialists’ Collaborative Group looked