In the United States, intensive care unit (ICU) mortality rates range from 8% to 25%, depending on a variety of factors.1 Patient demographics, facility location, etc. These numbers highlight an important problem. An ICU patient’s chances of survival clearly depend on where and how they are treated.
ICU doctors, or critical care doctors, are on the front lines of these life-or-death situations. Expertise in advanced life support and sophisticated medical techniques is essential to patient survival. For example, when administering early activation therapy2 This is very important in improving survival rates.
But how can patients evaluate a doctor’s competency in a hospital setting? Dr. Pierre Kory conducted research using this hypothesis as a guide to help patients receive the best possible care.
Assessing ICU physicians’ life-saving skills—a new perspective
From Kory’s research posted on the Substack page:3 He explains that doctors should be given similar ratings to National Football League (NFL) quarterbacks. Just as these athletes use specific criteria to evaluate their performance, Kory developed a method to evaluate the life-saving skills of ICU professionals. For background, “best doctors” are typically measured by imperfect metrics such as:
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Reputation – Recommendation through word of mouth, which medical school you graduated from, and years of work experience. |
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certification – Various professional qualifications held by doctors, etc. |
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History of Cheating — If you are sued by a former patient |
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Post-operative wound infection rate — According to Kory, “This is probably the only statistical measure by which we can judge doctors.” |
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Patient Complaints — Number of patients who have filed complaints against a particular doctor |
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Geography and Insurance/Schedule Availability — Some patients choose the option that is most convenient for them. |
To create an objective way to evaluate doctors, Kory’s study used the Acute Physiology, Age, and Chronic Health Evaluation (APACHE) score, which predicts a patient’s risk of death and identifies which clinicians are the most effective.
The underlying reasons for variation in ICU physician skills are varied. Factors such as the ability to make an early and accurate diagnosis, reliance on bedside diagnostic techniques, and the use of advanced technologies such as ultrasound play an important role. For example, Kory’s expertise in ultrasound helped reduce the need for additional testing. This approach not only saves resources but also minimizes wasted time, which is important when caring for ICU patients.
It is important to understand how these factors contribute to patient outcomes. If a doctor relies heavily on extensive testing, this may indicate uncertainty or lack of confidence in their diagnostic abilities. Conversely, those who use fewer resources, like Kory, often demonstrate higher levels of professionalism and efficiency. This is important to improve survival because timely and accurate intervention is essential in critical care settings.
An innovative way to analyze ICU physician performance
Before we go any further, please note that Kory’s research is personal research posted on his Substack page. The reason he did not publish this in a medical journal was because he was afraid that it might cause discord and controversy (and perhaps even embarrassment) among the intensive care unit team he was leading at the time. After establishing the background, he noted the remarkable changes in the life-saving abilities of ICU doctors.4
The study focused on patients admitted to the ICU under the care of a team of doctors previously led by Kory. By closely monitoring how each doctor utilized diagnostic tests and interventions, the study highlighted significant differences in approach and effectiveness.5
Kory, again an avid football fan, envisioned a system in which doctors would be evaluated similarly to NFL quarterbacks, assigning a ‘quarterback rating’ (QBR) based on each clinician’s performance.6 This analogy highlights the significant differences in skill levels that exist among ICU professionals.
Ignoring the six “traditional” indicators used to evaluate doctors, Kory used the APACHE score, a tool used to predict a patient’s risk of death based on a variety of health indicators.7
Kory developed observed/expected (O/E) mortality rates by calculating each physician’s observed patient mortality rate and comparing it to the expected mortality rate.8 Essentially, a lower O/E ratio means a more skilled ICU physician, while a higher ratio means lower performance.9
Kory found that many of his colleagues were overusing interventions such as invasive catheters, resulting in unnecessary procedures that did not improve patient outcomes.10 Excessive use of these resources not only increases costs but also indicates a lack of confidence in diagnostic abilities.11
To perform statistical analysis, Kory used advanced software called QlikView. This allowed Kory to assess how many tests each doctor ordered and how often they consulted with other specialists.12 This data-driven approach gave us a big picture of each doctor’s abilities and revealed significant variability in their practice.13
Ultimately, Kory’s goal is to challenge the status quo and advocate for a shift toward metrics that truly reflect clinical performance and patient outcomes. These changes will improve the quality of care and lead to better outcomes for patients.14
Changes in ICU resource use impact patient survival
The study focused on 17 ICU doctors, each of whom was identified by letter to keep their identity anonymous. Over an 18-month period, each physician managed an average of 130 patients. This study aimed to understand whether the frequency of testing and consultation orders influences the likelihood of a patient being discharged from the intensive care unit alive. The results are shown in the table below.
Our findings revealed shocking differences in resource usage. For example, Dr. G ordered 19 times as many tests as Dr. E (Cory), the least active physician who ordered the fewest CT scans.15 Surprisingly, these higher levels of resource use did not correlate with better patient outcomes. In fact, the first doctor, who ordered nearly twice as many chest CT scans as the second-place doctor, had the lowest rate of discharging alive patients from the intensive care unit.16
Conversely, doctors who adopted a more minimalist approach, using fewer tests and relying on bedside diagnostics such as ultrasound, had higher patient survival rates.17 These doctors were able to start the right treatment early in the disease process and had a direct impact on patient recovery. For example, the most resource-intensive physician, Physician C, used approximately twice as many resources as Physician E, but the results did not favor higher resource use.18
“Minimalist” doctors, Kory said, scored higher on conservative approaches and performed better at saving lives. In other words, more testing does not equal better treatment. Conversely, focusing on essential diagnoses and using resources efficiently improves patient survival. See the table below for overall scores.
As seen in the image above, a minimalist approach to resource use in the ICU, with fewer diagnostic tests and fewer interspecialty consultations, leads to better patient outcomes. Overuse of medical resources does not increase survival rates and, in some cases, can prevent timely and effective treatment. According to Kory, causes include increased radiation exposure to patients and the risk of transport within the hospital.
Practical steps to protect your health in a hospital environment
Although it is unrealistic to require hospitals to rank the best doctors, there are still ways to manage health in a clinical or inpatient setting to reduce the resources used (i.e., financial costs). Being an active participant in your health decisions gives you the power to advocate for treatments that truly benefit your well-being. Some of my recommendations are:
1. Choose a health care provider who listens and embraces a holistic approach. If you are seeking medical care, it is a priority to find a health care professional who listens carefully to your concerns and considers your entire health.
A doctor who adopts a holistic perspective will evaluate all aspects of your well-being rather than focusing only on individual symptoms or conditions. We will also develop a personalized comprehensive treatment plan. This holistic approach allows us to develop a more accurate diagnosis and effective treatment plan tailored to your current health profile.
2. Create a “Caregiver and Consent” document — We strongly recommend that you draft a “Caregiver and Consent” document to clearly explain your health care preferences and decisions. This document serves as a guide for the medical team and family receiving you and ensures that your wishes are respected, especially at critical moments.
The template for this article was created by Laura Bartlett and Greta Crawford of ProtocolKills.com. They developed the document in response to medical abuse suffered by patients during the COVID-19 pandemic. Preparing this document can give you peace of mind and clarity in high-pressure situations. Templates are available on the Patient Documentation page. Other documents for health care power of attorney are also available.19
3. Take an active role in your health — Staying informed about your health condition and taking an active part in your treatment will have a big impact on your outcomes. Monitor your health biomarkers regularly, ask your doctor questions, and stay committed to your treatment plan. Doing so will allow you to work effectively with your health care provider to adjust your approach as needed to ensure optimal recovery.
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