"The check is in the mail."
"I'll still respect you in the morning."
"I'm from the government, and I'm here to help you."
"I'm from academia, and I'm here to clarify things."
And many in the medical world have now added:
"Our patients are sicker."
The last Lake-Wobegon-inspired one occurs when you present a hospital leader or a doctor with risk-adjusted data showing that their record on quality and safety is below that of other places. (An accompanying phrase is often, "I don't believe the data.")
A study from the Annals of Surgery a few years ago (Volume 250, Number 6, December 2009) refutes this view of the world. A friend summarizes:
Some people thought that hospitals with higher mortality rates had higher complication rates, but that seems not to be the driving factor behind increased mortality, at least according to this study. Using the Medicare database, this group found that the risk of complications such as pneumonia, MI, hemorrhage, etc. after high risk surgery was only slightly different (36.4% vs. 32.7%) between high and low mortality hospitals; however, the risk of dying from a complication once it occurred (i.e. failure to rescue) was much worse in the worst performing hospitals compared to the best (16.7% vs. 6.8%). This failure to rescue was in fact the major contributor to the 2.5 fold increase in risk-adjusted mortality at the worst performing hospitals compared to the best (8% vs. 3%).
The authors concluded that high mortality hospitals are "not as good at recognition and management of complications once they occur." Although data on what makes a hospital good at patient rescue is limited, much of it may be related to trigger systems, teamwork, nursing culture and availability of certain services as they outlined in their interesting discussion.
In summary, the way work is organized in a hospital and a culture of communication and respect matter, even if "your patients are sicker."