The Bell Curve and the Virtue of Fidelity

Recently, I have been reflecting upon the work of Atul Gawande.  Gawande is a physician by training, but is also the well-known author of The Checklist Manifesto and Complications, both which deal primarily with topics and trends in medicine.   In 2004, Gawande published an important article, “The Bell Curve”, in the New Yorker.  While educators and researchers in the social sciences often use the term “bell curve” the term is used less frequently by physicians or those in the medical field.    Gawande’s observations and findings cut across disciplines, however, and are just as applicable to the world of education as they are to medicine.

In “The Bell Curve”, Gawande describes the medical community’s efforts to successfully treat cystic fibrosis, a genetic disease which thickens the body’s secretions and slowly fills the lung’s airways with hardened mucous, leaving those afflicted with severely reduced lung capacity – effectively smothering the ill from the inside out.  In 1966, the average life expectancy for a child with cystic fibrosis was 10 years.  Fortunately, we have made great strides over the last few decades; continuing research and enhanced treatment methods have increased life expectancy to 33 years.

Still, each year about 1,000 American children are diagnosed with the disease and there are now 117 treatment centers in our country.   To qualify as a treatment center, each center must undergo rigorous certification, follow the same standardized guidelines for treatment, and become ultra-specialized.  Each center must implement the same specialized treatment protocol.

Based on the fact that cystic fibrosis is a genetic disease and that all treatment centers are certified and follow same treatment protocols, one would surmise that most of the treatment centers have the same success rate in treating the disease.  Said differently, one would not expect average life expectancy to differ significantly across treatment centers.  That assumption is incorrect.  And I was stunned to learn that, in terms of average life expectancy, the success of the treatment centers is represented as a bell shaped curve.

How can that be?  How can a genetic disease that has a standardized treatment protocol have a health care outcome that looks like a bell shaped curve?    As the article makes clear, success is a product of aggressive implementation, or what I would label “treatment fidelity”.  The best performing centers did not passively implement the treatment protocols.  Instead, they were maniacally focused on implementing each and every component of the treatment, aiming at 100% fidelity in each and every visit with each patient.  Site visits revealed that success takes more than the knowledge and skills to succeed.  As Gawande makes distressingly clear, “even doctors with great knowledge and technical skills can have mediocre results”.

Now think of the profound implications the treatment of cystic fibrosis has for education.  If a genetic disease that has an agreed upon treatment protocol and is delivered by 117 certified treatment centers is subject to a bell shape distribution due to “fidelity of treatment”, then is it any wonder that we have uneven outcomes in reading and math achievement  across the 100,000+ schools around the US?   Like the treatment of cystic fibrosis, when it comes to the teaching of reading and math skills it is not a matter of how we do it, but how well we do it.  Passionate and unwavering fidelity of treatment would be a big step in ensuring that students continue to climb the ladder toward college and career readiness.  Lessons, like those found in ‘The Bell Curve’, resonate as we look toward education policy and should shape how we think about the educational outcomes across schools, districts, and states.