When I was 19 I was diagnosed with something called hydronephrosis. It's effect on my kidney function wasn't significant but my parents took me to see one of the most famous urologists (I think the hospital was in philadelphia) anyway. I don' remember the specifics but the doctor immediately recommended invasive surgery. My father then took me to another urologist he knew from a friend's recommendation. This doctor said that there was no reason to have surgery yet. The kidney with the hydronephrosis had something like 4% below utilization rate that was normal and that we should wait. We decided to follow the second doctors advice and do regular checkups every year and the problem actually just went away.
The most amazing thing about this experience was when we called 3 weeks in advance to cancel the appointment for surgery the nurse got angry with us and said something along the lines of "You actually dare to waste the doctor's time?". It was very surreal.
TLDR: Don't get pressured into getting surgery, go get second opinions.
Had the same thing happen when I broke my hand. The first doctor wanted to fill it with metal. A second opinion with a more conservative doctor caused me to avoid that surgery, and it healed just fine.
I encountered the same egregious attitude when cancelling the appointment. It made me realize all the more that it was a attempted money grab, with no real concern for my wellbeing.
It was quite the learning experience. I will now never not get a second opinion.
I've posted about this before - my wife is a highly specialized surgeon. This article really only scratches the surface of the issues with surgery around the US, as a software developer working in a pretty transparent and open industry I'm always horrified at how surgeons practice in the US. In my opinion the core of the problem is the lack of transparency in the entire system. There are just very few pressures for surgeons to really improve like they should have to. If, as a surgeon at a academic center, you want to just cruise along, no problem, you can just publish a few papers each year, be nice to patients, and you will be considered a leader in your field - even if you have terrible outcomes. There is little to no data out there to help patients objectively evaluate a surgeon, and to force surgeons to become better.
Speaking of things that I found strange - my wife was blown away at her current practice because for every operation they 'pair-surgeon' full time. This seemed very normal to me, but outside of surgeon training this is considered bizarre - when she tells other surgeons they ask her if it is something to do with billing! (it is not, they can't bill for the second surgeon). She loves it of course, it forces her to up her game and gives her someone she can bounce her thoughts off of during the surgery. I've asked her if she could go visit another surgeon in another facility somewhere and work along side them for a few days to learn, but because of the red-tape and state licensing, this is extremely difficult. The cross seeding of surgical expertise becomes glacially slow after your initial training in residency, you pretty much hope you were trained well and stumble along with a bit of help here and there.
Full transparency could have negative unintended consequences. For example, if surgeons knew their success rate were public, they would be incentivized to take easier cases. Who would take a difficult case if they knew it would constitute a bad mark on their record almost for sure?
Fundamentally, the issue is that it's impossible to observe for any given patient if that patient's outcome would have been better with a different surgeon. This is the same challenge we face with evaluating drugs: many more people who take aspirin survive than those who take anti-cancer drugs, but this likely reflects the kind of person who is taking each (people with headaches vs. people who have been diagnosed with cancer). To solve the problem there's no way around randomized trials. So, one idea would be to randomly assign patients to surgeons.
(Transparency might still be better on net, but important to keep these issues in mind.)
I really wish people would quit treating doctors as unquestionable authorities on health. Rather, they should be treated as consultants - expertise for hire - who should be able to give good answers to most questions, but should expect to have to defend their recommendations, and can sometimes be wrong.
Medical doctors are like auto-mechanics or, to make a more HN-relatable comparison, software engineers trying to debug a program. Except there's a little more schooling, a lot more rigor with boards examinations, and you don't really have the full source-code available to debug. Just like in any profession, you're going to have crappy auto-mechanics who'll just pull up the ODB-II code and perform patch-work without rigorous root-cause analysis, or have engineers who'll also perform similar patch-work to get it "good enough", you'll have the same hacks who make it through medical school. I'm with you 100% in that they're consultants offering their opinion, but I'll take your analogy a step further and say that some consultants are 27 year old kids fresh out of Wharton who can put together a pretty PowerPoint deck, and some consultants genuinely know their field.
> Despite often repeating the mantra “First, do no harm,” doctors have difficulty with doing less — even nothing. We find it hard to refrain from trying another drug, blood test, imaging study or surgery.
It's disappointing that the conflict-of-interest is not better recognized. Asking a surgeon if you need surgery? Do you really expect a person under a pile of medical-school debt to give you an unbiased answer?
The scenario of the person "under a pile of medical-school debt" isn't what's being looked at here. The study behind the article is looking at senior cardiologists, who, presumably, have paid off their student loans already.
What we're looking at here isn't economic conflict of interest, but simple bias. Doing things feels better than not doing things, so they do it. Experience might even work against them because we're biased to remember the good outcomes from things rather than consider carefully the general success rate of a procedure.
I wouldn't link that to money issue. Rather than that I would say: "When all you have is hammer, everything looks like nail". Surgeons try to solve all the problems, including changing a light-bulb, by surgery, psychiatrists by psychotherapy, traditional Chinese medicine adepts by acupuncture.
Yes absolutely. People are capable of looking past economic concerns when the lives of another are at stake and we should absolutely expect them to in this case. What's disappointing is the notion that we've sunk so low in our expectations of humanity that we even assume doctors are constantly calculating min/max selfish economic expectation when they advise their patients.
Luckily while some doctors are scam artists the vast majority of them have a sense of duty that transcends "maximize profits".
Most medical doctors in the US aren't paid as a function of patients seen. Unless they're in a niche subset of medicine (cosmetic surgery) or have their own practice setup (hint: you won't find surgeons buried in school debt operating their own practice; the overhead is insane [staff, material goods, and oh god the insurance] would bankrupt a surgeon straight out of residency/fellowship), they're going to be debtors regardless of whether or not that blood test or drug is administered, or whether or not they send out for that radiology consult. It's almost certainly "when all you've been trained with is a hammer <from MS3, through residency, then fellowship for most surgeons, ~7-8 years>, ..." syndrome as others here have said
You're completely missing the actual conflict of interest, balance the creed of 'do not harm' with the reality of protecting themselves from the patients. No one wants to be sued for 'not doing enough' and stick of a potential malpractice suite makes the already incentivized extra procedures make a lot more sense.
For once the larger problems don't lie with the system (although they certainly aren't helping), but rather the disgusting culture we have built up surrounding medical care and expectations. When your obese octogenarian grandmother dies the first thought shouldn't be litigation because the doctor didn't "run enough tests".
The article conflates "good" doctor with experienced doctor. There is no such evidence that experience leads to better outcomes in most divisions of medicine (1), and indeed many have found (just like this one) that less experienced doctors provide better care (2).
The most important variable in your doctor is their personality and your relationship with them, and not their experience (3).
Addendum: The quality of your doctors organization and staff may be even more important than that of your doctor (4).
(1) McAlister, F. A., Youngson, E., Bakal, J. A., Holroyd-Leduc, J., & Kassam, N. (2015). Physician experience and outcomes among patients admitted to general internal medicine teaching wards. Canadian Medical Association Journal, 187(14), 1041-1048.
(2) Southern, W. N., Bellin, E. Y., & Arnsten, J. H. (2011). Longer lengths of stay and higher risk of mortality among inpatients of physicians with more years in practice. The American journal of medicine, 124(9), 868-874.
I was surprised to see this study both written up so seriously in the NYTimes and then taken so seriously on HN because when it came out it was kind of used as a textbook example of how poor study design leads to bad conclusions.
Here's the asterisk:
> although adjusted percutaneous coronary intervention (PCI) rates were lower during meetings (20.8% vs 28.2%; P = .02)
IE: there are nearly 30% fewer angioplasties during annual cardiologist meetings.
Unfortunately the study looked at admissions dates rather than treatment dates (which also lines up with there not being angioplasties during those dates). Someone coming in with heart failure is going through the same procedures regardless of who is there to stabilize them, the actual repair is frequently done later, ie: when the senior doctor gets back from the conference. Another, totally reasonable, possibility emerges then: doctors coming back from conferences perform better for a small period of time after the conference.
Let's see this study repeated with treatment dates instead of admission dates and see what happens.
Not going to talk about this generally, but this may not be the case for surgeons, and it depends on the procedure etc. This was one study showing that surgical volumes improved outcomes:
Maybe when the top doctors are away at meetings the sickest patients no longer get transferred to the tertiary center for care and are kept at the local hospitals.
Very bad title: it implicitly equates "Good Doctors" with "famous doctors" rather than with "doctors whose actions benefit patients". The real point of the article is that one should ask questions and be personally involved in care decisions, rather than just taking the doctor's word. But the linkbait headline obfuscates that point.
The authors suggest it is due to a reduced number of unnecessary treatments:
>"Our results echo paradoxical findings documented during a labor strike by Israeli physicians in 2000, in which hundreds of thousands of outpatient visits and elective surgical procedures were cancelled, but by many accounts mortality rates dramatically fell during the year.27 Similar reports of decreased mortality during physician labor strikes exist elsewhere, with most hypotheses attributing mortality declines to lower rates of nonurgent surgical procedures.28"
However, they do not seem to consider that mortality rates are seasonal and so are the meeting dates. The seasonality differs for different causes of death. A quick search came up with this for heart-related causes, so for example:
>"When grouped by season, we observed the distribution of the 449 coronary heart disease fatalities to show a relative peak in winter (32%) and relative nadir in spring (21%)."
The article uses "best" and "senior" as well, more often than "famous", and explains that the data refers to times when "the senior cardiologists were out of town" (anyone attending conventions, for example.)
It's unlikely there are enough "famous" cardiologists alone to have accounted for "tens of thousands" of admissions. If so, the meaning of "famous" is downgraded to those who are sufficiently senior, rather than how we usually think of "famous."
Hmm, I think I disagree.
It was pretty obvious to me that when they used the term "good doctor" they meant better by some objective criteria that many people use as a proxy for "doctor whose actions benefit patients". If "good doctor" had meant "doctor whose actions benefit patients" it would be a contradiction that most would-be readers could dismiss.
Is it possible that top doctors are just taking on the most challenging cases?
The implicit "explanation" [which seems testable and currently unverified] is that senior cardiologists attempt more interventions [eg angioplasties], and each intervention carries some risk.
It could be true, but why report something that wasn't in the paper?
The study compared results at hospitals when senior doctors were away at cardiology conferences with the same hospitals when the senior doctors were present. They also restricted the study to "acute, life-threatening cardiac conditions" so presumably these were cases that could not be delayed until the senior doctors returned. That seems like it would eliminate most of the effect of case selection.
I highly recommend Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer (2008) by Shannon Brownlee.
When you have a hammer, everything looks like a nail. That's especially so when you're deep in debt from buying that hammer, and can earn huge speaking fees through promoting the brand to your peers.
I'd offer case-mix as a simple explanation of the findings. In other words, when lots of cardiologists in a hospital leave for a conference, elective procedures are deferred until their return... which means that emergency cases constitute a larger proportion of the reduced number of cases that do come into the hospital during the conference. It is completely reasonable to believe that emergency cases have a higher mortality rate than elective cases. This would raise the mortality rate, but not the mortality count. The same effect would probably be seen over long holidays, when people tend not to schedule elective cases.
When those senior doctors are out of town, are risky-but-necessary procedures performed by less senior doctors or delayed until the senior ones return?
Thats the reason I don't like dentists who are also proprietors and have fewer patients due to the location of their clinics. Too much conflict of interest - there is no point for them to wait and see if a tooth can reinitialize, they'd rather take off healthy tissue to make a buck. I'd rather go to a established chain clinic where dentists are employees and they always have patients anyway because of the location (large popular mall).
Maybe the most famous doctors only get called in on the most difficult cases (i.e. the ones with lowest probability of survival). When they're out of town, patients with these difficult cases get sent to other hospitals where the famous doctors are not out of town.
Residents won't want to do risky procedures that increase longevity more than plain, supportive care that will help the patient live 30 days, but not 3-5 years or more.
The problem with the statistic you bring up is that it lacks context like what percentage of the general population eats dark chocolate. If only 20% of the population eats dark chocolate then it's a very interesting statistic.
When I look at the article I don't see any crimes against statistics, and I'd be curious what statistic you think is contextless or misrepresentative.
I find your complaint rather baffling: statistics is how we figure out what is going on in large populations when many variables are in play. How else would we advance medical science?
Yes, as the recent "reproducibility crisis" has shown us (http://blogs.discovermagazine.com/neuroskeptic/2015/11/10/re...), there is severe danger in playing with statistics, even mildly. But that does not mean we should stop using statistics altogether: it means we should come up with better protocols and procedures to prevent the biases we discover.
[+] [-] moistgorilla|10 years ago|reply
The most amazing thing about this experience was when we called 3 weeks in advance to cancel the appointment for surgery the nurse got angry with us and said something along the lines of "You actually dare to waste the doctor's time?". It was very surreal.
TLDR: Don't get pressured into getting surgery, go get second opinions.
[+] [-] stronglikedan|10 years ago|reply
I encountered the same egregious attitude when cancelling the appointment. It made me realize all the more that it was a attempted money grab, with no real concern for my wellbeing.
It was quite the learning experience. I will now never not get a second opinion.
[+] [-] conorh|10 years ago|reply
Speaking of things that I found strange - my wife was blown away at her current practice because for every operation they 'pair-surgeon' full time. This seemed very normal to me, but outside of surgeon training this is considered bizarre - when she tells other surgeons they ask her if it is something to do with billing! (it is not, they can't bill for the second surgeon). She loves it of course, it forces her to up her game and gives her someone she can bounce her thoughts off of during the surgery. I've asked her if she could go visit another surgeon in another facility somewhere and work along side them for a few days to learn, but because of the red-tape and state licensing, this is extremely difficult. The cross seeding of surgical expertise becomes glacially slow after your initial training in residency, you pretty much hope you were trained well and stumble along with a bit of help here and there.
[+] [-] dbroockman|10 years ago|reply
Fundamentally, the issue is that it's impossible to observe for any given patient if that patient's outcome would have been better with a different surgeon. This is the same challenge we face with evaluating drugs: many more people who take aspirin survive than those who take anti-cancer drugs, but this likely reflects the kind of person who is taking each (people with headaches vs. people who have been diagnosed with cancer). To solve the problem there's no way around randomized trials. So, one idea would be to randomly assign patients to surgeons.
(Transparency might still be better on net, but important to keep these issues in mind.)
[+] [-] aggieben|10 years ago|reply
[+] [-] iheartmemcache|10 years ago|reply
[+] [-] doki_pen|10 years ago|reply
[+] [-] jpmattia|10 years ago|reply
It's disappointing that the conflict-of-interest is not better recognized. Asking a surgeon if you need surgery? Do you really expect a person under a pile of medical-school debt to give you an unbiased answer?
[+] [-] pmiller2|10 years ago|reply
What we're looking at here isn't economic conflict of interest, but simple bias. Doing things feels better than not doing things, so they do it. Experience might even work against them because we're biased to remember the good outcomes from things rather than consider carefully the general success rate of a procedure.
[+] [-] mamon|10 years ago|reply
[+] [-] wfo|10 years ago|reply
Luckily while some doctors are scam artists the vast majority of them have a sense of duty that transcends "maximize profits".
[+] [-] xiaoma|10 years ago|reply
Yes. I expect lives to be put ahead of economic gain. Someone lacking the ethical backbone to do this should never even be admitted to medical school.
[+] [-] iheartmemcache|10 years ago|reply
[+] [-] lordCarbonFiber|10 years ago|reply
For once the larger problems don't lie with the system (although they certainly aren't helping), but rather the disgusting culture we have built up surrounding medical care and expectations. When your obese octogenarian grandmother dies the first thought shouldn't be litigation because the doctor didn't "run enough tests".
[+] [-] m52go|10 years ago|reply
That's why the incentive-structure needs to be flipped to be outcome-driven, not treatment-driven...
[+] [-] andersonvieira|10 years ago|reply
[+] [-] thelettere|10 years ago|reply
The most important variable in your doctor is their personality and your relationship with them, and not their experience (3).
Addendum: The quality of your doctors organization and staff may be even more important than that of your doctor (4).
(1) McAlister, F. A., Youngson, E., Bakal, J. A., Holroyd-Leduc, J., & Kassam, N. (2015). Physician experience and outcomes among patients admitted to general internal medicine teaching wards. Canadian Medical Association Journal, 187(14), 1041-1048.
(2) Southern, W. N., Bellin, E. Y., & Arnsten, J. H. (2011). Longer lengths of stay and higher risk of mortality among inpatients of physicians with more years in practice. The American journal of medicine, 124(9), 868-874.
(3) https://www.researchgate.net/profile/Alan_Swann/publication/... and Wampold, B. E., Imel, Z. E., & Minami, T. (2007). The story of placebo effects in medicine: evidence in context. Journal of clinical psychology, 63(4), 379-390; and http://www.annfammed.org/content/7/3/261.full
(4) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2586978/ and http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3568449/
[+] [-] wdewind|10 years ago|reply
Here's the asterisk:
> although adjusted percutaneous coronary intervention (PCI) rates were lower during meetings (20.8% vs 28.2%; P = .02)
IE: there are nearly 30% fewer angioplasties during annual cardiologist meetings.
Unfortunately the study looked at admissions dates rather than treatment dates (which also lines up with there not being angioplasties during those dates). Someone coming in with heart failure is going through the same procedures regardless of who is there to stabilize them, the actual repair is frequently done later, ie: when the senior doctor gets back from the conference. Another, totally reasonable, possibility emerges then: doctors coming back from conferences perform better for a small period of time after the conference.
Let's see this study repeated with treatment dates instead of admission dates and see what happens.
[+] [-] conorh|10 years ago|reply
http://www.nejm.org/doi/full/10.1056/NEJMsa012337
[+] [-] uslic001|10 years ago|reply
[+] [-] pmiller2|10 years ago|reply
[+] [-] unknown|10 years ago|reply
[deleted]
[+] [-] pdonis|10 years ago|reply
[+] [-] nonbel|10 years ago|reply
>"Our results echo paradoxical findings documented during a labor strike by Israeli physicians in 2000, in which hundreds of thousands of outpatient visits and elective surgical procedures were cancelled, but by many accounts mortality rates dramatically fell during the year.27 Similar reports of decreased mortality during physician labor strikes exist elsewhere, with most hypotheses attributing mortality declines to lower rates of nonurgent surgical procedures.28"
http://archinte.jamanetwork.com/article.aspx?articleid=20389...
However, they do not seem to consider that mortality rates are seasonal and so are the meeting dates. The seasonality differs for different causes of death. A quick search came up with this for heart-related causes, so for example:
>"When grouped by season, we observed the distribution of the 449 coronary heart disease fatalities to show a relative peak in winter (32%) and relative nadir in spring (21%)."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3756551/
What they should have done is plot mortality by week so we can see if there is a sudden dip around the conference dates.
[+] [-] gdulli|10 years ago|reply
It's unlikely there are enough "famous" cardiologists alone to have accounted for "tens of thousands" of admissions. If so, the meaning of "famous" is downgraded to those who are sufficiently senior, rather than how we usually think of "famous."
[+] [-] JamesBarney|10 years ago|reply
[+] [-] unknown|10 years ago|reply
[deleted]
[+] [-] wrsh07|10 years ago|reply
The implicit "explanation" [which seems testable and currently unverified] is that senior cardiologists attempt more interventions [eg angioplasties], and each intervention carries some risk.
It could be true, but why report something that wasn't in the paper?
[+] [-] TheCoelacanth|10 years ago|reply
[+] [-] mirimir|10 years ago|reply
When you have a hammer, everything looks like a nail. That's especially so when you're deep in debt from buying that hammer, and can earn huge speaking fees through promoting the brand to your peers.
[+] [-] m52go|10 years ago|reply
Nassim Taleb discusses this concept from a broader perspective in Antifragile.
[+] [-] carbocation|10 years ago|reply
http://www.ncbi.nlm.nih.gov/m/pubmed/25531231/
[+] [-] maj0rhn|10 years ago|reply
[+] [-] unknown|10 years ago|reply
[deleted]
[+] [-] dspeyer|10 years ago|reply
[+] [-] theworstshill|10 years ago|reply
[+] [-] imgabe|10 years ago|reply
[+] [-] monkeyaround92|10 years ago|reply
[+] [-] unics|10 years ago|reply
[+] [-] ultim8k|10 years ago|reply
[+] [-] JamesBarney|10 years ago|reply
When I look at the article I don't see any crimes against statistics, and I'd be curious what statistic you think is contextless or misrepresentative.
[+] [-] scott_s|10 years ago|reply
Yes, as the recent "reproducibility crisis" has shown us (http://blogs.discovermagazine.com/neuroskeptic/2015/11/10/re...), there is severe danger in playing with statistics, even mildly. But that does not mean we should stop using statistics altogether: it means we should come up with better protocols and procedures to prevent the biases we discover.