Heart surgeons refuse difficult operations to avoid poor mortality ratings • Hacker News Board

Re: Heart surgeons refuse difficult operations to avoid poor mortality ratings

#211

Post by acjohnson55 » Sun, Apr 22, 2018, 3:36 AM UTC

We chose to have our daughter delivered at a hospital that is renowned for its neonatal ICU. It's obviously a great place to give birth, but if you look on paper, their c-section and other intervention rates are above average. Which makes sense when you understand that they are equipped to handle the highest risk pregnancies.

A similar phenomenon occurs in education. I taught high school in Baltimore, where the vast majority of my students were high risk. Baltimore has a few renowned high schools, but by and large, they serve the easiest students.

Re: Heart surgeons refuse difficult operations to avoid poor mortality ratings

#212

Post by daurnimator » Sun, Apr 22, 2018, 3:40 AM UTC

jpatokal wrote: post #172

finaliteration wrote: post #167

Earlier quoted context omitted.

I worked in a call center, as well, but they didn’t prioritize call length as a metric/KPI. Their number one KPI was “first call resolution”, meaning even if it took an hour as long as the problem was resolved the call was considered a success. I feel like it was a much healthier way to measure call center performance.

One support team I used to work with prioritized "first touch resolution" for email cases as well, so the agents would answer every case with a 16-page DYI flowchart listing every single possible problem and its resolution. KPIs are hard...

That sounds great!

I'm reminded of https://xkcd.com/810/

Re: Heart surgeons refuse difficult operations to avoid poor mortality ratings

#213

Post by acjohnson55 » Sun, Apr 22, 2018, 3:41 AM UTC

calcifer wrote: post #138

emodendroket wrote: post #101

Earlier quoted context omitted.

Perhaps the patient should have the right to decide what that threshold is for themselves rather than having the information hidden from them.

What information? Apparently the doctor told them he could do it. If he really believed in himself, then he told the patient everything she needed to know. Remember, the other option is "go die". So assigning a percentage chance on the successful outcome of a surgery is utterly meaningless when the alternative is a 100% "go die".

Realistically, you're going to die either way. We know that for sure. So what's really important is some notion of probability of quality time.

Re: Heart surgeons refuse difficult operations to avoid poor mortality ratings

#214

Post by jpmattia » Sun, Apr 22, 2018, 3:50 AM UTC

metaobject wrote: post #55

drewg123 wrote: post #17

It was not heart surgery, but after being diagnosed with lung cancer, my mother had one of her lungs removed by a surgeon who assured us he'd be able to get all the cancer. She had a miserable, painful recovery that I would not wish on anybody. Within a week or two of her recovering to the point where she could walk short distances, the cancer was found in her other lung and went on to kill her within a few more mont…

I guess I'm just shocked that the surgeon could offer that level of assurance about something like that.

> I guess I'm just shocked that the surgeon could offer that level of assurance about something like that

I'm not. That's been my experience with pretty much every surgeon, and even a fair amount of the non-surgical doctors. Letting patients see uncertainty and indecision is not part of the medical school culture, as near as I can tell.

It behooves anyone with serious medical issues to do independent research. (God help you if you don't already know how to deep learn on literature not in your field.)

Re: Heart surgeons refuse difficult operations to avoid poor mortality ratings

#215

Post by hliyan » Sun, Apr 22, 2018, 4:01 AM UTC

cs702 wrote: post #30

It's Goodhart's Law in action, this time with deadly consequences: "When a measure becomes a target, it ceases to be a good measure."[a] [a] https://en.wikipedia.org/wiki/Goodhart%27s_law

I prefer to think that this happens when you pick a measure that ignores key aspects of the results. For example, would the results be the same if the mortality rate was complexity-weighted?

Re: Heart surgeons refuse difficult operations to avoid poor mortality ratings

#216

Post by emodendroket » Sun, Apr 22, 2018, 4:12 AM UTC

briandear wrote: post #206

pmoriarty wrote: post #185

Earlier quoted context omitted.

There was recently a story about a 911 operator being jailed for hanging up on thousands of calls.[1] If someone could get away with it at a 911 call center, it could happen anywhere... and might happen oftener than we think. [1] - https://www.sfgate.com/news/article/911-dispatcher-sentenced...

That Houston lady that did that didn’t care about metrics, she literally just couldn’t be bothered. “Ain’t nobody got time for that.”

I have to imagine there are differences between a television customer service line and emergency dispatch anyway.

Re: Heart surgeons refuse difficult operations to avoid poor mortality ratings

#217

Post by Godel_unicode » Sun, Apr 22, 2018, 4:17 AM UTC

pmoriarty wrote: post #191

sp527 wrote: post #149

Earlier quoted context omitted.

As a corollary, this is along the lines of one of my favorite bits of wisdom from Poor Charlie's Almanac. If I recall correctly, Munger considers incentives to be the single most important concept to properly understand in order to drive successful business (and arguably life) outcomes. Not surprisingly, incentives are also chronically underestimated or outright ignored, even in situations where there's a strong, pro…

For a different view, see "Punished by Rewards: The Trouble with Gold Stars, Incentive Plans, A's, Praise, and Other Bribes" .[1] It's about extrinsic vs intrinsic motivation. Extrinsic motivation comes from outside of the person and is what's typically used by organizations to try to motivate people: salary, praise, bonuses, etc. Intrinsic motivation comes from within. [1] - https://www.amazon.com/Punished-Rewards-T…

I think this is frequently short-sighted. Surgeons are intrinsically motivated to be surgeons and help people, and they are trained to think clinically (pun somewhat intended) about risk-reward. They realize that trying to help high-risk patients will ultimately result in them being able to help fewer patients.

Re: Heart surgeons refuse difficult operations to avoid poor mortality ratings

#218

Post by Godel_unicode » Sun, Apr 22, 2018, 4:19 AM UTC

fc003153 wrote: post #73

cs702 wrote: post #30

It's Goodhart's Law in action, this time with deadly consequences: "When a measure becomes a target, it ceases to be a good measure."[a] [a] https://en.wikipedia.org/wiki/Goodhart%27s_law

I'm not so sure Goodhart's Law is correct. For example, if I target a high win percentage, is win percentage, then, not a good measure? Mortality rates are a pretty good measure for surgeons. The problem here is that they are inflating their measure by cherry picking. edit: Some measures should be targeted, the problem here is that it is done in an non genuine way

Mortality rate doesn't account for the outcomes of surgeries which are declined due to risk.

Re: Heart surgeons refuse difficult operations to avoid poor mortality ratings

#219

Post by TwoBit » Sun, Apr 22, 2018, 4:34 AM UTC

adolph wrote: post #75

This topic was discussed in the last EconTalk [1] podcast featuring the author of a recent book “The Tyranny of Metrics” [2]. I think one of the author’s interest insights is the distinction between metrics for diagnostics and those for incentives. 1. http://www.econtalk.org/archives/2018/04/_what_is_the_ap.htm... 2. https://www.amazon.com/Tyranny-Metrics-Jerry-Z-Muller-ebook/...

It's what I hate about the legal system. Prosecutors don't care about justice, they care about a record of putting thevmost people away.

Re: Heart surgeons refuse difficult operations to avoid poor mortality ratings

#220

Post by eslaught » Sun, Apr 22, 2018, 4:38 AM UTC

Johnny555 wrote: post #71

drewg123 wrote: post #17

It was not heart surgery, but after being diagnosed with lung cancer, my mother had one of her lungs removed by a surgeon who assured us he'd be able to get all the cancer. She had a miserable, painful recovery that I would not wish on anybody. Within a week or two of her recovering to the point where she could walk short distances, the cancer was found in her other lung and went on to kill her within a few more mont…

Sadly, it seems that your mother would not have had a better outcome with or without the surgery - if the doctor had said "I'm 75% sure that the cancer is contained in the one lung, so removing the lung will remove the cancer", would that have changed the decision to have the surgery? What it was was 50%? What is the threshold where someone with a fatal illness will accept the risk for a possible cure?

Ultimately, it's about responsibility: is the patient allowed to take responsibility for the decision, or does the doctor take that opportunity away by not presenting the information (or presenting it in a way that allows the patient to actually decide)? This may sound odd, but I've seen deep emotional scarring in friends and family who went through major surgeries, even when the operations themselves had medically "good" outcomes... and all because the time and care wasn't taken to give the patient autonomy over their own treatment.

Making a decision vs having one made for you are very different things, even if the outcome of the decision is the same.