Can there be positive self selection and specialization of the surgeons? Those who don’t believe they can probably operate successfully don’t do that at all and the others get more insensitive.
Heart surgeons refuse difficult operations to avoid poor mortality ratings
241–250 of 274 posts
Re: Heart surgeons refuse difficult operations to avoid poor mortality ratings
#242Earlier quoted context omitted.
I mean, in general, a hostile tactic like this is likely to get the agent to do as little as possible as he can to help you while staying within the rules. Plus in many cases the front-line agent doesn't have the permissions to do what you need anyway and has to transfer you to a "supervisor" (usually not actually one) or a retention guy to resolve your issue anyway.
I’ve even heard of some centers that are allowed to hang up on you if you try that.
The call center I used to work for expected us to give one warning for such hostile behavior, and then simply hang up if the customer kept being abusive and/or threatening.
In general its, simply a bad idea to be rude to the person you expect to provide assistance.
Re: Heart surgeons refuse difficult operations to avoid poor mortality ratings
#243To be fair, you wouldn't want heart surgeons to shrug and take on operations they didn't feel ready for, either.
Re: Heart surgeons refuse difficult operations to avoid poor mortality ratings
#244Earlier quoted context omitted.
Well I think you're an idiot. There's only one viable "approach", determined by the laws of probability I described above. You can try to shame people into doing actions that would ultimately get them fired and sued, but you're only going to look like a self-righteous asshole and nothing will happen.
Hey, this is a little too ad hom...
Sorry. Touches a nerve with me when people moralize what they do not understand.
Re: Heart surgeons refuse difficult operations to avoid poor mortality ratings
#245Earlier quoted context omitted.
This is one thing that still amazes me to this day. It's like doctor's stop thinking after they get their degree. Whenever I've visited a doc within the past few years I have noticed that instead of actually getting to know someone as a patient, many act as if they are a quick reference book. This is especially horrifying when you consider that there is a non-trivial portion of the population that exist outside of th…
> Nowadays, I'm usually making Doctors aware of advancements in their field... Scary stuff. I don't find that to be too surprising. I can be hyper-aware of my own ailments, but keeping up with an entire field is more difficult. Furthermore, treating to research runs the risk of using treatments where the outcomes haven't been replicated, or there are long-term complications. Unless you've exhausted more conventional…
>I don't find that to be too surprising. I can be hyper-aware of my own ailments, but keeping up with an entire field is more difficult.
I do not find the above to be sufficient justification to practice in ANY field without trying to stay aware of the state-of-the-art.
Yes, in medicine in particular, there is a justifiable bias toward applying more conservative treatments first. "Hear hoof beats, think horse first, not Zebra," is the axiom I believe is most frequently ground into new physicians.
The problem comes in when a physician becomes so conditioned to conservative treatments working that they become blind to the extremes. Running with the Zebra analogy, just because you hear hoof beats, you see a horse-like silhouette, and in this lighting you can't tell the color, does not mean you should IGNORE the possibility of Zebra.
As a practicing physician, you are DEPENDED upon to be the layman's gateway to the entirety of the collective medical knowledge base we've been able to accrue, verify, and are in the process of verifying. You owe it to your patients, just as an Engineer owes it to the public, to become as well acquainted with the medical literature as it pertains to them as possible.
I may be being a bit normative here, but an M.D. should be seen as a commitment to spending your life on the pursuit of the means by which to provide the highest quality of care for your body of patients. That at times means being ready to help the a patient access and navigate the less charted waters of the state-of-the-art if necessary.
I agree completely that state-of-the-art should not be the first hammer pulled from the toolbox, but one should not actively avoid it either. At the end of the day, data doesn't get generated out of thin air, and if the patient understands and accepts the risks after you have provided them the best guidance you can, you have done all that can be expected of you, have you not?
Re: Heart surgeons refuse difficult operations to avoid poor mortality ratings
#246Earlier quoted context omitted.
This incentivizes the doctor to maximize the appearance of risk in the medical record.
The one doing the estimate should obviously not be the same doctor doing the surgery.
The one doing the estimate will do so based off the records generated by the doctor doing the surgery.
Re: Heart surgeons refuse difficult operations to avoid poor mortality ratings
#247Earlier quoted context omitted.
This is one thing that still amazes me to this day. It's like doctor's stop thinking after they get their degree. Whenever I've visited a doc within the past few years I have noticed that instead of actually getting to know someone as a patient, many act as if they are a quick reference book. This is especially horrifying when you consider that there is a non-trivial portion of the population that exist outside of th…
> Nowadays, I'm usually making Doctors aware of advancements in their field... Scary stuff. Are you taking about your cases? Because keeping on top of the narrow score that's currently relevant to you is a different level of time investment than keeping on top of everything happening in the field, after already learning a large part of it, and keeping in mind current treating guidelines which lag behind research.
Alright, I'll concede that one.
I admit, things become a lot simpler once you limit your scope to issues immediately relevant to you as a patient.
However, I do still believe that when made aware of something new from a patient, a good physician should actively tackle the topic if only to be able to give a realistic assessment of where it falls on the risk/outcome spectrum.
NOTE: This may be assuming an above average level of patient investment. I in no way condone of wasting a physician's time having them wade through quackery. Nobody has time for that.
Re: Heart surgeons refuse difficult operations to avoid poor mortality ratings
#248It 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…
if it's any consolation, I'm a surgeon, and in my town, another surgeon's wife was diagnosed with lung cancer right after his last weekend of call. She underwent surgery / chemo / radiation and died within 4 months and later (he kept working bc his plans of taking time to see the world with his wife were ruined) he told me that she would have been better off just going on hospice bc she suffered. Hindsight, unfortunately, is 20-20.
Cardiac surgeons in the US have had their own database for >20 years, and vascular surgeons do too. General surgeons have gotten into it the last 10 years or so
https://www.facs.org/quality-programs/acs-nsqip
I'm the NSQIP champion for my hospital system and go to monthly meetings to review our system's data. There's a lot of controversy with the data. We show individuals their data as compared to their anonymized peer data. Recently, the credentialling committee wanted access to the data, and that is being discussed, but I'm against it because the data only samples your outcomes, not every case, so it can be biased (although as you get more cases sampled, hopefully, the pattern established becomes more relevant). Anyway, it can be humbling.
Moreover, all deaths / OR take backs / readmissions get reviewed by a hospital committee and in the 15 years I've been in practice, there have been 4 surgeons in town that have lost their privileges to operate at the hospital.
Re: Heart surgeons refuse difficult operations to avoid poor mortality ratings
#249Earlier quoted context omitted.
Ironically applied to not-good hearts
"These doctors are vile dogs. If I was a physician I would take all the hard patients, heal them all, and be a hero of the people." Yeah, if you were given one operation where the patient has a 100% chance of dying without it, but 80% of you killing them if you operate + 20% chance of them living after, maybe you'd do this once and get lucky. But try doing this twice, you have a a 96% chance of killing a patient, thr…
People die in surgery all the time, it's not nearly as big a deal for the surgeon as you're suggesting. ~5% chance of death within 30 days per major hart surgery means the average surgeon is losing several people in an average year.
Re: Heart surgeons refuse difficult operations to avoid poor mortality ratings
#250Earlier 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…
Luckily in most businesses incentives are used by the people designing the incentives to
1) cost as little as possible to the business
2) "optimize" their own pay/career
(There was a study saying that over 80% of sales people would deny their employer a million-dollar contract if it netted them $500 personally, so compared to that this is nothing)
Which makes sure that the incentives are not aligned with the business goals.
Now I guarantee that the best way to destroy intrinsic motivation, bar none, is to provide extrinsic motivation for things that aren't aligned with the business' goals.