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

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

#101

Post by emodendroket » Sat, Apr 21, 2018, 7:44 PM 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?

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

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

#102

Post by 2skep » Sat, Apr 21, 2018, 7:44 PM UTC

What would you prefer?

A surgeon who expects a poor outcome of your surgery:

a)decides to not operate on you? b)decides to operate on you nonetheless?

I am in camp a

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

#103

Post by emodendroket » Sat, Apr 21, 2018, 7:46 PM 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

When I was fresh out of a school I worked in a call center for a while. One of the most important metrics (and everything you did was measured) was the average length of each call. So it was common practice, when you got cases that basically were going to be long calls or ones you probably couldn't actually resolve (e.g., "I want the service back on but cannot pay"), to deliberately upset the customers so that they would demand a supervisor and you could transfer them.

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

#104

Post by emodendroket » Sat, Apr 21, 2018, 7:46 PM UTC

You would think that they could adjust these figures by patient age and condition.

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

#105

Post by emodendroket » Sat, Apr 21, 2018, 7:49 PM UTC

LoSboccacc wrote: post #97

fc003153 wrote: post #73

Earlier quoted context omitted.

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

the problem here is that mortality rate is not correlated/normalized with the patient risk factor. the problem lies in the performance indicator itself, not strictly people trying to optimizing for what they are asked for. it is likely inhumane to refuse patients that have slightly above average risk - even if there are some considerations to be had, like having replacement organs go to waste, but that is already cov…

I'm not an expert in cardiatric medicine or anything, but couldn't patient risk be determined by objective factors like patient age and history of previous heart issues?

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

#106

Post by xab9 » Sat, Apr 21, 2018, 7:51 PM UTC

kazinator wrote: post #44

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

Low mortality is a good damned measure. I don't want to be operated on some yahoo surgeon who unconditionally operates regardless of risk and has a high mortality track record as a result.

I'm so happy that this system of 'likes' works for some people.

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

#107

Post by [deleted] » Sat, Apr 21, 2018, 7:53 PM UTC

kankroc wrote: post #59

agumonkey wrote: post #36

it's been said a few times on /r/medicine, surgeons have their lawyer in mind when operating, they're skilled, but they first avoid anything that could damage their own life irreversably. Of course to an extent this goal aligns with the patient, but not always, and a bit sad on the ideal side.

Can someone really sue their surgeon in the US?

[deleted]

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

#108

Post by crusso » Sat, Apr 21, 2018, 7:54 PM UTC

Ultimately, we need to compare apples to apples by building rating systems that account for the difficulty of treating patients with various, ailments at various ages, with various complications.

Think of it in terms of competitive diving, gymnastics, or snowboarding: Your scores depend upon the difficulty of the moves you attempted combined with your performance of those specific moves. The more difficult the move, the more you're compensated for even attempting it when it comes to scoring.

The trick then is to prevent physicians from gaming the system by exaggerating the difficulty of the patients they're dealing with. You'd need to use as many objective metrics as possible and possibly some system of having different physicians assess ratings than the ones performing the procedures - maybe in some kind of double-blind fashion to prevent any kind of coordination strategy.

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

#109

Post by Arnt » Sat, Apr 21, 2018, 7:56 PM UTC

olliej wrote: post #99

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

It also kind of incentivizes the alternative as well: if you aren’t an amazing surgeon, you could work to ensure you exclusively work on “hard” cases you can claim all failures are due to patient difficulty rather than lack of competence (at least competence to deal with that difficulty). Then you can dismiss any claims you’re incompetent with “I have a high mortality rate because I’m willing to risk my reputation to…

I've listened to a physician make this argument (for a different metric, not mortalities). He sounded as though he expected everyone in the audience to disbelieve him, enough so that I wondered why he even tried.

So yes, could.

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

#110

Post by smsm42 » Sat, Apr 21, 2018, 7:56 PM UTC

kazinator wrote: post #44

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

Low mortality is a good damned measure. I don't want to be operated on some yahoo surgeon who unconditionally operates regardless of risk and has a high mortality track record as a result.

You are committing a common fallacy - when evaluating risk, you are considering only one of the alternatives and forgetting the risk of the other. Yes, nobody wants to be operated on by a yahoo. But mortality is not a good measure of yahoo-ness, because in some cases not operating carries larger risk of death than operating. And if a surgeon decides to operate in this case, the decision is right even if resulting risk is high - because the alternative is even higher risk. Considering only mortality rate of operations ignores this. It is a variation of survivorship bias, only on the opposite side.