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The Greedy Doctor Problem

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Re: The Greedy Doctor Problem

#111

Post by IggleSniggle »

goopthink wrote: post #93
thenoblesunfish wrote: post #90

Earlier quoted context omitted.

I think that the author is assuming that you, the patient, have no way to assess whether the diagnosis was correct. I think that eliminates what I also thought of as a strategy, which is how this works in real life - some combination of being able to tell, as the patient, when treatment is working, combined with (the threat of) second opinions, and of course all the “human” stuff that the author sets aside about doct…

The thing is, in many cases you don't need to know if the diagnosis is correct, so long as the results are directionally correct. If the outcome is an improvement in health, that meets your threshold for value delivered, hence payment rendered. I think there are many cases when you don't need to be smarter than the other person to benefit from their expertise. You can take it a step further and make the distinction b…

It is a balancing act, to be sure, regarding "feeling better" vs "less sick". Hospice care is indeed very important. It can go too far in this direction, however, and I have real sympathy for docs that get it "wrong" in either direction (too much "comfort" or too much "let's give you more years").

Notably: the prescription opioid epidemic is a great example of how this can go wrong in the opposite direction of healthcare providers valuing "relative" benefit vs "absolute" benefit.

My spouse is a primary care provider, and there was a period a couple decades ago where the prevailing wisdom was "if a patient says they are in pain, they are in pain, and you treat that pain. We are experts in medicine, but the patient is the expert of their own perception." This is still a complicated issue today, but there are clearly outcomes where we can make people "feel better" all the way to an early grave.

For the terminally ill, it seems absolutely appropriate to me to let the patient guide whether they wish to accelerate their death in exchange for quality of life. But "terminally ill" is often not such a black and white issue...we are all eventually mortal.

If things like heroin don't inspire a sense of horror or dread, then we just aren't speaking the same language. I, for one, don't want to live in a world where the human priority-at-large is everyone defining "living" as maximizing pleasure until their death. For the hedonists, I get why this makes a certain nihilistic sense, but I think the horror of the reality of it outweighs any momentary benefit.

In the very abstract, maybe it doesn't really matter one way or the other. In the concrete day-to-day reality of it, it's absolutely awful to see anyone struggling with any kind of addiction, out of control of their own lives...sometimes because they got on a treadmill-to-death on the _expert_ advice of someone trying to "help them out."

Re: The Greedy Doctor Problem

#112

Post by foolinaround »

ryanmcbride wrote: post #97
kwhitefoot wrote: post #96

Earlier quoted context omitted.

> Why not go to the "other, other obvious" solution, which is results-based payments? There is a story about doctors in ancient China who are paid by their clients only so long as the client is healthy. When they fall sick, the doctor is not paid again until the patient is healthy again. Then the goal is not a cure for a disease but the prevention of disease. I don't know if any such thing ever really happened but it…

It's an interesting idea but the pessimist in me just sees this as incentivizing under-diagnosing, running fewer tests, etc.

what if the diagnosing and treatment were done by different doctors?

Re: The Greedy Doctor Problem

#113

Post by samcgraw »

Very interesting read!

I suppose another such solution, for a patient with a given medical condition X, is to have a very large pool of doctors and see if any of them have condition X (with similar age, background, etc).

Then one could compare how treatment varies when doctors treat themselves with the same issue.

"Physician, heal thyself."

Re: The Greedy Doctor Problem

#114

Post by JoshCole »

ashtonkem wrote: post #101
SuoDuanDao wrote: post #73

Earlier quoted context omitted.

I noticed that when the 'laws of stupidity' article [1] came up here. I'm very familiar with it as I read it when I was young and impressionable, almost all the comments had nothing to do with the substance of the article. What makes it more poignant is that I typically go straight to the comments myself, assuming that intelligent commentary on an article will convey what the article was about faster than the article…

There’s a tragedy of the commons going on here. The best outcome as a group is if everyone reads the article. The best outcome individually is if you’re the only one that doesn’t read the article, then you get all the informed comments without spending the time to read it personally. The actual outcome is that very few people read the article, and the entire discussion is about the title and how people interpreted it…

I don't think it is true that the best outcome individually is if you're the only one to read the comments. In the wisdom of the crowds formulation the average is closest, but on Hacker News and similar websites there is a popularity contest which biases the responses. The average over a biased sample doesn't have the same mathematical reasoning suggesting it is better than any individuals estimate.

To use a specific example there was once a claim about a board seat for Tesla going to someone that people tend to dislike. The comments were largely in agreement that this would happen and it would happen basically because it was outraging and seemed evil which agreed with the commenters preconceptions. Anyone who posted contrary to this - which I did, quoting a primary source which disagreed with the claim, got downvoted. Ultimately I was right and the board seat didn't go to the 'evil' person.

This isn't intended to be a critique of me getting downvoted. Instead I'm trying to point out that if you read all the comments the consensus in the comments doesn't approximate the correct answer. So what do you have to do? You have to go primary sources in order to be able to get an unbiased estimator. Maybe the comments link to one, which is nice, but notice: you can't rely on the comments alone. Which means it was the people who read the primary sources, not the people who read the comments, which get the best outcome individually.

Unfortunately, the people who are doing this aren't becoming popular for doing this when it helps them. Quite the opposite. When this is effective, it is effective entirely because it is not in line with the popular opinion.

Re: The Greedy Doctor Problem

#115

Post by loldk »

samcgraw wrote: post #113

Very interesting read! I suppose another such solution, for a patient with a given medical condition X, is to have a very large pool of doctors and see if any of them have condition X (with similar age, background, etc). Then one could compare how treatment varies when doctors treat themselves with the same issue. "Physician, heal thyself."

This needs to happen. It doesn't have to be a requirement, but it needs to be a norm for all doctor's visits. It would save insurance companies money guaranteed.

Re: The Greedy Doctor Problem

#116

Post by GloriousKoji »

ProjectArcturis wrote: post #106
Robotbeat wrote: post #80

Earlier quoted context omitted.

Increasing the supply doesn't mean the average quality of care will fall. If I pay doctors $400,000 a year to work 80 hours a week and then double the number of doctors and pay them $200,000 a year to work 40 hours per week, the quality of care would almost certainly improve but costs would be constant. And actually, do we pay doctors a premium for those overtime hours where they're actually probably less effective?…

In theory, if you want to train twice as many doctors, you have to relax admissions criteria to let in twice as many people, and the new admitees wouldn't have qualified under the previous system.

But what if the limiting factor of admission criteria isn't scoring well but things like crippling amount of debt, archaic culture of hazing and adversity to stupid hours?

Re: The Greedy Doctor Problem

#118

Post by convolvatron »

ProjectArcturis wrote: post #106
Robotbeat wrote: post #80

Earlier quoted context omitted.

Increasing the supply doesn't mean the average quality of care will fall. If I pay doctors $400,000 a year to work 80 hours a week and then double the number of doctors and pay them $200,000 a year to work 40 hours per week, the quality of care would almost certainly improve but costs would be constant. And actually, do we pay doctors a premium for those overtime hours where they're actually probably less effective?…

In theory, if you want to train twice as many doctors, you have to relax admissions criteria to let in twice as many people, and the new admitees wouldn't have qualified under the previous system.

you're kind of assuming that the metrics that the use to admit students are predictive of care quality. thats certainly not true, but who knows how not true?

Re: The Greedy Doctor Problem

#119

Post by Robotbeat »

GloriousKoji wrote: post #116
ProjectArcturis wrote: post #106

Earlier quoted context omitted.

In theory, if you want to train twice as many doctors, you have to relax admissions criteria to let in twice as many people, and the new admitees wouldn't have qualified under the previous system.

But what if the limiting factor of admission criteria isn't scoring well but things like crippling amount of debt, archaic culture of hazing and adversity to stupid hours?

Right. Are doctors ubermensch who are the cream of the crop or did they just have a high tolerance for abuse? I’m not sure being ultra-selective gets you people who are fundamentally better doctors nor are the returns gonna be very linear even if they were. I’d much rather have enough well-rested doctors than have more “select” but highly stressed, sleep deprived doctors.

Re: The Greedy Doctor Problem

#120

Post by vanviegen »

dahfizz wrote: post #104
rectang wrote: post #74

Earlier quoted context omitted.

It's clear why performing unnecessary medical acts is problematic, but what is the issue if doctors being paid by the act work 3-4 days a week? Isn't this just piece work and you can add more doctors?

The median wait time to see a specialist in canada is 78 days[1]. Yes, in theory you could "just add more doctors". But there is clearly already less doctors than there needs to be. Policy that encourages doctors to work less exacerbates this issue. You can't just say "add more doctors" as if that helps anything. Shortages exist for a reason, and analyzing and fixing the system which creates the shortage is the only…

> You can't just say "add more doctors" as if that helps anything.

Why wouldn't it?

There are more than enough people who would want to become a doctor, and would be capable. Especially if the work/life balance would be better. At least in my part of the world, it seems that the system is rigged to keep the number of docters artificially low.

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