6 ms·

> 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

> 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?

xiaoma 11y ago
>Do you really expect a person under a pile of medical-school debt to give you an unbiased answer? 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.
- deleted 11y ago
  [deleted]
- TheCoelacanth 11y ago
  The gold standard for ethical behavior isn't to magically not let bias affect you when making decisions. It's to identify conflicts of interest and avoid them. Someone who knowingly allows a conflict of interest to exist is behaving unethically, no matter how hard they try to avoid letting their bias affect their decision.
wfo 11y ago
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".
- Retric 11y ago
  If A and B are equivalent, and B makes you money, most people have a large unconscious bias to B. Which is perfectly reasonable. The problem is if A is ever so slightly better that bias is still there. The is directly observed when doctors are for example incentivized or penalized for over prescribing medication. So, no expecting unbiased options it an unreasonable standard. PS: This is often why second opinions are so valuable. If a doctor has no economic stake in the outcome they often give better advice for the patient.
m52go 11y ago
You raise a good point though. Ethically, it's expected, but even ethical people are known to be drawn by greed on occasion. That's why the incentive-structure needs to be flipped to be outcome-driven, not treatment-driven...
mamon 11y ago
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.
- crpatino 11y ago
  Right, which is why the GPs were such an undervalued cornerstone of the old fashioned medical system. They were the ones supposed to hold the big picture in mind, and to cousel their patients when the intervention of an specialist was needed. Today, they have been turned into glorified technitians and the front end of a pipeline that leads to expensive and potentially unneed treatment. There's no wonder everything turns into hammers and nails when you keep busy your handymans holding the door open.
  - mamon 11y ago
    About not needed treatment: http://www.usatoday.com/story/news/nation/2013/06/18/unnecessary-surgery-usa-today-investigation/2435009/ http://www.usatoday.com/story/news/nation/2013/06/18/unneces...
pmiller2 11y ago
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.
lordCarbonFiber 11y ago
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".
- jlg23 11y ago
  That. Exactly that. That goes so far that even when it is only the choice between the original pharmaceutical product and a generic, doctors will think twice out of fear to be sued if something goes wrong. I have one very scientifically inclined doctor in my family who fully understands that the chance of a generic being less effective is negligible. But, depending on the patient, she will prescribe the much more expensive original. Financially she does not profit from this at all, writing a prescription can be billed in her country but the height of the bill does not depend on the price of the prescribed medicine.
- zaidf 11y ago
  You nailed it. The thread is full of doctor-blaming, as if doctors really relish in calling for useless scans. In fact, most doctors hate it and only do it to protect themselves against lawsuits. The other blindspot many people in this thread have is that just as you can have shitty doctors, you have many more patients with shitty knowledge of medicine. My own view is that once you pick your doctor, stay informed but at the end of the day, you need to trust his judgement. If you don't, find another doctor. Why? Because ultimately, no surgeon can guarantee a successful outcome. So if you don't trust the doctor or have any doubt about him, if the outcome is poor, you will be inclined to blame him irrespective of whether he is at fault(more times than no, he's not at fault.) This is not very different from being a developer. If I am hired as a developer, I will take my client's input on the big decisions and let him make the decision if he wants to for certain things. But if my client wants to micromanage me and pick the names of the variables I use in my code or question my coding style, well, he'd be better off with another developer. Ideally, he should have never hired me based on my sample code.
andersonvieira 11y ago
If the problem were the medical-school debt, I would expect junior physicians to be more worried about it than senior physicians, no?
iheartmemcache 11y ago
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
- FireBeyond 11y ago
  "or have their own practice setup" No, but they do form "associations". Small practices between 6-10 surgeons to share costs but otherwise be effectively a private practice.
  - iheartmemcache 11y ago
    Without derailing this discussion, yeah this happens but only at a later stage in your career where you have the 'name recognition' in your subset of surgery so that your colleagues trust you enough you to even bring you in as a partner. I'm limited to the NE region, but I've never once seen a surgeon or medical practitioner form his/her own association or join in as a JP into an already established association until they were well out of the burden of debt. In the same way that attorneys generally don't go straight into the market and form Johnson, Thompson LLP until they have a few wins under their belt at Skadden or Cravath and a few clients they know they can bring over, your typical niche association won't hire you into their surgical association even with half a decade out with a bunch of articles with you as lead surgeon in high-impact journals. You're still considered a risk as a partner (nepotistic situations notwithstanding).

xiaoma 11y ago

>Do you really expect a person under a pile of medical-school debt to give you an unbiased answer? 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.

deleted 11y ago
[deleted]
TheCoelacanth 11y ago
The gold standard for ethical behavior isn't to magically not let bias affect you when making decisions. It's to identify conflicts of interest and avoid them. Someone who knowingly allows a conflict of interest to exist is behaving unethically, no matter how hard they try to avoid letting their bias affect their decision.

wfo 11y ago

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".

Retric 11y ago
If A and B are equivalent, and B makes you money, most people have a large unconscious bias to B. Which is perfectly reasonable. The problem is if A is ever so slightly better that bias is still there. The is directly observed when doctors are for example incentivized or penalized for over prescribing medication. So, no expecting unbiased options it an unreasonable standard. PS: This is often why second opinions are so valuable. If a doctor has no economic stake in the outcome they often give better advice for the patient.

m52go 11y ago

You raise a good point though. Ethically, it's expected, but even ethical people are known to be drawn by greed on occasion. That's why the incentive-structure needs to be flipped to be outcome-driven, not treatment-driven...

mamon 11y ago

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.

crpatino 11y ago
Right, which is why the GPs were such an undervalued cornerstone of the old fashioned medical system. They were the ones supposed to hold the big picture in mind, and to cousel their patients when the intervention of an specialist was needed. Today, they have been turned into glorified technitians and the front end of a pipeline that leads to expensive and potentially unneed treatment. There's no wonder everything turns into hammers and nails when you keep busy your handymans holding the door open.
- mamon 11y ago
  About not needed treatment: http://www.usatoday.com/story/news/nation/2013/06/18/unnecessary-surgery-usa-today-investigation/2435009/ http://www.usatoday.com/story/news/nation/2013/06/18/unneces...

pmiller2 11y ago

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.

lordCarbonFiber 11y ago

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".

jlg23 11y ago
That. Exactly that. That goes so far that even when it is only the choice between the original pharmaceutical product and a generic, doctors will think twice out of fear to be sued if something goes wrong. I have one very scientifically inclined doctor in my family who fully understands that the chance of a generic being less effective is negligible. But, depending on the patient, she will prescribe the much more expensive original. Financially she does not profit from this at all, writing a prescription can be billed in her country but the height of the bill does not depend on the price of the prescribed medicine.
zaidf 11y ago
You nailed it. The thread is full of doctor-blaming, as if doctors really relish in calling for useless scans. In fact, most doctors hate it and only do it to protect themselves against lawsuits. The other blindspot many people in this thread have is that just as you can have shitty doctors, you have many more patients with shitty knowledge of medicine. My own view is that once you pick your doctor, stay informed but at the end of the day, you need to trust his judgement. If you don't, find another doctor. Why? Because ultimately, no surgeon can guarantee a successful outcome. So if you don't trust the doctor or have any doubt about him, if the outcome is poor, you will be inclined to blame him irrespective of whether he is at fault(more times than no, he's not at fault.) This is not very different from being a developer. If I am hired as a developer, I will take my client's input on the big decisions and let him make the decision if he wants to for certain things. But if my client wants to micromanage me and pick the names of the variables I use in my code or question my coding style, well, he'd be better off with another developer. Ideally, he should have never hired me based on my sample code.

andersonvieira 11y ago

If the problem were the medical-school debt, I would expect junior physicians to be more worried about it than senior physicians, no?

iheartmemcache 11y ago

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

FireBeyond 11y ago
"or have their own practice setup" No, but they do form "associations". Small practices between 6-10 surgeons to share costs but otherwise be effectively a private practice.
- iheartmemcache 11y ago
  Without derailing this discussion, yeah this happens but only at a later stage in your career where you have the 'name recognition' in your subset of surgery so that your colleagues trust you enough you to even bring you in as a partner. I'm limited to the NE region, but I've never once seen a surgeon or medical practitioner form his/her own association or join in as a JP into an already established association until they were well out of the burden of debt. In the same way that attorneys generally don't go straight into the market and form Johnson, Thompson LLP until they have a few wins under their belt at Skadden or Cravath and a few clients they know they can bring over, your typical niche association won't hire you into their surgical association even with half a decade out with a bunch of articles with you as lead surgeon in high-impact journals. You're still considered a risk as a partner (nepotistic situations notwithstanding).