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I've posted about this before - my wife is a highly specialized surgeon. This article really only scratches the surface of the issues with surgery around the US

by conorh 11y ago

I've posted about this before - my wife is a highly specialized surgeon. This article really only scratches the surface of the issues with surgery around the US, as a software developer working in a pretty transparent and open industry I'm always horrified at how surgeons practice in the US. In my opinion the core of the problem is the lack of transparency in the entire system. There are just very few pressures for surgeons to really improve like they should have to. If, as a surgeon at a academic center, you want to just cruise along, no problem, you can just publish a few papers each year, be nice to patients, and you will be considered a leader in your field - even if you have terrible outcomes. There is little to no data out there to help patients objectively evaluate a surgeon, and to force surgeons to become better. Speaking of things that I found strange - my wife was blown away at her current practice because for every operation they 'pair-surgeon' full time. This seemed very normal to me, but outside of surgeon training this is considered bizarre - when she tells other surgeons they ask her if it is something to do with billing! (it is not, they can't bill for the second surgeon). She loves it of course, it forces her to up her game and gives her someone she can bounce her thoughts off of during the surgery. I've asked her if she could go visit another surgeon in another facility somewhere and work along side them for a few days to learn, but because of the red-tape and state licensing, this is extremely difficult. The cross seeding of surgical expertise becomes glacially slow after your initial training in residency, you pretty much hope you were trained well and stumble along with a bit of help here and there.

dbroockman 11y ago
Full transparency could have negative unintended consequences. For example, if surgeons knew their success rate were public, they would be incentivized to take easier cases. Who would take a difficult case if they knew it would constitute a bad mark on their record almost for sure? Fundamentally, the issue is that it's impossible to observe for any given patient if that patient's outcome would have been better with a different surgeon. This is the same challenge we face with evaluating drugs: many more people who take aspirin survive than those who take anti-cancer drugs, but this likely reflects the kind of person who is taking each (people with headaches vs. people who have been diagnosed with cancer). To solve the problem there's no way around randomized trials. So, one idea would be to randomly assign patients to surgeons. (Transparency might still be better on net, but important to keep these issues in mind.)
- conorh 11y ago
  In places where they have implemented outcome tracking they give patients risk scores and adjust based on those scores - which in itself is tough (bias to give patients worse scores), but you have to start somewhere. I've had this discussion a few times and fundamentally I believe that transparency is better than the zero objective information we have now - currently we don't even know how many operations a surgeon does - let alone the outcomes!
- nchammas 11y ago
  > For example, if surgeons knew their success rate were public, they would be incentivized to take easier cases. Who would take a difficult case if they knew it would constitute a bad mark on their record almost for sure? Why would it be a "bad mark" if everyone understood the case was difficult? Given a difficult case, wouldn't a surgeon be graded badly only if they did poorer on average than other surgeons tackling similar cases? As long as a case's "difficulty" is measured in a consistent way, I don't see how surgeons would be incentivized to avoid difficult cases.
  - riahi 11y ago
    How do you measure difficulty? It's a surprisingly hard problem.
    - nchammas 11y ago
      Good question. Perhaps that is one of the root issues here. As a layperson, I wouldn't know how to answer it, but I'm guessing the answer probably involves more rigorously detailing the various aspects of each case so that comparisons can be fairly made across surgeons treating similar cases--apples to apples and all that.

by conorh 11y ago

dbroockman 11y ago

Full transparency could have negative unintended consequences. For example, if surgeons knew their success rate were public, they would be incentivized to take easier cases. Who would take a difficult case if they knew it would constitute a bad mark on their record almost for sure? Fundamentally, the issue is that it's impossible to observe for any given patient if that patient's outcome would have been better with a different surgeon. This is the same challenge we face with evaluating drugs: many more people who take aspirin survive than those who take anti-cancer drugs, but this likely reflects the kind of person who is taking each (people with headaches vs. people who have been diagnosed with cancer). To solve the problem there's no way around randomized trials. So, one idea would be to randomly assign patients to surgeons. (Transparency might still be better on net, but important to keep these issues in mind.)

conorh 11y ago
In places where they have implemented outcome tracking they give patients risk scores and adjust based on those scores - which in itself is tough (bias to give patients worse scores), but you have to start somewhere. I've had this discussion a few times and fundamentally I believe that transparency is better than the zero objective information we have now - currently we don't even know how many operations a surgeon does - let alone the outcomes!
nchammas 11y ago
> For example, if surgeons knew their success rate were public, they would be incentivized to take easier cases. Who would take a difficult case if they knew it would constitute a bad mark on their record almost for sure? Why would it be a "bad mark" if everyone understood the case was difficult? Given a difficult case, wouldn't a surgeon be graded badly only if they did poorer on average than other surgeons tackling similar cases? As long as a case's "difficulty" is measured in a consistent way, I don't see how surgeons would be incentivized to avoid difficult cases.
- riahi 11y ago
  How do you measure difficulty? It's a surprisingly hard problem.
  - nchammas 11y ago
    Good question. Perhaps that is one of the root issues here. As a layperson, I wouldn't know how to answer it, but I'm guessing the answer probably involves more rigorously detailing the various aspects of each case so that comparisons can be fairly made across surgeons treating similar cases--apples to apples and all that.