17 ms·

What happens when patients find out how good their doctors are? (2004)

314 points by adenadel 9y ago

skrap 9y ago
This one is from 2005. But IIRC it launched Gawande's career, and I think it's a great read. I saw him talk a few years after this. Very inspirational!
shkkmo 9y ago
That's a pretty interesting article. While the measurement of performance is critical towards improving it, we need to be careful about how we incentivize that performance. As performance on a metric becomes more economically important, the less useful the metric is in actually measuring performance and the less real improvement can be gained by its measurement.
- pjmorris 9y ago
  aka "When a measure becomes a target, it ceases to be a good measure." - Goodhart's Law [0] [0] https://en.wikipedia.org/wiki/Goodhart%27s_law https://en.wikipedia.org/wiki/Goodhart%27s_law
  - JauntyHatAngle 9y ago
    I like this, a lot, but I feel like I'm going to start incorrectly applying this in too many areas. It's dead true, but also a bit of a catch-all for so many IT scenarios.
- Grae 9y ago
  Only when the metric we're measuring and the dimension we're looking for improvement on differ. This concern doesn't seem to apply to measuring lung capacity.
  - shkkmo 9y ago
    If you tie the bonuses of the people measuring the lung capacity to that lung capacity, then you will make that metric less accurate.
jknz 9y ago
From the article, it seems that there are 2 opposite "evidence based medicine": (a) do research, publish papers, test thoroughly new treatments in well defined trials and slowly build up a biological theory as well as official guidelines and treatments. And (b): measure the outcomes of different hospitals, declare the best performer's methods as the state of the art and expand these methods elsewhere. If the measurement is sound, one can argue that they are both evidence based. The former is slow but may provide a deeper understanding of the inner workings of the deaease. The latter is fast but it's hard to tell exactly why it works so well. The was a shift in machine learning research in recent years. (a): write theoretical papers and study using math the generalization performance of algorithms. (b) release a new challenging dataset every year (except a test set) and organize a prediction competition on this dataset. The winner algorithm is declared the state of the art, and can be applied to other datasets, event though Boone understands why it works so well. The approach (b) was particularly fruitful and efficient in recent years. Let's hope that applying this approach to medicine Will lead to great outcomes!
- make3 9y ago
  The obvious difference here is that no one dies if I start training my new weird deep learning architecture on some challenging training set on an AWS gpu instance and said architecture turns out to be crap. Meanwhile, medicine is a lot less forgiving of wild goose chases, and requiring that the taking of risks is soundly justified seems pretty reasonable, as exciting as the idea of unrelenting research sounds.
  - Hello71 9y ago
    except that people are already dying. it is not the case that nobody dies now and only this newfangled method has some chance of people dying. people are dying now, and the faster we can make fewer people die, the better. even the notoriously slow and bureaucratic US drug approval process recognizes that sometimes new drugs are discovered that are so much better than the status quo that is is unethical to check if there are unknown side effects; it doesn't really matter if someone gets kidney disease ten years down the road if they have advanced cancer right now. edit: of course I agree that the new way is not necessarily better, I'm just saying that the old way is also not necessarily better.
EwanG 9y ago
Not a bad article, but it is from 2004. Might be time for a follow-up.
ams6110 9y ago
> It belies the promise that we make to patients who become seriously ill: that they can count on the medical system to give them their very best chance at life. Medicine makes no such promise. Doctors are going to handle any given condition with the currently accepted "reasonable and prudent" treatment. This is going to be appropriate for the vast majority of patients but it isn't necessarily everyone's "very best chance."
- killjoywashere 9y ago
  I predict that with rigorous study we will find that fully half of all hospitals will be below average.
aleyan 9y ago
This article spent paragraphs describing a normal distribution where a couple of descriptive statistics would do (mean and standard deviation). Ok, I kid, that would be too technical. The old adage still stands though: a picture is worth a thousand words. Instead of showing us what this curve looks like, they wasted the one graphic of their column inches on a useless stethoscope Gordian knot illustration. One a plus side, this article appears to be famous and from 2004. Somebody must have produced graphic of this bell curve of CF outcomes by hospitals. Anybody got a link?
- 2bitencryption 9y ago
  ...we know what the graph would look like. the author knows what the graph would look like, the editor knows what the graph would look like. The article isn't about the curve proves, the article is about what the curve means. (it also says in an early paragraph that you will see different distributions for different diseases/operations; there isn't just one curve)
  - aleyan 9y ago
    I know what a normal distribution looks like, but I have seen too many flaws in data or flaws in characterization of data revealed by graphs of data. If this data and its graph is so earth shaking, show it.
- wavegeek 9y ago
  I actually wonder if it really is a normal distribution. A lot of people think any distribution with spread is a "bell curve". In a lot of fields like this the tails are a lot fatter than they should be in a normal distribution. And doctors (author is a surgeon) don't get much statistical training. I was once told by a doctor that all random distributions are normal curves.
- learnstats2 9y ago
  Worse than that: if all hospitals were functioning perfectly, we would expect to see exactly a bell curve due to small random variations adding up. A bell curve is not evidence that anything is wrong, and in fact it could be taken as evidence that everything is fine: a bell curve suggests that no hospital is doing remarkably badly. So this part of the article makes it into the headline despite telling us nothing, and reduces the credibility of the whole thing.
MarkMc 9y ago
Needs [2004] in the title
- adenadel 9y ago
  Unfortunately, the title already was maxing out the character limit when I submitted.
- dang 9y ago
  We'll add it.
MarkMc 9y ago
The article's author Atul Gawande more recently published a study showing that you are 3 times more likely to die if you are treated in some hospitals compared to others [1] Both the article and study suggest what I believe is a major failing in modern medicine: We should be measuring risk-adjusted outcomes for hospital treatments, then publishing a rating for each hospital on a bell curve. With such an approach, patients will naturally gravitate towards the better hospitals and the poorer hospitals will have an incentive to improve their procedures. Here's something to consider: According to the article, "In 1964... the median estimated age at death for patients in Matthews’s center was twenty-one years, seven times the age of patients treated elsewhere...After Warwick’s report came out, Matthews’s treatment quickly became the standard in this country." If Matthews's treatment had been less spectacular - say only twice the life expectancy of patients treated elsewhere - how much longer would it have taken for his treatment to become the standard? Perhaps never? [1] https://www.nytimes.com/2016/12/14/business/hospitals-death-rates-quality-vary-widely.html https://www.nytimes.com/2016/12/14/business/hospitals-death-...
- SapphireSun 9y ago
  I the interesting thing to consider is what happens to the hospitals that do terribly, but not so poorly that they should be shut down. The publication of their rating will start causing doctors and patients to avoid them. In our fee-for-service model, this causes the hospital to starve and enter a vicious feedback loop. Perhaps we should have an independent commission that has the ability to perform an outside investigation into these cases and attempt to understand what's going wrong. For hospitals that are under-resourced, they would have to power to increase allocations. On the flip side, it could shut down the ones that are irreparably broken that can safely be removed from a region. Also, we should do away with fee-for-service for good. It is the worst bag of incentives this side of the line between healing and hurting.
  - JumpCrisscross 9y ago
    > In our fee-for-service model, this causes the hospital to starve and enter a vicious feedback loop Sounds like an alignment of interests between hospital management and patients.
michaelbuckbee 9y ago
An interesting corollary to this article is this: http://slatestarcodex.com/2017/08/29/my-irb-nightmare/ http://slatestarcodex.com/2017/08/29/my-irb-nightmare/
- epmaybe 9y ago
  Everything in this story is so relevant to my current trials and tribulations with medical IRB approval. I read this monthly just because I need to relate with someone else's experiences.
Barrin92 9y ago
>> What makes the situation especially puzzling is that our system for CF care is far more sophisticated than that for most diseases. The hundred and seventeen CF centers across the country are all ultra-specialized, undergo a rigorous certification process, and have lots of experience in caring for people with CF. They all follow the same detailed guidelines for CF treatment. They all participate in research trials to figure out new and better treatments. You would think, therefore, that their results would be much the same. Yet the differences are enormous. Patients have not known this. So what happens when they find out? Maybe this is simply correct and the variance in care is small, but the regional resources, environmental and other co-factors are distorting the patients results. If income and insurance are lower patients might have to take on more stressful jobs. If education is lower parents might not be able to care as effectively because they don't understand the physician's instructions. Other environmental cofactors in impoverished regions might worsen certain diseases but not do so in others, and so forth. This is a very important point because it might heavily distort how good the care actually is, there was surprisingly little methodology in the article.
WalterBright 9y ago
If health care was free, a problem arises. Everyone will think they're entitled to the best doctor. Who gets the best doctor? Under a market system, the best doctor goes to the patient willing to pay the most.
- rexpop 9y ago
  > Under a market system, [a problem arises.] The best doctor goes to the patient [capable of paying] the most.
  - dogruck 9y ago
    Exactly. Add that to the long list of reasons for working hard to earn more money. It's not just about the bigger house and the faster car -- it's also to get treated by the best doctor. The alternative mechanism amounts to "the best doctor goes to the person who has the most connections and somehow subjugated the most people." That's why elected officials in Congress get to the front of the line.
    - JetSpiegel 9y ago
      > That's why elected officials in Congress get to the front of the line There are more doctors than members of congress, so it's a global improvement on the status quo, unless doctors not treating Congress critters just sit around twiddling their thumbs.
      - pessimizer 9y ago
        It's only an improvement on the status quo if you assume that the status quo is that there are fewer doctors for some reason, or that Congresspeople create an excess of doctors than are needed to treat Congresspeople? What is the "status quo" in this comment?
- Anticapitalist 9y ago
  :s/willing/able
neuro_imager 9y ago
As a physician, I often think about how we lack truely objective assessment of patient outcomes (either in the context of evaluating physician competence or, probably more importantly, assessing and improving upon clinical practises). I would really appreciate insight on how this could be achieved. There are several issues which are particularly vexing: - The distinct lack of verifiable, objective markers of physician competence. - Each patient's case is unique and cases with the highest levels of difficulty are often treated by the most experienced people. These cases, of course, are likely to have worse outcomes than simple cases which may be treated by less experienced (worse?) physicians. - Clinical outcomes are largely recorded by the same people treating the patient so reported outcomes are often erroneous or frankly fraudulent. - This is made worse by the hierarchical nature of clinical medicine and deference to seniority and title. - Medicine is parochial so clinical practises for the same disorder vary tremendously. You might be treated a dozen different ways for the same disorder and presentation depending on the facility and especially on the specialty that ends up treating you. - Outcomes are not necessarily determined by clinician ability. There are several other factors at play: the pre- and post-care (such as work-up by ancillary staff or ICU care after a surgery), the cohesiveness of the facility and its efficiencies (or lack thereof), availability and preferences for resources such as medical devices, drugs and hospital equipment which may be largely out of the hands of the physician.
- lowglow 9y ago
  No lie this sounds like a great fit for a reputation based system of openly evaluated experiments on an immutable, open, decentralized ledger.
  - neuro_imager 9y ago
    By "reputation based", do you mean patient report outcomes or something else? Could you expand on "openly evaluated experiments", maybe with an example?
    - lowglow 9y ago
      Give participants (patients, doctors) access to subscribe to health data or symptoms (input) and create a consensus of possible treatment plans, iterate through those plans ordered by some metric (reputation, time, cost, availability). When cure confirmed by patient, diagnosis is proven correct, data is captured, reputation increased among participants in consensus that were correct. You could even use this as human-in-the-loop machine learning model training for open models. If you want to explore what it might take to build this, we've just launched an alpha of our data/ml network that can facilitate a dapp built on top of Synapse https://synapse.ai/ https://synapse.ai/ Happy to reach out and chat more.
agumonkey 9y ago
Reminds me of Vince DeVita approach to cancer. Never give up, do not care much about standard practice if they fail you. Rant: the medical world is large and stretched, it's impossible to discuss anything with a doctor (you'll have more answers than doctors asked, and they won't tell you all). But whatever they say is godspel (or even more) so if they decide to drop the ball, you will. And if a sibling goes against the doctors advice, you'll only make the situation more tense.
dang 9y ago
Discussed in 2014 at https://news.ycombinator.com/item?id=7664301 https://news.ycombinator.com/item?id=7664301.
Hasz 9y ago
While Warwick and Matthews are both excellent physicians, what if there use of non traditional/peer-reviewed methods ended up shortening someone's life? How does a system as large an bureaucratic as health care allow for individual discretion and experimentation at the individual physician level without harming patients?
creep 9y ago
This is interesting from another angle. I'm not sure if it has been mentioned in the comments but I will go ahead and present it anyways. I was diagnosed with anorexia when I was 14. The physical, medical care that I received at my local children's hospital was alright, and I have no comparison of course. I was refed, kept in bed, and slowly gained weight to a healthy level. However, the psychological treatment was abhorrent. I was sent to an outpatient eating disorder program, which treated both children and adults, at the same hospital. I came from that place at a healthy weight, but with the same ideas about food that I'd always had up to that point. I no longer have an overt eating disorder, but of course they say with these things anorexics are always in recovery. However, it took me four years to learn healthy eating habits on my own. I did not have external help for this at all. It took me four years to teach myself how to eat. I still look back on the eating disorder program with distaste and distrust for the medical system. My point is, it was very obvious to me that my psychological care was not up-to-par, but I still don't know how my medical treatment was-- that is, fixing the parts of my physical body that I'd damaged with malnutrition. Most people think of psychologists, psychiatrists, and therapists in terms of their skill and efficacy. But medical doctors are mostly assumed to be equally proficient. I am not sure what can be done about this particular assumption, but it is very real and can be life-threatening.
avastmick 9y ago
The depth of this article allows thinking beyond the medical domain. Warren Warwick's success because of 'a capacity to learn and adapt—and to do so faster than everyone else.' To do so, there needs to be a fierce consistency of approach to enable easy measurement, yet at the edge a wild experimentalism to ensure improvement. Fascinating. Continuous improvement in action.
brohee 9y ago
The Don Berwick December 1999 speech mentioned in the article is here: https://www.youtube.com/watch?v=00aa6xcOXf4 https://www.youtube.com/watch?v=00aa6xcOXf4
ransom1538 9y ago
Before you have a procedure performed, ask your doctor a simple question: "How many times have you performed this procedure". What I have noticed doctors absolutely hate his question - I have witnessed doctors become visibly angry. I have never once had a doctor answer this question. I have heard answers from: "We don't keep those records" to "We don't keep totals". Are these records not kept? Why wouldn't this be public information? There must be practices with 0 performed procedures completed, and are you patient 1? How can doctors improve if they don't keep transparent numbers of procedures performed, procedures failed, procedures which were successful? "How can you define procedures failed?" - I can hear some say. But that is a discussion these professionals need to have to find incompetence hiding among their ranks.
- wavegeek 9y ago
  You should also ask "how often, recently?". I did ask my surgeon and he answered. But he is pretty exceptional in a number of ways.
- gambiting 9y ago
  The problem with this is that except for some really routine stuff, a lot of operations are really custom-tailored to the patient. This might be a 100th time the surgeon is removing a certain type of tumor, but first time doing it in an obese person, or a child, or someone with rare blood condition, or million other things. Once you get to the real life-saving stuff no two operations are the same, even though on paper they might seem like they are. That's why it's hard to put a number on it.
  - taejo 9y ago
    Sure, but I'd rather have a stomach tumor removed by the surgeon who'd performed twenty custom-tailored stomach tumor removals in the last year than the one who'd done one. My opthalmologist used to do LASIK as part of her regular practice, before deciding it was better to refer patients to somebody who was doing the same type of operation over and over - probably getting five times as much practice or more.
  - lightbyte 9y ago
Timshel 9y ago
Thank you for the repost, I read this article many years ago and was never able to find it again.
ataturk 9y ago
I've been thinking about some of the same issues but with dentists--all the sites to locate dentists are utter garbage and there are no reliable ratings for dentists. Worse, dentists toe (and I argue, cross) the ethical line when it comes to patient care, performing often unnecessary fillings in order to make money. The whole dental industry is a cesspool of shady vendors and salesmen pushing dentists to up sell "patients" and be able to charge bigger bills to insurance.
bawana 9y ago
So why is this 13 yr old article in hacker news? Or rather how? Is there a bot among us?
- buttcoinslol 9y ago
  It's an excellent article that illustrates the difference between 'good' and 'excellent' care and the attention to detail it requires to obtain 'excellent' results. Dr. Warwick's line of questioning that revealed his patient Janelle's reasons for not doing her treatments was illuminating and not every doctor will dig for answers that allow their treatment plan to remain 99.95% effective. After finishing the article, I decided to take inventory of myself and see where I can improve from 99.5 to 99.95 even though my job doesn't deal with life and death patient outcomes. Sometimes articles that aren't about computer touching can make you think about computer touching in a different way, it's good to read a variety of things.
kwhitefoot 9y ago
It isn't necessary to be the best. What is needed is that patient outcomes get better. Those who are at the wrong end of the curve need to acknowledge that they need to do better and those in charge of the system need to assist them to improve. Making payment conditional on results is not likely to have the desired effect, especially if the decision to pay or not is not made by the person actually affected. If anything it will simply drive medics away from difficult areas of expertise. Take the above with the usual scepticism, I'm a software developer after all, not a medic. But it seems to me that you always need to have carrots as well as sticks, or perhaps just carrots.
dennis_jeeves 9y ago
When it comes to chronic cases I would think that the outcomes are more measurable. For example treatment of diabetes or Lyme's disease. Word of mouth, both from patients and other doctors, the internet etc. will work relatively well depending on one's ability to separate wheat from chaff. Any physicians reading this - feel free to contact me, I'm looking for physicians for the long term for my own chronic, but relatively minor health problems. I find the average physician some what mechanical on how they approach a health condition and sometime (1)dismissive of my concerns/views. Since I'm somewhat inclined to dig into details of a health condition, I read up things on the internet and that means I may be more likely to question a doctor's recommendations. (1)= I fully understand why they would normally do it. One certainly cannot entertain a patient who forms an opinion based on the first few articles that they read up on the web, which is what I presume most people do.
iliasku 9y ago
As a patient, i feel that there is a need for the doctors themselves to acknowledge that there is a need to measure their performance and give a way to us patients to take informed decisions. That would be step n.1. once we have established this need we can look on the how this can be done.

314 points by adenadel 9y ago

This one is from 2005. But IIRC it launched Gawande's career, and I think it's a great read. I saw him talk a few years after this. Very inspirational!

shkkmo 9y ago

That's a pretty interesting article. While the measurement of performance is critical towards improving it, we need to be careful about how we incentivize that performance. As performance on a metric becomes more economically important, the less useful the metric is in actually measuring performance and the less real improvement can be gained by its measurement.

pjmorris 9y ago
aka "When a measure becomes a target, it ceases to be a good measure." - Goodhart's Law [0] [0] https://en.wikipedia.org/wiki/Goodhart%27s_law https://en.wikipedia.org/wiki/Goodhart%27s_law
- JauntyHatAngle 9y ago
  I like this, a lot, but I feel like I'm going to start incorrectly applying this in too many areas. It's dead true, but also a bit of a catch-all for so many IT scenarios.
Grae 9y ago
Only when the metric we're measuring and the dimension we're looking for improvement on differ. This concern doesn't seem to apply to measuring lung capacity.
- shkkmo 9y ago
  If you tie the bonuses of the people measuring the lung capacity to that lung capacity, then you will make that metric less accurate.

jknz 9y ago

From the article, it seems that there are 2 opposite "evidence based medicine": (a) do research, publish papers, test thoroughly new treatments in well defined trials and slowly build up a biological theory as well as official guidelines and treatments. And (b): measure the outcomes of different hospitals, declare the best performer's methods as the state of the art and expand these methods elsewhere. If the measurement is sound, one can argue that they are both evidence based. The former is slow but may provide a deeper understanding of the inner workings of the deaease. The latter is fast but it's hard to tell exactly why it works so well. The was a shift in machine learning research in recent years. (a): write theoretical papers and study using math the generalization performance of algorithms. (b) release a new challenging dataset every year (except a test set) and organize a prediction competition on this dataset. The winner algorithm is declared the state of the art, and can be applied to other datasets, event though Boone understands why it works so well. The approach (b) was particularly fruitful and efficient in recent years. Let's hope that applying this approach to medicine Will lead to great outcomes!

make3 9y ago
The obvious difference here is that no one dies if I start training my new weird deep learning architecture on some challenging training set on an AWS gpu instance and said architecture turns out to be crap. Meanwhile, medicine is a lot less forgiving of wild goose chases, and requiring that the taking of risks is soundly justified seems pretty reasonable, as exciting as the idea of unrelenting research sounds.
- Hello71 9y ago
  except that people are already dying. it is not the case that nobody dies now and only this newfangled method has some chance of people dying. people are dying now, and the faster we can make fewer people die, the better. even the notoriously slow and bureaucratic US drug approval process recognizes that sometimes new drugs are discovered that are so much better than the status quo that is is unethical to check if there are unknown side effects; it doesn't really matter if someone gets kidney disease ten years down the road if they have advanced cancer right now. edit: of course I agree that the new way is not necessarily better, I'm just saying that the old way is also not necessarily better.

EwanG 9y ago

Not a bad article, but it is from 2004. Might be time for a follow-up.

ams6110 9y ago

> It belies the promise that we make to patients who become seriously ill: that they can count on the medical system to give them their very best chance at life. Medicine makes no such promise. Doctors are going to handle any given condition with the currently accepted "reasonable and prudent" treatment. This is going to be appropriate for the vast majority of patients but it isn't necessarily everyone's "very best chance."

killjoywashere 9y ago
I predict that with rigorous study we will find that fully half of all hospitals will be below average.

aleyan 9y ago

This article spent paragraphs describing a normal distribution where a couple of descriptive statistics would do (mean and standard deviation). Ok, I kid, that would be too technical. The old adage still stands though: a picture is worth a thousand words. Instead of showing us what this curve looks like, they wasted the one graphic of their column inches on a useless stethoscope Gordian knot illustration. One a plus side, this article appears to be famous and from 2004. Somebody must have produced graphic of this bell curve of CF outcomes by hospitals. Anybody got a link?

2bitencryption 9y ago
...we know what the graph would look like. the author knows what the graph would look like, the editor knows what the graph would look like. The article isn't about the curve proves, the article is about what the curve means. (it also says in an early paragraph that you will see different distributions for different diseases/operations; there isn't just one curve)
- aleyan 9y ago
  I know what a normal distribution looks like, but I have seen too many flaws in data or flaws in characterization of data revealed by graphs of data. If this data and its graph is so earth shaking, show it.
wavegeek 9y ago
I actually wonder if it really is a normal distribution. A lot of people think any distribution with spread is a "bell curve". In a lot of fields like this the tails are a lot fatter than they should be in a normal distribution. And doctors (author is a surgeon) don't get much statistical training. I was once told by a doctor that all random distributions are normal curves.
learnstats2 9y ago
Worse than that: if all hospitals were functioning perfectly, we would expect to see exactly a bell curve due to small random variations adding up. A bell curve is not evidence that anything is wrong, and in fact it could be taken as evidence that everything is fine: a bell curve suggests that no hospital is doing remarkably badly. So this part of the article makes it into the headline despite telling us nothing, and reduces the credibility of the whole thing.

MarkMc 9y ago

Needs [2004] in the title

adenadel 9y ago
Unfortunately, the title already was maxing out the character limit when I submitted.
dang 9y ago
We'll add it.

MarkMc 9y ago

The article's author Atul Gawande more recently published a study showing that you are 3 times more likely to die if you are treated in some hospitals compared to others [1] Both the article and study suggest what I believe is a major failing in modern medicine: We should be measuring risk-adjusted outcomes for hospital treatments, then publishing a rating for each hospital on a bell curve. With such an approach, patients will naturally gravitate towards the better hospitals and the poorer hospitals will have an incentive to improve their procedures. Here's something to consider: According to the article, "In 1964... the median estimated age at death for patients in Matthews’s center was twenty-one years, seven times the age of patients treated elsewhere...After Warwick’s report came out, Matthews’s treatment quickly became the standard in this country." If Matthews's treatment had been less spectacular - say only twice the life expectancy of patients treated elsewhere - how much longer would it have taken for his treatment to become the standard? Perhaps never? [1] https://www.nytimes.com/2016/12/14/business/hospitals-death-rates-quality-vary-widely.html https://www.nytimes.com/2016/12/14/business/hospitals-death-...

SapphireSun 9y ago
I the interesting thing to consider is what happens to the hospitals that do terribly, but not so poorly that they should be shut down. The publication of their rating will start causing doctors and patients to avoid them. In our fee-for-service model, this causes the hospital to starve and enter a vicious feedback loop. Perhaps we should have an independent commission that has the ability to perform an outside investigation into these cases and attempt to understand what's going wrong. For hospitals that are under-resourced, they would have to power to increase allocations. On the flip side, it could shut down the ones that are irreparably broken that can safely be removed from a region. Also, we should do away with fee-for-service for good. It is the worst bag of incentives this side of the line between healing and hurting.
- JumpCrisscross 9y ago
  > In our fee-for-service model, this causes the hospital to starve and enter a vicious feedback loop Sounds like an alignment of interests between hospital management and patients.

michaelbuckbee 9y ago

An interesting corollary to this article is this: http://slatestarcodex.com/2017/08/29/my-irb-nightmare/ http://slatestarcodex.com/2017/08/29/my-irb-nightmare/

epmaybe 9y ago
Everything in this story is so relevant to my current trials and tribulations with medical IRB approval. I read this monthly just because I need to relate with someone else's experiences.

Barrin92 9y ago

>> What makes the situation especially puzzling is that our system for CF care is far more sophisticated than that for most diseases. The hundred and seventeen CF centers across the country are all ultra-specialized, undergo a rigorous certification process, and have lots of experience in caring for people with CF. They all follow the same detailed guidelines for CF treatment. They all participate in research trials to figure out new and better treatments. You would think, therefore, that their results would be much the same. Yet the differences are enormous. Patients have not known this. So what happens when they find out? Maybe this is simply correct and the variance in care is small, but the regional resources, environmental and other co-factors are distorting the patients results. If income and insurance are lower patients might have to take on more stressful jobs. If education is lower parents might not be able to care as effectively because they don't understand the physician's instructions. Other environmental cofactors in impoverished regions might worsen certain diseases but not do so in others, and so forth. This is a very important point because it might heavily distort how good the care actually is, there was surprisingly little methodology in the article.

WalterBright 9y ago

If health care was free, a problem arises. Everyone will think they're entitled to the best doctor. Who gets the best doctor? Under a market system, the best doctor goes to the patient willing to pay the most.

rexpop 9y ago
> Under a market system, [a problem arises.] The best doctor goes to the patient [capable of paying] the most.
- dogruck 9y ago
  Exactly. Add that to the long list of reasons for working hard to earn more money. It's not just about the bigger house and the faster car -- it's also to get treated by the best doctor. The alternative mechanism amounts to "the best doctor goes to the person who has the most connections and somehow subjugated the most people." That's why elected officials in Congress get to the front of the line.
  - JetSpiegel 9y ago
    > That's why elected officials in Congress get to the front of the line There are more doctors than members of congress, so it's a global improvement on the status quo, unless doctors not treating Congress critters just sit around twiddling their thumbs.
    - pessimizer 9y ago
      It's only an improvement on the status quo if you assume that the status quo is that there are fewer doctors for some reason, or that Congresspeople create an excess of doctors than are needed to treat Congresspeople? What is the "status quo" in this comment?
Anticapitalist 9y ago
:s/willing/able

neuro_imager 9y ago

As a physician, I often think about how we lack truely objective assessment of patient outcomes (either in the context of evaluating physician competence or, probably more importantly, assessing and improving upon clinical practises). I would really appreciate insight on how this could be achieved. There are several issues which are particularly vexing: - The distinct lack of verifiable, objective markers of physician competence. - Each patient's case is unique and cases with the highest levels of difficulty are often treated by the most experienced people. These cases, of course, are likely to have worse outcomes than simple cases which may be treated by less experienced (worse?) physicians. - Clinical outcomes are largely recorded by the same people treating the patient so reported outcomes are often erroneous or frankly fraudulent. - This is made worse by the hierarchical nature of clinical medicine and deference to seniority and title. - Medicine is parochial so clinical practises for the same disorder vary tremendously. You might be treated a dozen different ways for the same disorder and presentation depending on the facility and especially on the specialty that ends up treating you. - Outcomes are not necessarily determined by clinician ability. There are several other factors at play: the pre- and post-care (such as work-up by ancillary staff or ICU care after a surgery), the cohesiveness of the facility and its efficiencies (or lack thereof), availability and preferences for resources such as medical devices, drugs and hospital equipment which may be largely out of the hands of the physician.

lowglow 9y ago
No lie this sounds like a great fit for a reputation based system of openly evaluated experiments on an immutable, open, decentralized ledger.
- neuro_imager 9y ago
  By "reputation based", do you mean patient report outcomes or something else? Could you expand on "openly evaluated experiments", maybe with an example?
  - lowglow 9y ago
    Give participants (patients, doctors) access to subscribe to health data or symptoms (input) and create a consensus of possible treatment plans, iterate through those plans ordered by some metric (reputation, time, cost, availability). When cure confirmed by patient, diagnosis is proven correct, data is captured, reputation increased among participants in consensus that were correct. You could even use this as human-in-the-loop machine learning model training for open models. If you want to explore what it might take to build this, we've just launched an alpha of our data/ml network that can facilitate a dapp built on top of Synapse https://synapse.ai/ https://synapse.ai/ Happy to reach out and chat more.

agumonkey 9y ago

Reminds me of Vince DeVita approach to cancer. Never give up, do not care much about standard practice if they fail you. Rant: the medical world is large and stretched, it's impossible to discuss anything with a doctor (you'll have more answers than doctors asked, and they won't tell you all). But whatever they say is godspel (or even more) so if they decide to drop the ball, you will. And if a sibling goes against the doctors advice, you'll only make the situation more tense.

dang 9y ago

Discussed in 2014 at https://news.ycombinator.com/item?id=7664301 https://news.ycombinator.com/item?id=7664301.

Hasz 9y ago

While Warwick and Matthews are both excellent physicians, what if there use of non traditional/peer-reviewed methods ended up shortening someone's life? How does a system as large an bureaucratic as health care allow for individual discretion and experimentation at the individual physician level without harming patients?

creep 9y ago

This is interesting from another angle. I'm not sure if it has been mentioned in the comments but I will go ahead and present it anyways. I was diagnosed with anorexia when I was 14. The physical, medical care that I received at my local children's hospital was alright, and I have no comparison of course. I was refed, kept in bed, and slowly gained weight to a healthy level. However, the psychological treatment was abhorrent. I was sent to an outpatient eating disorder program, which treated both children and adults, at the same hospital. I came from that place at a healthy weight, but with the same ideas about food that I'd always had up to that point. I no longer have an overt eating disorder, but of course they say with these things anorexics are always in recovery. However, it took me four years to learn healthy eating habits on my own. I did not have external help for this at all. It took me four years to teach myself how to eat. I still look back on the eating disorder program with distaste and distrust for the medical system. My point is, it was very obvious to me that my psychological care was not up-to-par, but I still don't know how my medical treatment was-- that is, fixing the parts of my physical body that I'd damaged with malnutrition. Most people think of psychologists, psychiatrists, and therapists in terms of their skill and efficacy. But medical doctors are mostly assumed to be equally proficient. I am not sure what can be done about this particular assumption, but it is very real and can be life-threatening.

avastmick 9y ago

The depth of this article allows thinking beyond the medical domain. Warren Warwick's success because of 'a capacity to learn and adapt—and to do so faster than everyone else.' To do so, there needs to be a fierce consistency of approach to enable easy measurement, yet at the edge a wild experimentalism to ensure improvement. Fascinating. Continuous improvement in action.

brohee 9y ago

The Don Berwick December 1999 speech mentioned in the article is here: https://www.youtube.com/watch?v=00aa6xcOXf4 https://www.youtube.com/watch?v=00aa6xcOXf4

ransom1538 9y ago

Before you have a procedure performed, ask your doctor a simple question: "How many times have you performed this procedure". What I have noticed doctors absolutely hate his question - I have witnessed doctors become visibly angry. I have never once had a doctor answer this question. I have heard answers from: "We don't keep those records" to "We don't keep totals". Are these records not kept? Why wouldn't this be public information? There must be practices with 0 performed procedures completed, and are you patient 1? How can doctors improve if they don't keep transparent numbers of procedures performed, procedures failed, procedures which were successful? "How can you define procedures failed?" - I can hear some say. But that is a discussion these professionals need to have to find incompetence hiding among their ranks.

wavegeek 9y ago
You should also ask "how often, recently?". I did ask my surgeon and he answered. But he is pretty exceptional in a number of ways.
gambiting 9y ago
The problem with this is that except for some really routine stuff, a lot of operations are really custom-tailored to the patient. This might be a 100th time the surgeon is removing a certain type of tumor, but first time doing it in an obese person, or a child, or someone with rare blood condition, or million other things. Once you get to the real life-saving stuff no two operations are the same, even though on paper they might seem like they are. That's why it's hard to put a number on it.
- taejo 9y ago
  Sure, but I'd rather have a stomach tumor removed by the surgeon who'd performed twenty custom-tailored stomach tumor removals in the last year than the one who'd done one. My opthalmologist used to do LASIK as part of her regular practice, before deciding it was better to refer patients to somebody who was doing the same type of operation over and over - probably getting five times as much practice or more.
- lightbyte 9y ago

Timshel 9y ago

Thank you for the repost, I read this article many years ago and was never able to find it again.

ataturk 9y ago

I've been thinking about some of the same issues but with dentists--all the sites to locate dentists are utter garbage and there are no reliable ratings for dentists. Worse, dentists toe (and I argue, cross) the ethical line when it comes to patient care, performing often unnecessary fillings in order to make money. The whole dental industry is a cesspool of shady vendors and salesmen pushing dentists to up sell "patients" and be able to charge bigger bills to insurance.

bawana 9y ago

So why is this 13 yr old article in hacker news? Or rather how? Is there a bot among us?

buttcoinslol 9y ago
It's an excellent article that illustrates the difference between 'good' and 'excellent' care and the attention to detail it requires to obtain 'excellent' results. Dr. Warwick's line of questioning that revealed his patient Janelle's reasons for not doing her treatments was illuminating and not every doctor will dig for answers that allow their treatment plan to remain 99.95% effective. After finishing the article, I decided to take inventory of myself and see where I can improve from 99.5 to 99.95 even though my job doesn't deal with life and death patient outcomes. Sometimes articles that aren't about computer touching can make you think about computer touching in a different way, it's good to read a variety of things.

kwhitefoot 9y ago

It isn't necessary to be the best. What is needed is that patient outcomes get better. Those who are at the wrong end of the curve need to acknowledge that they need to do better and those in charge of the system need to assist them to improve. Making payment conditional on results is not likely to have the desired effect, especially if the decision to pay or not is not made by the person actually affected. If anything it will simply drive medics away from difficult areas of expertise. Take the above with the usual scepticism, I'm a software developer after all, not a medic. But it seems to me that you always need to have carrots as well as sticks, or perhaps just carrots.

dennis_jeeves 9y ago

When it comes to chronic cases I would think that the outcomes are more measurable. For example treatment of diabetes or Lyme's disease. Word of mouth, both from patients and other doctors, the internet etc. will work relatively well depending on one's ability to separate wheat from chaff. Any physicians reading this - feel free to contact me, I'm looking for physicians for the long term for my own chronic, but relatively minor health problems. I find the average physician some what mechanical on how they approach a health condition and sometime (1)dismissive of my concerns/views. Since I'm somewhat inclined to dig into details of a health condition, I read up things on the internet and that means I may be more likely to question a doctor's recommendations. (1)= I fully understand why they would normally do it. One certainly cannot entertain a patient who forms an opinion based on the first few articles that they read up on the web, which is what I presume most people do.

iliasku 9y ago

As a patient, i feel that there is a need for the doctors themselves to acknowledge that there is a need to measure their performance and give a way to us patients to take informed decisions. That would be step n.1. once we have established this need we can look on the how this can be done.