4 ms·

In my mind it gets worse when the procedure is identified: A difficult shoulder surgery by an orthopedic surgeon gets refused because it might be result in a me

by lcuff 5y ago

In my mind it gets worse when the procedure is identified: A difficult shoulder surgery by an orthopedic surgeon gets refused because it might be result in a mediocre outcome and lower his 'success' rate. The patient can't get the surgery because no surgeon wants to 'risk' his success rate numbers.

grog454 5y ago
Seems like a good system to me. If a doctor expects a lower than average success rate for performing some specific operation, he should let some other doctor do it anyway.
- rscho 5y ago
  Other doctors? And where will you find those? No one will ever touch you, except if you pay more. Pay more for worse outcomes, really.
- lcuff 5y ago
  In my mind it is not a good system, because if the surgeon is looking at a much-more-difficult than average circumstance, than he could reasonably expect a lower-than-average result, but a result that might be much better than average for a case so difficult. As a separate observation, any time data is kept, turned into metrics that then become the basis for goals ("I want to have a better-than-average success rate, as a surgeon") then the system gets gamed. I had a boss once propose to down-rate agile teams that didn't get done everything they took on in a sprint. He apparently didn't realize that teams would immediate game the system by taking on less actual work. They could up their 'point' estimates for each task, and always get the work done.
  - grog454 5y ago
    I think you are right that there is a natural and understandable psychological resistance to a data-based evaluation system. I understand that the doctor may realize something about the patient that will lower his/her chances of success. I'm arguing that a sufficiently comprehensive system would take in to account whatever that doctor realized (and perhaps much more) and compensate for it when determining expected outcomes.
    - lcuff 5y ago
      I'm guessing that the bureaucracy of such a system would be a significant burden. To avoid having the system badly gamed, you'd need a second evaluation, yes? By a _neutral_ party, (not a doctor working in the same practice, e.g.) At added cost and time. Not to mention I've heard more than one surgeon say "That was more difficult than I expected based on the imaging ... once we got in there we found <>". I'm also arguing that it's not just a psychological resistance to a data-based evaluation system. That people understand the system would be subject to being gamed, and the overall quality of the work would actually suffer. (A bit analogous to how peer-review and the tenure game has interfered with good science practices.)
    - LorenPechtel 5y ago
      This assumes a level of knowledge that simply doesn't exist. A simple illustration: I have medical issues with no meaningful diagnosis, despite seeing many doctors. If the medical community can't figure out what's wrong, how can they have an understanding of all the relevant factors in determining risk?
      - grog454 5y ago
        > I have medical issues with no meaningful diagnosis, despite seeing many doctors. This isn't directly related to your point, but why is this even the norm? Why are you going from human to human seeking answers to some arcane mystery like you're on a Skyrim quest. Imagine a system where you wouldn't need to see any doctors. You would type in all of your symptoms as accurately as you can with as much detail as you can, perhaps with a timeline, and as output you'd get the most likely causes (a diagnosis). Maybe that system would even have your medical history (and that of other people and related diagnoses) to better predictions. It seems to me that a system like this would be significantly better than going to a couple of humans that are arbitrarily local to you and asking them to figure it out. It is slowly improving all the time just in the form of Google and WebMD. Even before 2010 I accurately diagnosed myself with Bell's palsy with the internet and the doctor begrudgingly asked how I had made that diagnosis. Confirmation from the human doctor was nice but redundant.
- PeterisP 5y ago
  If a doctor estimates that this particular patient+disease+procedure combination has a lower chance of success than the average patient who needs a similar category of procedure, then unless they're severely mistaken, every other doctor will also estimate the same way and refuse that difficult case.
- refurb 5y ago
  Agree if there is another doctor who feels they could have a better success . And this does happen, doctor will say "I don't feel comfortable doing this". But there may be no other doctor. Think of this way - if you're a doctor specializing in the treatment of septicemia, a lot of your patients will die. If you're really good, you'll likely get the hardest cases. So your "success rate" may be lower than another doctor who isn't as good but doesn't see such tough cases.

by lcuff 5y ago

grog454 5y ago

Seems like a good system to me. If a doctor expects a lower than average success rate for performing some specific operation, he should let some other doctor do it anyway.

rscho 5y ago
Other doctors? And where will you find those? No one will ever touch you, except if you pay more. Pay more for worse outcomes, really.
lcuff 5y ago
In my mind it is not a good system, because if the surgeon is looking at a much-more-difficult than average circumstance, than he could reasonably expect a lower-than-average result, but a result that might be much better than average for a case so difficult. As a separate observation, any time data is kept, turned into metrics that then become the basis for goals ("I want to have a better-than-average success rate, as a surgeon") then the system gets gamed. I had a boss once propose to down-rate agile teams that didn't get done everything they took on in a sprint. He apparently didn't realize that teams would immediate game the system by taking on less actual work. They could up their 'point' estimates for each task, and always get the work done.
- grog454 5y ago
  I think you are right that there is a natural and understandable psychological resistance to a data-based evaluation system. I understand that the doctor may realize something about the patient that will lower his/her chances of success. I'm arguing that a sufficiently comprehensive system would take in to account whatever that doctor realized (and perhaps much more) and compensate for it when determining expected outcomes.
  - lcuff 5y ago
    I'm guessing that the bureaucracy of such a system would be a significant burden. To avoid having the system badly gamed, you'd need a second evaluation, yes? By a _neutral_ party, (not a doctor working in the same practice, e.g.) At added cost and time. Not to mention I've heard more than one surgeon say "That was more difficult than I expected based on the imaging ... once we got in there we found <>". I'm also arguing that it's not just a psychological resistance to a data-based evaluation system. That people understand the system would be subject to being gamed, and the overall quality of the work would actually suffer. (A bit analogous to how peer-review and the tenure game has interfered with good science practices.)
  - LorenPechtel 5y ago
    This assumes a level of knowledge that simply doesn't exist. A simple illustration: I have medical issues with no meaningful diagnosis, despite seeing many doctors. If the medical community can't figure out what's wrong, how can they have an understanding of all the relevant factors in determining risk?
    - grog454 5y ago
      > I have medical issues with no meaningful diagnosis, despite seeing many doctors. This isn't directly related to your point, but why is this even the norm? Why are you going from human to human seeking answers to some arcane mystery like you're on a Skyrim quest. Imagine a system where you wouldn't need to see any doctors. You would type in all of your symptoms as accurately as you can with as much detail as you can, perhaps with a timeline, and as output you'd get the most likely causes (a diagnosis). Maybe that system would even have your medical history (and that of other people and related diagnoses) to better predictions. It seems to me that a system like this would be significantly better than going to a couple of humans that are arbitrarily local to you and asking them to figure it out. It is slowly improving all the time just in the form of Google and WebMD. Even before 2010 I accurately diagnosed myself with Bell's palsy with the internet and the doctor begrudgingly asked how I had made that diagnosis. Confirmation from the human doctor was nice but redundant.
PeterisP 5y ago
If a doctor estimates that this particular patient+disease+procedure combination has a lower chance of success than the average patient who needs a similar category of procedure, then unless they're severely mistaken, every other doctor will also estimate the same way and refuse that difficult case.
refurb 5y ago
Agree if there is another doctor who feels they could have a better success . And this does happen, doctor will say "I don't feel comfortable doing this". But there may be no other doctor. Think of this way - if you're a doctor specializing in the treatment of septicemia, a lot of your patients will die. If you're really good, you'll likely get the hardest cases. So your "success rate" may be lower than another doctor who isn't as good but doesn't see such tough cases.