4 ms·

I gather you are not a healthcare professional, hence the artificial dichotomy stemming from your perception as an outsider. Medical competency is very difficul

by rscho 4y ago

I gather you are not a healthcare professional, hence the artificial dichotomy stemming from your perception as an outsider. Medical competency is very difficult to assess objectively. You're good/bad because people say so. There isn't any form of performance feedback.

chiefalchemist 4y ago
How can that be? A patient gets diagnosed. There's treatment. There's an outcome. That can't be measured? And assessed? There's data flowing all over the place. But perhaps the lawyers and the insurance stand in the way of improvement?
- rscho 4y ago
  Insurance, precisely. Insurance companies are pushing for performance assessment to put pressure on prices. All well and good until you understand that you can't force hospitals/practitioners to all get a random sample of patients. So measurements are biased, and therefore people game the system. In practice, it means all healthcare providers will concentrate on easy cases to lower risk and maximize revenue. So as you see, free market thought doesn't really work in healthcare.
- nradov 4y ago
  It's not a legal or insurance issue, it's a data gathering and classification issue. There is no such thing as a standard patient. Especially when it comes to surgical procedures, everyone is unique. We generally don't have ways to accurately assess the impact of factors like patient age, fitness level, body composition, and co-morbid conditions. So instituting a quality measurement system like you describe would have the perverse effect of causing physicians to keep their numbers up by refusing to take the riskiest patients on at all.
- giantg2 4y ago
  There are too many variables. You could have two people with the same diagnosis but one has a complication. Even if you do everything 'right' the success isn't 100% because there are slight variations in people and diseases.
  - chiefalchemist 4y ago
    Agreed. All the more reason to look for patterns of what works or what might not. The human body is complex. Why not look for as much help as possible?
    - nradov 4y ago
      We don't even know what all the factors are, and we don't have a practical or affordable way to gather and record all that data in a high-quality, consistent manner.
      - chiefalchemist 4y ago
        So we don't even start to try? That's not a good enough reason. Given the social and financial magnitude the excuse is nearly criminal.
        rscho 4y ago
        We do try. But what we've got is not nearly good enough. You underestimate the messiness and overestimate the information retrieval capabilities of healthcare systems.
        chiefalchemist 4y ago
        Oh. I understand the healthcare system's systems are a shitshow. I've seen it first hand. FFS the staff isn't even aware of the importance of sleep (i.e., lights left on, TV left blasting). But. If they can identify the importance of hand sanitation and implement programs to ensure that, then there is hope. But as it is, it feels like the land of "that's how we've always done things." Note: this isn't only hospitals but extended care facilities. They're printing money on the backs of the suffering and losses of others. Do no harm?? Perhaps it once meant something. No much anymore.
        nradov 4y ago
        It's always disappointing to see comments like this on HN by arrogant, ignorant technologists who haven't done their homework and fail to understand the complexities of healthcare delivery. Biology is a lot harder than software or engineering. There are many researchers working in this area but outside of a few limited areas they haven't succeeded in creating models that are useful for assessing the quality of individual practitioners. And that generally wouldn't even be useful since healthcare is a team activity where systems matter more than individuals. We can do somewhat better at measuring quality for larger provider organizations across patient populations. The NCQA HEDIS measures are evidence based and reflect current consensus on best practices. https://www.ncqa.org/hedis/ https://www.ncqa.org/hedis/
- aidenn0 4y ago
  One example of how it can go wrong: GP: This condition X is much worse than normal, so I'm going to refer you to Dr. A, the best I know in the field. Aggregate enough of this and Dr. A has worse outcomes on paper for condition X than everybody else, since s/he gets the patients with the hardest to treat coming in.
reader_x 4y ago
Anecdote here, but my friend who is an anesthesiologist (MD) says:(1) anesthesiologists know exactly who the good and bad surgeons are (they see the outcomes and also must manage fluid loss), and (2) bedside manner by surgeons has no correlation to good surgical technique so patients have no idea.
- rscho 4y ago
  Am also MD and anesthesiologist. This is partly true. The true part is because anesthesiologists are more able to appreciate medical abilities than the layman is. The false part is that people, including colleagues, tend to judge on what they see and hear. Oftentimes, you won't work every day with the same surgeon, so you actually have no idea regarding success/failure statistics. That's why I said you're what people say you are. Heck, I don't know my own statistics and I don't know where I stand in comparison to my colleagues. Yet I enjoy a very good reputation with colleagues, but patients often are weary of me because I'm socially awkward.
  - pnutjam 4y ago
    I believe "wary" is the work you're looking for. This means the are guarded and maybe suspicious. Weary means tired.
    - rscho 4y ago
      Yes thanks, autocorrect :-)
      - slowhand09 4y ago
        *"ought-to-correct""
- spaetzleesser 4y ago
  I work at a medical device company and I also had reps warn me of certain surgeons when I looked for one for a friend.
- 4y ago
renewiltord 4y ago
There are lots of reasons why it is not easy to determine surgeon performance but it's not impossible. I'll let you make some quick inferences using this video https://www.nejm.org/do/10.1056/NEJMdo004274/full/?requestType=popUp&amp%3BrelatedArticle=10.1056%2FNEJMsa1300625 https://www.nejm.org/do/10.1056/NEJMdo004274/full/?requestTy... from this paper https://www.nejm.org/doi/full/10.1056/NEJMsa1300625 https://www.nejm.org/doi/full/10.1056/NEJMsa1300625 Crucially, if you can get someone to hide which surgeon is skillful and which one is not and view the video and judge for yourself, you might be surprised at your skill in differentiation. In my experience, my friends have 100% guessed which surgeon is better correctly. So it is possible that this is Sorites-style.
- rscho 4y ago
  From everyday work experience, I strongly believe people to be totally unable to fairly assess a surgeon in an everyday clinical context. Looks, manners and personal sympathies are the main drivers for that kind of judgment. I know a surgeon with a substantial rate of spectacular failure and a very bad reputation. But most of the time, outcomes are excellent. Is that a bad surgeon on average? No idea. And Im in the OR every day.
  - renewiltord 4y ago
    FWIW, in this respect, I'm just relaying from my parents: dad's an ortho trauma surgeon who now runs a trauma department, and mum's an ophthal surgeon. As much as I'd like to claim I'm casually reading the NEJM every day, I've only ever read papers they share with me, which they do at an annoying frequency considering I'm in trading. I assume the general silent belief would be that your guy with the spectacular failure is some kind of "take the tough cases" dude? By the way, when I was much younger (maybe 10-15 years ago), I recall my dad coming back from an AO Foundation conference where there was a talk about some particular procedure in some Scandinavian country where the range of outcome quality was so high for a particular non-emergency THR/TKR or something like that and so they shut down the procedure in the remote hospitals and centralized it in a few (3?) tertiary healthcare centres. Do you recall something like that? I have this memory in my head but I can't find the original material. The story is so good: EBM driving patient outcomes; but I can't find it so I don't share it and I would like very much to, if it is true.

by rscho 4y ago

chiefalchemist 4y ago

How can that be? A patient gets diagnosed. There's treatment. There's an outcome. That can't be measured? And assessed? There's data flowing all over the place. But perhaps the lawyers and the insurance stand in the way of improvement?

rscho 4y ago
Insurance, precisely. Insurance companies are pushing for performance assessment to put pressure on prices. All well and good until you understand that you can't force hospitals/practitioners to all get a random sample of patients. So measurements are biased, and therefore people game the system. In practice, it means all healthcare providers will concentrate on easy cases to lower risk and maximize revenue. So as you see, free market thought doesn't really work in healthcare.
nradov 4y ago
It's not a legal or insurance issue, it's a data gathering and classification issue. There is no such thing as a standard patient. Especially when it comes to surgical procedures, everyone is unique. We generally don't have ways to accurately assess the impact of factors like patient age, fitness level, body composition, and co-morbid conditions. So instituting a quality measurement system like you describe would have the perverse effect of causing physicians to keep their numbers up by refusing to take the riskiest patients on at all.
giantg2 4y ago
There are too many variables. You could have two people with the same diagnosis but one has a complication. Even if you do everything 'right' the success isn't 100% because there are slight variations in people and diseases.
- chiefalchemist 4y ago
  Agreed. All the more reason to look for patterns of what works or what might not. The human body is complex. Why not look for as much help as possible?
  - nradov 4y ago
    We don't even know what all the factors are, and we don't have a practical or affordable way to gather and record all that data in a high-quality, consistent manner.
    - chiefalchemist 4y ago
      So we don't even start to try? That's not a good enough reason. Given the social and financial magnitude the excuse is nearly criminal.
      - rscho 4y ago
        We do try. But what we've got is not nearly good enough. You underestimate the messiness and overestimate the information retrieval capabilities of healthcare systems.
        chiefalchemist 4y ago
        Oh. I understand the healthcare system's systems are a shitshow. I've seen it first hand. FFS the staff isn't even aware of the importance of sleep (i.e., lights left on, TV left blasting). But. If they can identify the importance of hand sanitation and implement programs to ensure that, then there is hope. But as it is, it feels like the land of "that's how we've always done things." Note: this isn't only hospitals but extended care facilities. They're printing money on the backs of the suffering and losses of others. Do no harm?? Perhaps it once meant something. No much anymore.
      - nradov 4y ago
        It's always disappointing to see comments like this on HN by arrogant, ignorant technologists who haven't done their homework and fail to understand the complexities of healthcare delivery. Biology is a lot harder than software or engineering. There are many researchers working in this area but outside of a few limited areas they haven't succeeded in creating models that are useful for assessing the quality of individual practitioners. And that generally wouldn't even be useful since healthcare is a team activity where systems matter more than individuals. We can do somewhat better at measuring quality for larger provider organizations across patient populations. The NCQA HEDIS measures are evidence based and reflect current consensus on best practices. https://www.ncqa.org/hedis/ https://www.ncqa.org/hedis/
aidenn0 4y ago
One example of how it can go wrong: GP: This condition X is much worse than normal, so I'm going to refer you to Dr. A, the best I know in the field. Aggregate enough of this and Dr. A has worse outcomes on paper for condition X than everybody else, since s/he gets the patients with the hardest to treat coming in.

reader_x 4y ago

Anecdote here, but my friend who is an anesthesiologist (MD) says:(1) anesthesiologists know exactly who the good and bad surgeons are (they see the outcomes and also must manage fluid loss), and (2) bedside manner by surgeons has no correlation to good surgical technique so patients have no idea.

rscho 4y ago
Am also MD and anesthesiologist. This is partly true. The true part is because anesthesiologists are more able to appreciate medical abilities than the layman is. The false part is that people, including colleagues, tend to judge on what they see and hear. Oftentimes, you won't work every day with the same surgeon, so you actually have no idea regarding success/failure statistics. That's why I said you're what people say you are. Heck, I don't know my own statistics and I don't know where I stand in comparison to my colleagues. Yet I enjoy a very good reputation with colleagues, but patients often are weary of me because I'm socially awkward.
- pnutjam 4y ago
  I believe "wary" is the work you're looking for. This means the are guarded and maybe suspicious. Weary means tired.
  - rscho 4y ago
    Yes thanks, autocorrect :-)
    - slowhand09 4y ago
      *"ought-to-correct""
spaetzleesser 4y ago
I work at a medical device company and I also had reps warn me of certain surgeons when I looked for one for a friend.
4y ago

renewiltord 4y ago

There are lots of reasons why it is not easy to determine surgeon performance but it's not impossible. I'll let you make some quick inferences using this video https://www.nejm.org/do/10.1056/NEJMdo004274/full/?requestType=popUp&amp%3BrelatedArticle=10.1056%2FNEJMsa1300625 https://www.nejm.org/do/10.1056/NEJMdo004274/full/?requestTy... from this paper https://www.nejm.org/doi/full/10.1056/NEJMsa1300625 https://www.nejm.org/doi/full/10.1056/NEJMsa1300625 Crucially, if you can get someone to hide which surgeon is skillful and which one is not and view the video and judge for yourself, you might be surprised at your skill in differentiation. In my experience, my friends have 100% guessed which surgeon is better correctly. So it is possible that this is Sorites-style.

rscho 4y ago
From everyday work experience, I strongly believe people to be totally unable to fairly assess a surgeon in an everyday clinical context. Looks, manners and personal sympathies are the main drivers for that kind of judgment. I know a surgeon with a substantial rate of spectacular failure and a very bad reputation. But most of the time, outcomes are excellent. Is that a bad surgeon on average? No idea. And Im in the OR every day.
- renewiltord 4y ago
  FWIW, in this respect, I'm just relaying from my parents: dad's an ortho trauma surgeon who now runs a trauma department, and mum's an ophthal surgeon. As much as I'd like to claim I'm casually reading the NEJM every day, I've only ever read papers they share with me, which they do at an annoying frequency considering I'm in trading. I assume the general silent belief would be that your guy with the spectacular failure is some kind of "take the tough cases" dude? By the way, when I was much younger (maybe 10-15 years ago), I recall my dad coming back from an AO Foundation conference where there was a talk about some particular procedure in some Scandinavian country where the range of outcome quality was so high for a particular non-emergency THR/TKR or something like that and so they shut down the procedure in the remote hospitals and centralized it in a few (3?) tertiary healthcare centres. Do you recall something like that? I have this memory in my head but I can't find the original material. The story is so good: EBM driving patient outcomes; but I can't find it so I don't share it and I would like very much to, if it is true.