3 ms·

Doctor here 1. It’s generally difficult to quantify such risks in any meaningful manner 2. Provision of any number adds liability, and puts you in a damned-if

Doctor here 1. It’s generally difficult to quantify such risks in any meaningful manner 2. Provision of any number adds liability, and puts you in a damned-if-does, damned-if-it-doesn’t-work-out situation 3. The operating surgeon is not the best to quantify these risks - the surgeon owns the operation, and the anaesthesiologist owns the patient / theatre 4. Gamblers quantify risk because they make money from accurate assessment of risk. Doctors are in no way incentivised to do so 5. The returned chance of 1/3 probably had an error margin of +/-33% itself

fc417fc802 1y ago
> It’s generally difficult to quantify such risks in any meaningful manner According to the literature 33 out of 100 patients who underwent this operation in the US within the past 10 years died. 90% of those had complicating factors. You [ do / do not ] have such a factor. Who knows if any given layman will appreciate the particular quantification you provide but I'm fairly certain that data exists for the vast majority of serious procedures at this point. I've actually had this exact issue with the veterinarian. I've worked in biomed. I pulled the literature for the condition. I had lots of different numbers but I knew that I didn't have the full picture. I'm trying to quantify the possible outcomes between different options being presented to me. When I asked the specialist, who handles multiple such cases every day, I got back (approximately) "oh I couldn't say" and "it varies". The latter is obviously true but the entire attitude is just uncooperative bullshit. > puts you in a damned-if-does, damned-if-it-doesn’t-work-out situation Not really. Don't get me wrong, I understand that a litigious person could use just about anything to go after you and so I appreciate that it might be sensible to simply refuse to answer. But from an academic standpoint the future outcome of a single sample does not change the rigor of your risk assessment. > Doctors are in no way incentivised to do so Don't they use quantifications of risk to determine treatment plans to at least some extent? What's the alternative? Blindly following a flowchart? (Honest question.) > The returned chance of 1/3 probably had an error margin of +/-33% itself What do you mean by this? Surely there's some error margin on the assessment itself but I don't see how any of us commenting could have any idea what it might have been.
- munificent 1y ago
  > According to the literature 33 out of 100 patients who underwent this operation in the US within the past 10 years died. 90% of those had complicating factors. You [ do / do not ] have such a factor. Everyone has complicating factors. Age, gender, ethnicity, obesity, comorbidities, activity level, current infection status, health history, etc. Then you have to factor in the doctor's own previous performance statistics, plus the statistics of the anaesthesiologist, nursing staff, the hospital itself (how often do patients get MRSA, candidiasis, etc.?). And, of course, the more factors you take into account, the fewer relevant cases you have in the literature to rely on. If the patient is a woman, how do you correctly weight data from male patients that had the surgery? What are the error bars on your weighting process? It would take an actuary to chew through all the literature and get a maximally accurate estimate based on the specific data that is known for that patient at that point in time.
  - chipsrafferty 1y ago
    Don't they use quantifications of risk to determine treatment plans to at least some extent?
    - fiddlerwoaroof 1y ago
      I doubt doctors do: my guess would be most doctors follow a list of best practices devised by people like malpractice actuaries and by their sense of the outcomes from experience.
  - fc417fc802 1y ago
    No one said anything about a maximally accurate estimate. This is exactly the sort of obtuse attitude I'm objecting to. By complicating factors I was referring to things that are known to have a notable impact on the outcome of this specific procedure. This is just summarizing what's known. It explicitly does not take into account the performance of any particular professional, team, or site. Something like MRSA is entirely separate. "The survival rate is 98 out of 100, but in this region of the country people recovering from this sort of thing have been exhibiting a 10% risk of MRSA. Unfortunately our facility is no exception to that." If the recipients of a procedure are predominately female and the patient is a male then you simply indicate that to them. "The historical rate is X out of Y, but you're a bit unusual in that only 10% of past recipients are men. I'm afraid I don't know what the implications of that fact might be." You provide the known facts and make clear what you don't know. No weasel words - if you don't know something then admit that you don't know it but don't use that as an excuse to hide what you do know. It's utterly unhelpful.
Jach 1y ago
Not a lawyer but I do wonder if refusal to provide any number also adds liability, especially if it can be demonstrated to a court later that a reasonable estimate was known or was trivial to look up, and the deciding party would not have gone through with the action that ended in harm if they had been provided said number. I'm also not seeing how giving a number and then the procedure working out results in increased risk, perhaps you can expand on that? Like, where's the standing for a lawsuit if everything turned out fine but in one case you said the base rate number for a knee replacement surgery was around 1/1000 for death at the hospital and 1/250 for all-cause death within 90 days, but in another case you refused to quantify?
garrickvanburen 1y ago
I would rather not have a surgeon considering failure rates ahead of any operation they're about to conduct.
- kmoser 1y ago
  On the off chance you're not being facetious: why? Isn't it part of their job description to weigh the ups and downs of any operation before conducting it? I'd imagine failure to do so would open them to liability.
  - garrickvanburen 1y ago
    There are 2 parts: 1. Presumably, the surgeon has determined that this specific intervention is the best possible intervention of all the possible ones (fewest downsides, best outcome, etc). There are always alternatives - including #wontfix. 2. Once this decision has been made, I don't want them second guessing, I want them 100% confident in the decision and their abilities. If there's any lingering doubt - then return to step 1 and re-evaluate.
ekianjo 1y ago
> It’s generally difficult to quantify such risks in any meaningful manner It's not for lack of data, that's for sure...
erikerikson 1y ago
Thanks for sharing the realities you experience. The rest of this is picayuni. > Doctors are in no way incentivised to do so Personal pride, care for patient, and avoiding the mess of a bad outcome seem like powerful incentives. That said, I assume you mean they are not given explicit bonuses for good outcomes (the best trend to attract business and the highest salaries).
ninalanyon 1y ago
In Norway a pregnant woman over forty is offered genetic counselling because of the risk of Downs syndrome. These risks are definitely quantifiable and no liability is generated by providing them. The counsellor (a doctor) explains the risks and the syndrome and apart from this appointment is not otherwise involved. This could surely be done for other situations, especially surgical procedures as the statistics should be collected and associated not only with the procedure but also the hospital and surgeon.

fc417fc802 1y ago

> It’s generally difficult to quantify such risks in any meaningful manner According to the literature 33 out of 100 patients who underwent this operation in the US within the past 10 years died. 90% of those had complicating factors. You [ do / do not ] have such a factor. Who knows if any given layman will appreciate the particular quantification you provide but I'm fairly certain that data exists for the vast majority of serious procedures at this point. I've actually had this exact issue with the veterinarian. I've worked in biomed. I pulled the literature for the condition. I had lots of different numbers but I knew that I didn't have the full picture. I'm trying to quantify the possible outcomes between different options being presented to me. When I asked the specialist, who handles multiple such cases every day, I got back (approximately) "oh I couldn't say" and "it varies". The latter is obviously true but the entire attitude is just uncooperative bullshit. > puts you in a damned-if-does, damned-if-it-doesn’t-work-out situation Not really. Don't get me wrong, I understand that a litigious person could use just about anything to go after you and so I appreciate that it might be sensible to simply refuse to answer. But from an academic standpoint the future outcome of a single sample does not change the rigor of your risk assessment. > Doctors are in no way incentivised to do so Don't they use quantifications of risk to determine treatment plans to at least some extent? What's the alternative? Blindly following a flowchart? (Honest question.) > The returned chance of 1/3 probably had an error margin of +/-33% itself What do you mean by this? Surely there's some error margin on the assessment itself but I don't see how any of us commenting could have any idea what it might have been.

munificent 1y ago
> According to the literature 33 out of 100 patients who underwent this operation in the US within the past 10 years died. 90% of those had complicating factors. You [ do / do not ] have such a factor. Everyone has complicating factors. Age, gender, ethnicity, obesity, comorbidities, activity level, current infection status, health history, etc. Then you have to factor in the doctor's own previous performance statistics, plus the statistics of the anaesthesiologist, nursing staff, the hospital itself (how often do patients get MRSA, candidiasis, etc.?). And, of course, the more factors you take into account, the fewer relevant cases you have in the literature to rely on. If the patient is a woman, how do you correctly weight data from male patients that had the surgery? What are the error bars on your weighting process? It would take an actuary to chew through all the literature and get a maximally accurate estimate based on the specific data that is known for that patient at that point in time.
- chipsrafferty 1y ago
  Don't they use quantifications of risk to determine treatment plans to at least some extent?
  - fiddlerwoaroof 1y ago
    I doubt doctors do: my guess would be most doctors follow a list of best practices devised by people like malpractice actuaries and by their sense of the outcomes from experience.
- fc417fc802 1y ago
  No one said anything about a maximally accurate estimate. This is exactly the sort of obtuse attitude I'm objecting to. By complicating factors I was referring to things that are known to have a notable impact on the outcome of this specific procedure. This is just summarizing what's known. It explicitly does not take into account the performance of any particular professional, team, or site. Something like MRSA is entirely separate. "The survival rate is 98 out of 100, but in this region of the country people recovering from this sort of thing have been exhibiting a 10% risk of MRSA. Unfortunately our facility is no exception to that." If the recipients of a procedure are predominately female and the patient is a male then you simply indicate that to them. "The historical rate is X out of Y, but you're a bit unusual in that only 10% of past recipients are men. I'm afraid I don't know what the implications of that fact might be." You provide the known facts and make clear what you don't know. No weasel words - if you don't know something then admit that you don't know it but don't use that as an excuse to hide what you do know. It's utterly unhelpful.

Jach 1y ago

Not a lawyer but I do wonder if refusal to provide any number also adds liability, especially if it can be demonstrated to a court later that a reasonable estimate was known or was trivial to look up, and the deciding party would not have gone through with the action that ended in harm if they had been provided said number. I'm also not seeing how giving a number and then the procedure working out results in increased risk, perhaps you can expand on that? Like, where's the standing for a lawsuit if everything turned out fine but in one case you said the base rate number for a knee replacement surgery was around 1/1000 for death at the hospital and 1/250 for all-cause death within 90 days, but in another case you refused to quantify?

garrickvanburen 1y ago

I would rather not have a surgeon considering failure rates ahead of any operation they're about to conduct.

kmoser 1y ago
On the off chance you're not being facetious: why? Isn't it part of their job description to weigh the ups and downs of any operation before conducting it? I'd imagine failure to do so would open them to liability.
- garrickvanburen 1y ago
  There are 2 parts: 1. Presumably, the surgeon has determined that this specific intervention is the best possible intervention of all the possible ones (fewest downsides, best outcome, etc). There are always alternatives - including #wontfix. 2. Once this decision has been made, I don't want them second guessing, I want them 100% confident in the decision and their abilities. If there's any lingering doubt - then return to step 1 and re-evaluate.

ekianjo 1y ago

> It’s generally difficult to quantify such risks in any meaningful manner It's not for lack of data, that's for sure...

erikerikson 1y ago

Thanks for sharing the realities you experience. The rest of this is picayuni. > Doctors are in no way incentivised to do so Personal pride, care for patient, and avoiding the mess of a bad outcome seem like powerful incentives. That said, I assume you mean they are not given explicit bonuses for good outcomes (the best trend to attract business and the highest salaries).

ninalanyon 1y ago

In Norway a pregnant woman over forty is offered genetic counselling because of the risk of Downs syndrome. These risks are definitely quantifiable and no liability is generated by providing them. The counsellor (a doctor) explains the risks and the syndrome and apart from this appointment is not otherwise involved. This could surely be done for other situations, especially surgical procedures as the statistics should be collected and associated not only with the procedure but also the hospital and surgeon.