
Heart surgeons refuse difficult operations to avoid poor mortality ratings - prostoalex
https://www.telegraph.co.uk/science/2016/06/03/one-in-three-heart-surgeons-refuse-difficult-operations-to-avoid/
======
cs702
It's Goodhart's Law in action, this time with deadly consequences:

"When a measure becomes a target, it ceases to be a good measure."[a]

[a]
[https://en.wikipedia.org/wiki/Goodhart%27s_law](https://en.wikipedia.org/wiki/Goodhart%27s_law)

~~~
kazinator
Low mortality is a good damned measure.

I don't want to be operated on some yahoo surgeon who unconditionally operates
regardless of risk and has a high mortality track record as a result.

~~~
croon
Then maybe mortality rate should be attributed to doctors not operating as
well. Low mortality is a good metric on patients, not doctors.

But on the other hand, I don't want to be treated by a doctor who cares more
about his sellable stats than saving lives.

~~~
ScottBurson
Maybe it's a good metric for hospitals. There are other pressures discouraging
hospitals from rejecting patients altogether, or such is my impression,
anyway.

------
carbocation
The advent of public reporting of outcomes after intervention for myocardial
infarction (heart attack) led to an _increase in mortality_ in Massachusetts
and New York.[1]

1 =
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4368858/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4368858/)

~~~
fricat1ve
A better way to make this claim would be to plot the mortality rates for the
states over time and show that the rates in those places requiring reporting
begin to diverge as the new policy is implemented.

~~~
carbocation
They effectively did that: they compared public reporting states with other
geographically adjacent states.

~~~
fricat1ve
There's nothing like Boston or NYC in the control states. If the effect is as
big as they seem to think--a 21% increase in mortality--that should be visible
on a plot of deaths over time.

------
drewg123
It was not heart surgery, but after being diagnosed with lung cancer, my
mother had one of her lungs removed by a surgeon who assured us he'd be able
to get all the cancer. She had a miserable, painful recovery that I would not
wish on anybody. Within a week or two of her recovering to the point where she
could walk short distances, the cancer was found in her other lung and went on
to kill her within a few more months. She may have gained several months of
life from this operation, but it was a painful few months without dignity.

It was 20 years ago, so my memory is fuzzy, but I don't remember ever being
presented with anything but certainty from the surgeon that he could cure her.
I think that patients and surgeons need to have a better idea of the realistic
chance of success from a major surgery in order to make an informed decision.
Perhaps if surgeons at least have to worry about their own numbers, they might
hesitate before attempting cases like my mother's.

~~~
Johnny555
Sadly, it seems that your mother would not have had a better outcome with or
without the surgery - if the doctor had said "I'm 75% sure that the cancer is
contained in the one lung, so removing the lung will remove the cancer", would
that have changed the decision to have the surgery? What it was was 50%? What
is the threshold where someone with a fatal illness will accept the risk for a
possible cure?

~~~
emodendroket
Perhaps the patient should have the right to decide what that threshold is for
themselves rather than having the information hidden from them.

~~~
calcifer
What information? Apparently the doctor told them he could do it. If he really
believed in himself, then he told the patient everything she needed to know.
Remember, the other option is "go die". So assigning a percentage chance on
the successful outcome of a surgery is utterly meaningless when the
alternative is a 100% "go die".

~~~
9a89df7a09sdf8
respectfully, this isn't the way to conceptualize any medical therapy. it's
never "this will save you" or "go die", it's always "you will eventually die,
this might forestall it, we're never sure, and there's a big list of potential
drawbacks."

a person who can be helped by a medical intervention will die no matter what,
but if they get an organ transplant or a pacemaker or continuous dialysis or a
cancer removed, they may live a little bit longer, as far as scientists
observe, although sometimes with significant difficulties. immunosuppression
and chemotherapy both deactivate certain organ systems.

no one can see the future. cancer treatments seem to help some people and be
useless for others, and it might all come down to something like, "uh cancer
stem cell #13491340 was not destroyed, and there was metastasis." the idea
with tumor excision is usually to prevent there from being so many
potentially-metastatic stems.

------
crusso
Ultimately, we need to compare apples to apples by building rating systems
that account for the difficulty of treating patients with various, ailments at
various ages, with various complications.

Think of it in terms of competitive diving, gymnastics, or snowboarding: Your
scores depend upon the difficulty of the moves you attempted combined with
your performance of those specific moves. The more difficult the move, the
more you're compensated for even attempting it when it comes to scoring.

The trick then is to prevent physicians from gaming the system by exaggerating
the difficulty of the patients they're dealing with. You'd need to use as many
objective metrics as possible and possibly some system of having different
physicians assess ratings than the ones performing the procedures - maybe in
some kind of double-blind fashion to prevent any kind of coordination
strategy.

~~~
calcifer
> some system of having different physicians assess ratings than the ones
> performing the procedures - maybe in some kind of double-blind fashion to
> prevent any kind of coordination strategy.

That would simply result in an unwritten rule where everyone gives everyone
else good ratings.

------
adolph
This topic was discussed in the last EconTalk [1] podcast featuring the author
of a recent book “The Tyranny of Metrics” [2]. I think one of the author’s
interest insights is the distinction between metrics for diagnostics and those
for incentives.

1\.
[http://www.econtalk.org/archives/2018/04/_what_is_the_ap.htm...](http://www.econtalk.org/archives/2018/04/_what_is_the_ap.html)

2\. [https://www.amazon.com/Tyranny-Metrics-Jerry-Z-Muller-
ebook/...](https://www.amazon.com/Tyranny-Metrics-Jerry-Z-Muller-
ebook/dp/B076ZWW2MN)

~~~
TwoBit
It's what I hate about the legal system. Prosecutors don't care about justice,
they care about a record of putting thevmost people away.

------
martyvis
In Australia, we have a neurosurgeon Charlie Teo that is well known for
operating on "inoperable" brain tumours. While he has a lot of respect in the
general community, to many of his surgical peers he is seen as a reckless
maverick. I would think his stats on average are bad, but because he will
tackle outliers he has won the support of the people that matter - his
patients.

------
tgraham
66% of 115 specialists polled did not refuse a difficult operation.

33% thought about how it would impact their statistics, or put more
generously, thought hard about the probability of the patient surviving
presumably quite serious surgery.

Yes mortality is a blunt statistic for a surgeon, but perhaps giving people
pause for thought about the odds of success is no bad thing.

Contra point: would you rather not know how many cases your surgeon has done
that year, and the issues they have had?

~~~
maxerickson
A large portion of the people undergoing heart surgeries still face a high
risk of death if they don't have the surgery (with the surgery bringing the
chance of a longer, more comfortable life).

Here's why your hot take isn't the best take:

“About 30 percent of them said they had turned patients down for surgery even
when they knew full well that surgery was in their best interest.”

~~~
TheRealPomax
Here's the converse of that, though: why do we think it's okay to expect a
team of doctors and nurses to be okay with almost assuredly killing someone
during surgery? They're not robots, "it's their job" is not an acceptable
answer.

Even if the surgery is in a patient's best interest, if the odds of killing
them are all but guaranteed then it's most definitely not a matter of looking
at the patient and rationalising it with "they will die otherwise anyway".
It's not just about the patient.

People who make this argument seem to forget that there's also an entire team
of medical professionals that your rationalisation says should be okay with
going into a surgery knowing they are almost guaranteed to kill this patient.
They have the stats, the stats say "this person will die under the knife",
many more lives are affected in this decision than just the patient.

So expecting them to just do the surgery instead of going "No. This will kill
the patient, I don't want that on me and my team" is very far from an okay
attitude towards fellow human beings, and leads to terrible medical practices.

~~~
maxerickson
I don't see where the article says "the odds of killing them are all but
guaranteed", so I don't really appreciate you stuffing that meaning into my
comment. I highly doubt that surgeries at that level of risk are actually in
the medical interests of the patient (the standard I used).

Are you speaking from further knowledge of the the statistics of the cases
where surgery is refused? If so, why not drop that instead of the lecture?

------
samfisher83
Sports athletes do this. For example players won't attempt end of the quarter
half court shots since that will lower their percentages, or QBs taking sacks
to not lower their QB ratings. What they do in sports is keep advanced stats.
Instead of just giving a pure mortality rating have mortality rating, by
surgery type.

~~~
credit_guy
Maybe in other sports this happens, but I seriously doubt QB's engage in that.
First of all, taking a sack is not pleasant. In the extreme it can take you
out of the game, or land you on the IR (injured reserve). Drew Bledsoe was
replaced by Tom Brady after such a sack, and was never the star he had been
before. Second, the number of sacks a QB takes is a statistic in itself.
Third, the top stats for a QB are in this order: touchdowns, interceptions,
passing yards, and completion percentage. If a QB takes a sack to avoid an
interception, I'm 100% happy with that. If he takes a sack so that his
completion percentage is higher by 0.01%, I would not be, but then the
completion percentage is reported at the 0.1% level of precision. There is
simply too much physical pain in taking a sack for a QB to trade that for an
imperceptible gain in a pretty unimportant stat.

~~~
fernandotakai
some QBs like aaron rodgers will take a sack instead of throwing the ball
away.

rodgers had a 50 sack season twice in his career and has a sack career of
6.96. this is reflected on his interception rate (which is the best in the
nfl). he just prefers to take a sack to attempt a pass that could be
intercepted -- and everybody looks at those int/td numbers and don't look a
lot at sack numbers (because sacks are usually not the qb fault).

------
mitko
Shameless plug - I wrote an essay recently on how any metric becomes a vanity
metric [http://dimitarsimeonov.com/2018/03/22/the-vanity-metric-
para...](http://dimitarsimeonov.com/2018/03/22/the-vanity-metric-paradox)

Some excerpts:

\- having clear, well defined metrics is the single largest driver of progress
within a company

\- _Any metric sufficiently optimized becomes a vanity metric_

\- Building products is not science. What makes a good product is usually
dependent on so many factors that are subject to change and evolve.

\- Over time, a product no longer stands to die if these metrics degrade.

\- According to EdwardTufte - people and institutions cannot keep their own
score

Hope someone finds it useful!

------
fedups
Econtalk had a good interview this month on this general phenomenon discussing
the book "The Tyranny of Metrics"

[http://www.econtalk.org/archives/2018/04/jerry_muller_on.htm...](http://www.econtalk.org/archives/2018/04/jerry_muller_on.html)

------
amelius
Why don't we keep track of refusals as well?

~~~
B1FF_PSUVM
Not a bad idea, per se, but then which is better - the doctor with 0% refusals
and 20% deaths, or the one with 20% refusals and 10% deaths?

~~~
dredmorbius
Include the outcomes of the refused cases.

Note that this also works to _improve_ stats on docs who choose hard cases.

------
wastra
The incorrect assumption your readers are making is that heart surgery is a
good thing in all cases. America is the leader in futile medical procedures:
it may well be a good thing to have fewer risky procedures on patients who
were more likely to be harmed. "primum no nocere" may be advanced!

------
billfruit
On a related vein, do surgical procedures involve any type of quality control,
where the work is independently audited? If so I wasn't aware. Quality control
is such an important cogwheel of processes in many other industries, yet I
don't hear much talk of it in relation to medical profession.

~~~
fricat1ve
In the US, if the surgery is in hospital:

\- Well-regarded hospitals will vet surgeons before granting privileges.

\- Average hospitals give out privileges fairly easily if there are no actions
against a person's license.

\- There is a "collegial" review of big screw-ups that carry major
reputational risk.

\- As with any fee-for-service firm, "rainmakers" are highly sought after and
get away with more.

\- Privileges are difficult to take away once granted. (Have stronger legal
protections than academic tenure in some states.)

If the surgery is in an ambulatory surgery center or doctor's office:

Basically anything goes. Ice-pick lobotomies, tonsillectomy mills, boob job
factories in strip malls....all have happened in recent US history. About as
well-regulated as traveling carnivals.

~~~
billfruit
I was thinking something more akin to routine inspection program carried out
by independent personnnel applicable to all procedures, not just the reviews
that are necessitated due to screw ups.

~~~
fricat1ve
As far as a performance evaluation that directly scores a surgeon's judgment
and whether the procedures s/he is performing are actually beneficial...in the
absence of a big screw-up or complaint, I don't believe there is any forum to
do that after training is complete.

------
agumonkey
it's been said a few times on /r/medicine, surgeons have their lawyer in mind
when operating, they're skilled, but they first avoid anything that could
damage their own life irreversably. Of course to an extent this goal aligns
with the patient, but not always, and a bit sad on the ideal side.

~~~
kankroc
Can someone really sue their surgeon in the US?

~~~
KMag
Absolutely. You can sue for pretty much anything. Winning is another story,
but doctor's don't generally make sympathetic defendants. Juries know they
have money and that they pay huge insurance fees to cover these cases. Of
course, after losing a big case where the insurance company pays out millions
of dollars, they likely become uninsurable and unemployable. But hey, the
money is good until you hit the anti-lottery.

My father was an anesthesiologist (who retired in good standing), and I
remember him telling me a case he read about a Caesarean section. The surgeon
was using an electrocautery pen to sear closed the ends of blood vessels. The
surgeon set down the pen on the surgical cart, lifted the baby out, set the
baby on the cart, and the baby's heel touched the pen. Now the baby has a
small scar on the bottom of his/her heel for life. The parents sued the
surgeon, the cart nurse overseeing the cart, and the anesthesiologist was
close to the surgical cart. All 3 defendants settled out of court, since
babies almost always win jury cases against rich doctors, regardless of merit.

The litigant's lawyer would almost certainly bring up a below median survival
rate as evidence of a pattern of gross incompetence.

Also, of course, in the U.S., I believe only governments are immune to
lawsuits (sovereign immunity) without their consent. The courts have
consistently ruled that many rights, including the right to sue, cannot be
legally waived by contract. In a similar way, if you sell yourself into
slavery by entering into a contract that waives your right against unlawful
detention, that contract cannot be legally enforced.

My grandfather was an anesthesiologist. My dad was an anesthesiologist (and
did well enough on the MCAT to go to med school after 3 years of undergrad...
practiced medicine without an undergrad degree... med school is too
competitive today to do such a thing). I was a good student: I graduated from
MIT. However, my brother and I saw all of the BS and stress (anesthesiologists
have a high suicide rate) and constantly rotating sleep/work shifts and both
went into engineering.

~~~
lopmotr
If he really had a pattern of gross incompetence, wouldn't there have been
some other process to stop him doing that? Are courts really that incompetent
themselves that they can't understand such simple statistical errors as using
survival rate to measure competence?

~~~
KMag
It's not about gross incompetence; it's about a jury's perception of
incompetence, colored by their perception of the doctor and their perception
of the grieving family members. If it comes to a jury trial, the court relies
on the jury to make legally factual findings, so the courts end up relying
upon the statistical abilities of the median juror, colored by the
aforementioned biases.

There are medical boards to remove incompetent doctors, but those influence
jury trials primarily through submissions of findings as evidence for
consideration by juries. A good lawyer will portray medical boards as a bunch
of doctors biased against passing judgement on fellow doctors.

------
randyrand
Easily solvable. Have a person whos jobs it is to rank how likely a person is
to live. He gets paid based on how accurate he is.

Doctors would then be ranked as an offset from this previous mortality
prediction.

~~~
Consultant32452
This incentivizes the doctor to maximize the _appearance_ of risk in the
medical record.

~~~
Too
The one doing the estimate should obviously not be the same doctor doing the
surgery.

~~~
Consultant32452
The one doing the estimate will do so based off the records generated by the
doctor doing the surgery.

~~~
dredmorbius
Not for referrals.

~~~
Consultant32452
The only way to get reasonably accurate results with this is to have two
surgeons do completely separate diagnostics in a double-blind where neither
they nor the patient knows which one is going to be performing the surgery.
That seems unworkable at scale.

~~~
dredmorbius
Surgeons don't do diagnostics, as a general rule.

Internists, paths, triage, GP, trauma do.

------
paulcole
This exact topic was discussed in the 1968 novel Case of Need by Jeffrey
Hudson. It was his first book, written while a medical student at Harvard. The
novel raised a stir as it was critical of Harvard faculty and in some ways the
practice of medicine in general. The book eventually won an Edgar Award.

Some may know Jeffrey Hudson better by his given name, Michael Crichton.

[https://en.m.wikipedia.org/wiki/A_Case_of_Need](https://en.m.wikipedia.org/wiki/A_Case_of_Need)

------
probo
You cannot compare crude outcomes. You have to adjust for so called "case-
mix". For mortality after cardiac surgery, the risk can be calculated using
the EuroSCORE II.
[http://www.euroscore.org/calc.html](http://www.euroscore.org/calc.html) And
even then, often the numbers for individual surgeons are too small to draw
conclusions.

------
dosycorp
That means there's an opportunity / gap in the market.

Demand for risky operations by motivated buyers, should lead to some doctors
taking on the role / label of risk-takers / explorers.

Since they can get the customers other, risk averse doctors are turning away,
and pull in rare-treatment seekers on their own.

------
oliwarner
The only way this changes is removing the choice from the surgeon doing the
cutting.

Sounds a bit dramatic but if they think action is genuinely inappropriate,
they should make the case to their colleagues, or a Multi Disciplinary Team,
and let them have the final say. Together they should be able to enforce the
Royal College and NICE guidelines for operating and the CQC —the main
monitoring body— should be able to work out (both from data and on-the-ground
inspectors) whether hospitals are doing as they should.

I realise that's pretty UK specific but the ACS should be able to achieve
something similar.

------
tomohawk
Relatedly, I've met many people who had a surgery where they used to live and,
after moving, other surgeons won't touch them. They have to travel back to
where they used to live to get care. Seems really unethical.

------
NTDF9
Reminds me of why some devs will not touch critical pieces of code because the
next time a bug comes in that module, git log shows they were last editors and
will be asked to take a look (even if the bug is unrelated to them)

------
acjohnson55
We chose to have our daughter delivered at a hospital that is renowned for its
neonatal ICU. It's obviously a great place to give birth, but if you look on
paper, their c-section and other intervention rates are above average. Which
makes sense when you understand that they are equipped to handle the highest
risk pregnancies.

A similar phenomenon occurs in education. I taught high school in Baltimore,
where the vast majority of my students were high risk. Baltimore has a few
renowned high schools, but by and large, they serve the easiest students.

------
stevenwoo
There was a counterintuitive study of obstetricians that I cannot find right
now that showed that in one state over many (10?) years the ones who did the
most C-sections were the best doctors - because when researchers looked at the
underlying data the realized these doctors treated the patients who had the
worst predicted outcomes and beat the national odds - I think they theorized
that these doctors had the best ability to choose the optimal method of birth
and were not afraid to choose c-section when it was necessary.

~~~
dredmorbius
There's a very strong relationship between experience (number of procs
performed) and outcomes. High-volume is almost always beetter.

This may of course favour unnecessary ops...)

~~~
stevenwoo
Yes, I think this was particularly against the grain because mothers are
commonly told to look for a doctor/practice who does not resort to a C-section
right away, and judge this by the number of C-sections a doctor/practice
performs.

~~~
dredmorbius
Hospital rather than doc rates are far more useful here.

Look to c-sec vs. vag deliveries.

------
refurb
This is the classic problem where people use averages as a metric, but ignore
the fact that variations are not distributed evenly.

I remember looking at the economics of a clinic for our product. Someone said
"let's just give them a 5% discount as on average they will break-even.

That works if you look at on average how much they make, but ignore the fact
that every clinic has a different mix of insurance companies and *their own
economics are all different."

------
c3534l
My mother went two years with a horrible stomach condition and couldn't get
anyone to treat it until she wound up in the hospital and they were legally
required to treat it. It was for exactly that reason: risky surgery looks bad,
even if it's necessary. When there aren't a lot of doctors who can perform the
surgery in question to begin with, say only two in your state, then you might
just die.

------
imaadrashied
This isn't surprising because humans will do what they're incentivized to do
(speaking mainly in a professional setting here).

Might be effective to add a measure to the transparency that shows something
to the effect of, "likelihood to perform life-saving and risky procedures."
Therefore a high win-loss with a lower risk threshold would be weighted lower
than a so-so win-loss with a higher risk threshold.

------
lopmotr
1/3 of heart surgeons violate medical ethics. That shows how flimsy and easily
corrupted doctors are. That they don't really care about doing what's best for
their patients' health as soon as an incentive makes that inconvenient. I hope
some more data will reveal who has statistical anomalies in who they're
turning away so the frauds can be identified.

------
sunstone
Fertility clinics are subject to the same pressures. They need to keep their
success rates up so they avoid cases with poor prognoses.

------
SilasX
We bundle up too many conflicting jobs into the role of the doctor. Rating the
difficulty and status of an incoming patient should be completely separate
from the job of treating them, and all judgments about doctor effectiveness
should be judged relative to those assessments.

(Credit: alerted to this misincentive by Yudkowsky’s recent book _Inadequate
Equilibria_.)

------
sebazzz
Would it be possible to determine a "risk" factor and count that in the
mortality ratings, or is this too simple?

~~~
MarkMc
There is probably already _some_ adjustment for risk - anyone can see that a
smoker in his 60s will have higher mortality than a non-smoker in his 30s.

The problem might be that the statistician doing the risk adjustment doesn't
have 'skin in the game', so his/her assessment of risk is worse than the
surgeon's. (Although if that were the case I would expect the statistician to
be just as likely to overestimate the risk than underestimate it, yet I never
hear about surgeons _favouring_ the difficult cases because they think they
can improve on the expected mortality rate in such cases).

------
ianformanek
There might be several decent ways to improve (at least as a next step) to
avoid this particular way to game the KPIs: \- use an assessed upfront
difficulty (if available in measurable form) to adjust for the outcome rating
\- add additional KPI for % of refused operations (perhaps again adjusted for
difficulty)

------
2skep
What would you prefer?

A surgeon who expects a poor outcome of your surgery:

a)decides to not operate on you? b)decides to operate on you nonetheless?

I am in camp a

~~~
calcifer
I'm definitely in camp B. 90% chance of dying on the table beats a 100% chance
of dying without the surgery, every single time.

~~~
jack9
Quality of life matters in most of these marginal cases. If they are going to
give you the Konno procedure (scrape extra tissue out of a thickened
ventricle), there's tons of things that can go wrong OTHER than death. Death
is assured, either way, for everyone.

------
tyingq
Metrics do drive behavior. Like, in the IT space, percentage of successful
change requests. Encouraged you to power though even if things look bad.
Because aborting is a 100% chance of a ding to the metric, while taking the
risk is something less.

The stakes are lower, of course, but the idea is similar.

------
justonepost
Alternatively, you have a good idea of what your mortality rate will be if a
surgeon picks you for a case.

------
SteveGerencser
I firmly believe that this is why my mother-in-law died. She needed surgery to
fix a hernia that basically left her unable to eat at all. Is she did not have
the surgery she was going to die. The surgeon stopped the surgery because the
'risk' was too high.

48 hours later she was dead.

~~~
hycaria
You don't die in 48h from not eating. So many elements missing there, this is
such a terrible depiction. I hope anyone passing by will have a bit of
critical thinking.

------
narrator
They need to add a difficulty correlated metric to the statistics. Maybe BMI
and age? I am sure IVF clinics wouldn't offer the procedure to anyone over 35
if the rather detailed statistics they are required to report didn't also
include the patient's age.

~~~
Lxr
I imagine it’s extremely difficult to come up with a metric that captures
everything about the case. BMI, age, tumor type, tumor shape, history of
kidney disease, diabetes, where do you stop?

~~~
MarkMc
You don't need a metric which captures everything about the case - you just
need a statistical model whose risk assessment is at least as accurate as the
surgeon's assessment. This is not as difficult as it sounds - in Chapter 21 of
_Thinking Fast and Slow_ , Kahneman makes a strong case that simple algorithms
are very often better than expert clinical judgement.

------
flatfilefan
Can there be positive self selection and specialization of the surgeons? Those
who don’t believe they can probably operate successfully don’t do that at all
and the others get more insensitive.

------
JumpCrisscross
If you’re a patient, wouldn’t this still mean starting with the lowest-
mortality surgeon? If they take your case, you’re least likely to die. If not,
you have a better appraisal of your odds.

~~~
stordoff
I'm not so sure. That might mean going with a surgeon where you are at the top
end of their "risk profile", rather than a more skilled surgeon who has higher
mortality rates due to routinely taking more difficult cases. I'm not sure you
can generalise the mortality rate of all patients to your specific chance of
death (a more skilled surgeon would likely be better for you, c.p.).

------
skookumchuck
One possibility is to offer the surgeons more money for difficult surgeries,
and more money for a successful outcome, to balance out the reputational risk
to the surgeon.

~~~
dfox
How do you estimate the difficulty in a way that does not involve wrong
incentives on the part of the surgeon or whoever is doing the estimation when
money is involved?

------
qrbLPHiKpiux
A colleague of mine was interviewed by a new hospital heart program. He was
asked what his mortality rate was. He replied, what do you want it to be?

------
firstplacelast
Check out the comments over on /r/medicine and you will likely be horrified.
It is career over everything. There was even a thread this week about how you
should NEVER correct someone above you (med students should never correct a
resident and a resident should never correct an attending).

That mentality is terrible for everyone and every thing, except the
physicians' careers.

I don't know if we need to select for better people when admitting them to
medical school or if the culture is just completely fucked.

~~~
bradlys
If you think about what it takes to get into med school then it seems pretty
natural that you're going to get hyper competitive surgeons in the end. It
starts before med school. You get assigned 10 unobtainable books that only the
library has. Finals week comes around, all the books are missing even though
they have to stay in the library. Turns out your classmates hid them inside
the library so they could have a competitive advantage and get a higher grade
on the curve.

You already devoted probably half your life to becoming a surgeon, why would
you screw it up and lose so much ground so easily?

~~~
carbocation
What decade are you describing? In my medical school, all of the required
material aside from our anatomy textbook was given to us as a PDF or a
printout.

~~~
bradlys
This was within the last 7 years. I don't doubt each school is different. This
was at UW in Seattle.

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fallingfrog
To be fair, you wouldn't want heart surgeons to shrug and take on operations
they didn't feel ready for, either.

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Nuzzerino
Can we get a (2016) on the thread title?

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aantix
The subjective is always where there is value.

I wish there were surgeons that would accept these challenges and colleagues
would objectively assign a degree of difficulty score.

And a site that aggregated such scores. I really don’t care how “friendly” a
doctor is - did the get the diagnosis right? Did they improve longevity? Did
they improve quality of life?

Not easy to score but what everyone wants to know.

~~~
sky_rw
Does the NHS provide enough free market choice that anybody could take
advantage of a score even if they wanted to?

~~~
ealexhudson
You can choose where to get treatment and who treats you; the main issue is
whether you get the timeline you'd prefer. Generally, patients will choose a
clinical center (to the extent that some hospitals have stopped offering
specific treatments, because their stats were never good enough - e.g you need
to do a certain number of children's heart ops per year to be good enough to
get good stats). If you have the option to go private, either through your
insurance or the NHS, then obviously there's another layer of choice.

Most of the private surgeons are also NHS, anyway.

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txsh
Should “NHS” be added to the title? This seems to only apply to British heart
surgeons.

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Dowwie
I recommend listening to the new EconTalk episode about the tyranny of metrics

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emodendroket
You would think that they could adjust these figures by patient age and
condition.

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trackofalljades
Sounds a lot like police work in Japan (they love their stats).

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rdiddly
Goodhart's Law again!

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trumped
Some doctors probably refuse patients that left bad reviews at competing
offices...

~~~
Mononokay
"I don't appreciate the service they provide and they're terrible people !!!"

"Okay, we won't serve you if you're just going to trash us."

"EVIL HOW DARE YOU!"

~~~
trumped
I meant if you left a bad review somewhere else...

Of course someone should not go back where they don't like to go....

~~~
viraptor
That only works if you have more than one choice available.

~~~
trumped
The shitty US health/dental insurance system make it hard, but I still would
be surprised if most people don't have a choice of more then one doctor...

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Numberwang
It's sad to hear this when it's totally unnecessary.

Hear disease has been a solved problem for decades. Just compare the rates of
disease for vegans with the general population.

~~~
danans
> Just compare the rates of disease for vegans with the general population.

"Disease" is such a broad category that it's sort of meaningless here.

Maybe veganism is healthier than an animal diet, but the degree of its impact
can only be stated only after removing the many other environmental factors
that might be contributing to lower disease rates among vegans, including
income and location.

~~~
Numberwang
Yes, lot's of things are always involved. Including air quality etc as I think
I saw on HN just the other day.

I find it interesting though that the right type of vegan diet will basically
make you hypertension and heart attack proof and that it may also reverse
heard disease (the only diet to do so). Especially when you look at mortality
and costs of healthcare this really need to be more generally recognized.

~~~
danans
> I find it interesting though that the right type of vegan diet will
> basically make you hypertension and heart attack proof

A diet making someone heart-attack-proof is a pretty strong claim. Have a
citation?

I think the only thing one can say with near-certainty about a well balanced
vegan diet is that it has much lower environmental externalities (i.e carbon
footprint, water usage) than a meat-based diet, while being no worse for you
than any other comparably healthy diet.

That alone is a great reason to be a vegan, without having to rely on possibly
hyperbolic claims of health benefits.

