
Patients do better when cardiologists are away at academic meetings - lelf
http://theincidentaleconomist.com/wordpress/patients-do-better-when-cardiologists-are-away-at-academic-meetings/
======
jostmey
The FAA responded to a number of high profile aviation accidents by making a
series of important changes in the cockpit. Their studies revealed that some
mistakes happened because subordinates were too afraid to question the
captain. After these changes, the captain was still left firmly in command but
a new environment was created where subordinates felt (more) comfortable to
voice any questions or concerns.

A similar thing needs to happen in medicine. Doctors walk around like gods in
the hospital but they are still human and make mistakes. The problem is that
everyone is too afraid to correct the doctors when they make obvious mistakes.
Don't get me wrong---the doctors must remain in charge, but they will still
goof up so people need to feel free to offer advice and criticism.

~~~
jacquesm
And it'd be nice if they treated their patients with some respect and as if
they had a functioning brain instead of as objects. Obviously this does not
apply to all doctors but this happens with alarming regularity.

~~~
dmix
How often has this been said to programmers/tech startups? The answer is
typically shield the nerds from customer support by introducing extroverts.
And doctors who are often nerds are forced by design to deal with people
constantly. No easy solution here.

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moioci
The linked article glosses over the distinction between teaching hospitals,
which did show a difference, and nonteaching hospitals, which did not see a
significant difference. At teaching hospitals, there are research
cardiologists and administrative types (division chair, officers of national
organizations, journal editors) in addition to plain old clinicians. Everybody
has to do time "on-service" directing the care of hospitalized patients.
Naturally, the chiefs and the lab rats have to attend the big meetings, so
their on-service time is in other months of the year. During the meetings the
clinical cardiologists are mostly left in charge, and their clinical skills
are better maintained, leading to better outcomes. Note that these outcomes
had to do with acute high-risk cases, not elective interventions, etc.

------
AliAdams
It seems that having most of the cardio guys away at the conferences means
there are less invasive procedures.

I would guess that what is scewing the result though is that the invasive
procedures carry short term risk for a long term health benefit. The study
only sees the decrease in short term risk (less invasive procedures) but is
blind to the long term consequences of not doing the procedure.

~~~
pja
Your post brings to mind an article by (I think) Ben Goldacre in which he
recounts that inserting a stent to "solve" narrowing of the arteries has never
been shown to be a net benefit to the average patient (except for emergency
cases).

Nevertheless, cardiologists have continued to carry out operations to insert
"new! improved!" stents which successively claim to eliminate the problems of
previous designs over what is now something like three decades of medical
practice. None of them have worked.

I'll try and find the article, but a quick web search hasn't turned it up.

~~~
et2o
This was originally unknown and non-obvious (massively narrowed coronary
arteries are ok?) but now known and modern clinical guidelines (which are
written by physicians) have changed to reflect this reality. This was
confirmed by well controlled multi-center trials. It's not cardiologists
inserting "new! improved!" stents for the thrill of it.

This doesn't reflect the case of the example patient who has angina upon
exercise with significant stenosis, but is not undergoing an active MI. That
patient may still be stented and have their lifestyle improved drastically,
despite there not being an urgent requirement.

~~~
pja
It's not that it was unknown and non-obvious - it's that as each successive
stent was shown not be an effective treatment, cardiologists continued to
operate for decades, confident that the next "new! improved!" version would
work, even though none of the previous ones had.

The reasons for this are a combination of the difficulty of publishing neutral
or negative results & surgeons' entirely natural inclination to do something
rather than nothing, even if nothing is actually the right thing to do,
because operating is what they've trained their entire lives to do.

The same thing happened with extreme chemotherapy followed by bone marrow
transplant as treatment for many cancers in the 80s: something like a $billion
was wasted on treatments that didn't work. The reasons why it took so long to
demonstrate that that particular treatment was ineffective were not entirely
the same - read "The Emperor of All Maladies" for the details - but shared the
optimism of doctors & patients combined with a plausible theory, which is what
ultimately makes for a potentially toxic combination.

------
gwern
Fulltext:
[https://pdf.yt/d/Ans8OYU3MwjkbN3J](https://pdf.yt/d/Ans8OYU3MwjkbN3J) /
[https://www.dropbox.com/s/bexaqbczwjyi47f/2014-jena.pdf](https://www.dropbox.com/s/bexaqbczwjyi47f/2014-jena.pdf)
/ [http://sci-
hub.org/downloads/7a09/10.0000@archinte.jamanetwo...](http://sci-
hub.org/downloads/7a09/10.0000@archinte.jamanetwork.com@generic-88DD2FA3BEC9.pdf)

------
dollaaron
When cardiologists are away, I'd imagine no non-emergency procedures/surgeries
are performed (no heart transplants, quintuple bypasses, etc), which has to be
a significant factor here.

~~~
Pxtl
Then that effect should appear in other disciplines, shouldn't it?

~~~
tgb
My understanding is that they only looked at cardiac patients, so that
wouldn't contradict the study.

------
et2o
This is complete clickbait.

It's because many fewer interventional procedures are done when there aren't
any doctors to do them. This isn't even really very new. For example, during
the Canadian physicians' strike, mortality also went down dramatically.

Any mortality differences would be temporary. The next study will show that
mortality increases after cardiologists return from the conferences as they do
all of the procedures that they put off, and then levels out again. Simple.

Really not very impressed with this headline, but any opportunity to rag on
doctors is typically taken in the mainstream media.

------
analog31
I didn't read the article, but only the summary:

>>> High risk patients admitted with heart failure during meetings had a
30-day mortality rate of 17.5%, compared to 24.8% when more cardiologists were
there. Cardiac arrest 30-day mortality was 59% during meetings and 69.4% at
other times. Not surprisingly, the rates of percutaneous coronary intervention
were lower during meetings, too (20.8% versus 28.2%).

In my view, they could have done with one or two fewer significant digits
based on the size of the error bars in the graph. My interpretation: Need to
collect more data and see if this is reproducible.

~~~
danieltillett
Signifacant figure abuse is surprisingly widespread in science. At least
23.432361% (+-10%) of papers I have read have managed to get their significant
figures wrong.

------
magicalist
If the mods are around, the ars technica summary of this study covers it
better than this post: [http://arstechnica.com/science/2014/12/when-the-
doctors-away...](http://arstechnica.com/science/2014/12/when-the-doctors-away-
the-patient-is-more-likely-to-survive/)

Among other things, more focus is put on the possible interpretations of this
(and it explicitly cites the source of those possibilities as the research
paper), and has a better explanation of the source of the data for the
analysis.

~~~
jkldotio
There's nothing wrong with the original at all, it should stay.

In fact the original is far superior to the Ars "summary" because it provides
a more neural headline, also provides link to the paper up front, provides the
abstract, provides the key graph with error bars and information about
comparison to other disciplines. It ends with a reasonable evaluation that
this hasn't proven anything either way and calls for more investigation.

Furthermore it was also written December 23rd by a site specialising on these
matters rather than by Ars, a pretty low brow generalist site, on December
27th. While the Ars author has a PhD in biology, the guy who got the scoop
four days earlier is eminently qualified in this area.[1]

The original link is a better article, published earlier, by a more
appropriate author on what appears to be (although that isn't hard) a better
site. The HN mods shouldn't be changing the links except in extreme cases
anyway.

[1]"Aaron E. Carroll, MD, MS is a Professor of Pediatrics and Assistant Dean
for Research Mentoring at Indiana University School of Medicine. He is also
the director of the Center for Health Policy and Professionalism Research. He
earned a BA in chemistry from Amherst College, an MD from the University of
Pennsylvania School of Medicine, and an MS in health services from the
University of Washington, where he was also a Robert Wood Johnson Clinical
Scholar.

Aaron’s research focuses on the study of information technology to improve
pediatric care and areas of health policy including physician malpractice, the
pharmaceutical industry/physician relationship, and health care financing
reform."

------
nutate
There is the anecdotal correlation to the contrary w/ May being the first or
second most popular suicide month and also the month when the American
Psychiatric Association has its annual meeting. I think that was mentioned in
Infinite Jest or some other novel, but it is true as far as correlations go.

------
lsiebert
See this is why I love science. Somebody does a study, and we learn something
absolutely new that we wouldn't have known.

More follow up research needs to be done, but this potentially means that the
doctors can change how they treat patients and significantly improve patient
mortality.

------
nullc
They need to add the individual doctors as factors in their regression.

Otherwise this could just be "inexperienced or checked-out doctors are more
likely to go to the conferences.". It's no surprise that there are differences
in survival that depend on which doctor you get.

------
refraktured
[http://www.bmj.com/content/316/7146/1734](http://www.bmj.com/content/316/7146/1734)

 _cough_ "Half of all doctors are below average" _cough_

------
Confusion
Linkbait headline is linkbait.

Certain patients (those classified as 'high risk') do better when
cardiologists in certain hospitals (teaching hospitals) are away at academic
meetings.

