"When a measure becomes a target, it ceases to be a good measure."[a]
I'm reminded of https://xkcd.com/810/
It is far better when call length is not a KPI. I would never go back.
IMO, if call length is a KPI, it's a key indicator that the company isn't willing to hire enough agents and is trying to apply pressure to shorten calls for purposes of coverage.
If someone could get away with it at a 911 call center, it could happen anywhere... and might happen oftener than we think.
 - https://www.sfgate.com/news/article/911-dispatcher-sentenced...
Of course some people would just say the issue was solved, falsely (which, you know, it was a little easier to get caught so it was higher-risk, in addition to being probably less moral), and there was also the X factor of how much you liked the customer, considering the extreme amount of verbal abuse the job entailed.
In general its, simply a bad idea to be rude to the person you expect to provide assistance.
If I recall correctly, Munger considers incentives to be the single most important concept to properly understand in order to drive successful business (and arguably life) outcomes.
Not surprisingly, incentives are also chronically underestimated or outright ignored, even in situations where there's a strong, profit-driven incentive (#meta) to get them right.
> From all business, my favorite case on incentives is Federal Express. The heart and soul of their system – which creates the integrity of the product – is having all their airplanes come to one place in the middle of the night and shift all the packages from plane to plane. If there are delays, the whole operation can’t deliver a product full of integrity to Federal Express customers. And it was always screwed up. They could never get it done on time. They tried everything – moral suasion, threats, you name it. And nothing worked. Finally, somebody got the idea to pay all these people not so much an hour, but so much a shift and when it’s all done, they can all go home. Well, their problems cleared up overnight.
It's about extrinsic vs intrinsic motivation. Extrinsic motivation comes from outside of the person and is what's typically used by organizations to try to motivate people: salary, praise, bonuses, etc. Intrinsic motivation comes from within.
 - https://www.amazon.com/Punished-Rewards-Trouble-Incentive-Pr...
1) cost as little as possible to the business
2) "optimize" their own pay/career
(There was a study saying that over 80% of sales people would deny their employer a million-dollar contract if it netted them $500 personally, so compared to that this is nothing)
Which makes sure that the incentives are not aligned with the business goals.
Now I guarantee that the best way to destroy intrinsic motivation, bar none, is to provide extrinsic motivation for things that aren't aligned with the business' goals.
So yes, could.
In this case they should have had a metric that took into account the estimated prior probability of a good outcome given an ordinary surgeon.
Survival is the intended effect, but that's much more of a binary thing.
Yeah, if you were given one operation where the patient has a 100% chance of dying without it, but 80% of you killing them if you operate + 20% chance of them living after, maybe you'd do this once and get lucky. But try doing this twice, you have a a 96% chance of killing a patient, three times makes a 99.2% chance of killing at least a single patient. This probability quickly approaches 100%. If you kill a patient you get dragged into court, branded as a murderer by the opposing lawyer, and your career which you have spent your youth, your 20s and a half a million dollars training for is down the drain. Taking risky cases, if that's not your niche, is is guaranteed to have you out of a job and in debt from legal fees.
To suggest that "bad hearts" are involved in this necessary calculation, is incredibly naive.
But aside from that, I completely disagree with your comment. The approach you are defending, even if legal, is completely unethical and immoral. It should be something we chastise, not condone.
The subtext is that the system won't improve; rather, something in the system will be sacrificed to improve the metric. The end result (usually quality) won't improve.
Not sure how much stock I can put into the rest of the article given this. Goodhart's Law can seemingly only apply if the variables are highly non-normal, or are negatively correlated (e.g. worse doctors are more likely to refuse the difficult operations than good doctors).
I don't think your statements contradict anything that it says. For reference, here are all the sentences in the "Quick Reference" part, which I'm assuming is the part you read.
Regressional Goodhart - When selecting for a proxy measure, you select not only for the true goal, but also for the difference between the proxy and the goal.
Model: When U is equal to V+X, where X is some noise, a point with a large U value will likely have a large V value, but also a large X value.
Thus, when U is large, you can expect V to be predictably smaller than U.
Example: height is correlated with basketball ability, and does actually directly help, but the best player is only 6'3", and a random 7' person in their 20s would probably not be as good
Is any particular one of these sentences false?
> If U measures V plus some noise X, assuming V and X form a bivariate normal distribution, then the conditional expectation of V is maximized by selecting the greatest U.
The word "maximized" carries some assumptions. If the only thing you can do is select based on U, then that statement is correct. However, if you had some means of selecting directly on V, then it's extremely likely that this would do better than selecting on U.
Suppose you're selecting the top 10 people. Suppose X ranges 0-10 chosen by a die roll, and V ranges 0-10, and it happens there are ten people with V=10, a hundred people with V=9, and a thousand with V=8 (and a lot more with lower Vs). On average, you'll have ten V=9s who score U=19, ten V=9s and a hundred V=8s who score U=18, and so on; in order for selecting on U to perform as well as selecting on V, every one of the V=10s would have to roll X=9 or X=10, which is exceedingly unlikely. It is true that taking people with high U scores yields people with higher Vs than taking people at random, and it is further true that taking the U=19s will give you better results than taking the U=18s or U=12s. It is simultaneously true that, when you take the U=19s, you'll be getting people whose X was 9 or 10, much higher than if you selected people at random or if you selected directly for high V. The first two sentences from the text state exactly this. (One consequence of this observation is, e.g., if you're doing admissions based on some test score, and you're considering raising the required score by ∆U, you should know the effect will be to raise average V and to raise average X, with ∆V=∆U-∆X, and if ∆X is large, you may be disappointed in the results. This is simple regression to the mean.)
I imagine you know all these concepts; I think you're interpreting the text as a stronger statement than it is.
For example, if I target a high win percentage, is win percentage, then, not a good measure?
Mortality rates are a pretty good measure for surgeons.
The problem here is that they are inflating their measure by cherry picking.
Some measures should be targeted, the problem here is that it is done in an non genuine way
For surgeons, the direct target is for the patient to get better - or at least live longer and with higher quality of life. Proxy is the measure of a mortality of a specific surgeon. It is not a direct target - as the surgeon can achieve zero mortality by not doing any surgery at all, but his patients would die of suffer from the lack of treatment.
That's what the article is describing, surgeons won't even play the game, they won't even attempt to help certain people because it might hurt their "win percentage".
Mortality rates are one measure of many that can tell a story, but they're like incarceration rates in that they've become a perverse incentive that exacerbates an issue. If we say that putting more people in prison is a good thing, that's predicated on an assumption that only those that are being put in prisons are people worthy of being there, whose freedom is more costly to society than their imprisonment. When a district is rewarded for putting people in prisons, what types of things might you expect to happen to the legal systems and populations in those places? Would prosecutors then be incentivized to trump up charges and force people into serving prison time unnecessarily to make themselves look like bigger "winners"? Might police make more frivolous arrests or even stir up trouble in communities to paint a picture of rampant criminality so they can look to be "tough on crime"? Wouldn't you expect to see an all-causes decrease in long term crime?
The problem isn't just cherry picking, but if people can game a system built around limited and gameable measures, then it's going to encourage min-maxing for profit.
also, normalizing for the patient risk will likely just lead to people overstating patient risk, because once you reduce performance to an index, people will focus on what's measured before on what the intended goal for the measurement is.
(And besides that, although software estimation is notoriously inaccurate, it is still done and written into contracts all the time, because it serves a useful purpose that outweighs its inaccuracy)
>Some measures should be targeted, the problem here is that it is done in an non genuine way
The "not in a genuine way" is exactly what he's talking about.
I disagree with the downvotes your comment's received.
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.
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.
Your comment also shows that patients are just as much of an issue by focusing on the metric more than the cases involved.
Essentially, the doctor has decided that he doesn't want to take the risk of killing you, even if you're willing to accept it. Why should that be the doctor's choice to make, and why is he being given this additional risk, when the benefit/loss should clearly be yours?
You're looking at this.
1 = https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4368858/
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.
They left the decision in our hands, and in many ways that's not better - how on earth are we supposed to decide? They also can't tell you with any certainty what the after-effects will be because no-one knows.
Probabilities and outcomes, or the process? Patients do get pretty good estimates and information these days. They don't have a good idea what chemo feels like though and what people think about the side effects. Doctors get that from seeing their patients.
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.
Making a decision vs having one made for you are very different things, even if the outcome of the decision is the same.
Having said that, I just wanted to add a small message of hope for those in similar situations. Atleast in the case of lung cancer, the situation is vastly improved now. The variants of lung cancer that are most prevalent now can be managed with oral medication alone and the patients can recover to go on and lead normal lives. This is from experience seeing another close relative suffer terribly from lung cancer (mainly because diagnosis of lung cancer itself is very hard as the symptoms show up very late and can be mistaken for other issues) and has now miraculously recovered and is back onto his normal routine.
When I was an undergraduate I worked in the lab of Dr. Robert Bast to pad my resume - he went on to head cancer research at MD Anderson. He's the doctor that discovered the CA-125 ovarian tumor marker. Anyway, 26 years ago he told me he thought we'd have a cure for cancer in the next 10 years. I think he's off by 40-50, but we are making strides
I work with software and we gotta give estimates in hours (because the managers didn't like complexity numbers), you know, like add a dropown to the search page or whatnot and I say yeah sure, it's simple, one hour... and then I end up in prehistoric spaghetti land for two days.
Cardiac surgeons in the US have had their own database for >20 years, and vascular surgeons do too. General surgeons have gotten into it the last 10 years or so
I'm the NSQIP champion for my hospital system and go to monthly meetings to review our system's data. There's a lot of controversy with the data. We show individuals their data as compared to their anonymized peer data. Recently, the credentialling committee wanted access to the data, and that is being discussed, but I'm against it because the data only samples your outcomes, not every case, so it can be biased (although as you get more cases sampled, hopefully, the pattern established becomes more relevant). Anyway, it can be humbling.
Moreover, all deaths / OR take backs / readmissions get reviewed by a hospital committee and in the 15 years I've been in practice, there have been 4 surgeons in town that have lost their privileges to operate at the hospital.
It's irresponsible for the doctor to not give a reasonable prognosis!
I'm not. That's been my experience with pretty much every surgeon, and even a fair amount of the non-surgical doctors. Letting patients see uncertainty and indecision is not part of the medical school culture, as near as I can tell.
It behooves anyone with serious medical issues to do independent research. (God help you if you don't already know how to deep learn on literature not in your field.)
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.
That would simply result in an unwritten rule where everyone gives everyone else good ratings.
Doctors only get investigated when derogatory facts accumulate to an extent that this "standard narrative" collapses. It's not really an objective or scientific standard.
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?
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.”
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.
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?
However let us add someone that is really sick and will most likely die within 6 months if they don't get surgery. They are in bad shape so surgery has a 25% risk of killing them. Most patients would probably want to take that gamble but for the surgeon who operates on patients like that frequently that would mean that their stats would go from almost perfect to pretty bad. You don't want to surgery from a guy with where 10% of his patients die from heart surgery when you can get another guy where only 0.1% die.
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).
Durant is particularly bad at this. In an AMA on Reddit, Daryl Morey said he tells his players they keep their own internal stats (most teams do) and ignore heaves. The idea is they’ll be more likely to take them knowing the team won’t hold it against them when negotiating a contract.
- 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!
Note that this also works to improve stats on docs who choose hard cases.
- 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.
You can see one example here
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.
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.
This is entirely reasonable and I cannot imagine how you could have a medical system where you can't?
What do you do if your surgeon operates drunk and kills you? Hope that a bunch of other doctors don't close ranks and protect their own at your expense? Why would anyone have any faith in their fellow man. People are terrible.
Can you see that this introduces a level of recklessness that isn't present in the parents question? Parent is asking about normal death by medical error. That's likely to have complex causes and is rarely as simple as "doctor was negligent".
But assuming that a doctor does kill someone: most relatives don't want a pay out. They want to know that this mistake won't happen again; that people and the orgnisation have learnt from the death; and they want an explanation of what went wrong along with an apology.
Doctors would then be ranked as an offset from this previous mortality prediction.
It targets inflation and unemployment goals.
Goals are measured by the Department of Labour (BLS).
Internists, paths, triage, GP, trauma do.
Some may know Jeffrey Hudson better by his given name, Michael Crichton.
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.
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.
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.
This may of course favour unnecessary ops...)
Look to c-sec vs. vag deliveries.
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."
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.
(Credit: alerted to this misincentive by Yudkowsky’s recent book Inadequate Equilibria.)
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).
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
The stakes are lower, of course, but the idea is similar.
48 hours later she was dead.
Have surgeons predict their own chance of success. Preferably, gather multiple second++ opinions for each case.
The difficulty of the surgery is based on some combination of the different surgeon's predictions.
A surgeon's stats would then be based on his successful and unsuccessful surgeries, weighted against the difficulty.
Using this method, not only can you still rank the surgeons based on the successes of their surgeries, but also on the accuracy of their predictions, which will be in larger sample size and also perhaps a better indicator of their mastery of medical knowledge.
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.
You already devoted probably half your life to becoming a surgeon, why would you screw it up and lose so much ground so easily?
From my own struggles of trying to find healing for chronic pain I have, I have realized that doctors/professionals are selected for for their memorization and not for critical thinking skills.
It's like doctor's stop thinking after they get their degree.
Whenever I've visited a doc within the past few years I have noticed that instead of actually getting to know someone as a patient, many act as if they are a quick reference book.
This is especially horrifying when you consider that there is a non-trivial portion of the population that exist outside of the medical literature.
Every one of the best Doctors I've ever had has ALWAYS been a researcher at heart. They observe, take notes, treat what they can now, and come back later and can clue me in on the latest research they've come across.
Nowadays, I'm usually making Doctors aware of advancements in their field... Scary stuff.
I don't find that to be too surprising. I can be hyper-aware of my own ailments, but keeping up with an entire field is more difficult. Furthermore, treating to research runs the risk of using treatments where the outcomes haven't been replicated, or there are long-term complications. Unless you've exhausted more conventional treatments/the treatment guidelines, there's something of an advantage of not being right at the bleeding edge.
I do not find the above to be sufficient justification to practice in ANY field without trying to stay aware of the state-of-the-art.
Yes, in medicine in particular, there is a justifiable bias toward applying more conservative treatments first. "Hear hoof beats, think horse first, not Zebra," is the axiom I believe is most frequently ground into new physicians.
The problem comes in when a physician becomes so conditioned to conservative treatments working that they become blind to the extremes. Running with the Zebra analogy, just because you hear hoof beats, you see a horse-like silhouette, and in this lighting you can't tell the color, does not mean you should IGNORE the possibility of Zebra.
As a practicing physician, you are DEPENDED upon to be the layman's gateway to the entirety of the collective medical knowledge base we've been able to accrue, verify, and are in the process of verifying. You owe it to your patients, just as an Engineer owes it to the public, to become as well acquainted with the medical literature as it pertains to them as possible.
I may be being a bit normative here, but an M.D. should be seen as a commitment to spending your life on the pursuit of the means by which to provide the highest quality of care for your body of patients. That at times means being ready to help the a patient access and navigate the less charted waters of the state-of-the-art if necessary.
I agree completely that state-of-the-art should not be the first hammer pulled from the toolbox, but one should not actively avoid it either. At the end of the day, data doesn't get generated out of thin air, and if the patient understands and accepts the risks after you have provided them the best guidance you can, you have done all that can be expected of you, have you not?
It's not a justification of not _trying_ to stay aware of the state of the art, but you always (potentially) stay ahead if you are focused on a smaller sub-field. I doubt it's possible to be completely aware of every single advancement for every condition you might encounter as it happens, nor is it suggesting that you should ignore the chance of zebra - for me, the best doctors have been those who will say "_I_ don't know; I will consult others or the literature", recognising that it's not possible for a single doctor to have exhaustive knowledge.
Are you taking about your cases? Because keeping on top of the narrow score that's currently relevant to you is a different level of time investment than keeping on top of everything happening in the field, after already learning a large part of it, and keeping in mind current treating guidelines which lag behind research.
I admit, things become a lot simpler once you limit your scope to issues immediately relevant to you as a patient.
However, I do still believe that when made aware of something new from a patient, a good physician should actively tackle the topic if only to be able to give a realistic assessment of where it falls on the risk/outcome spectrum.
NOTE: This may be assuming an above average level of patient investment. I in no way condone of wasting a physician's time having them wade through quackery. Nobody has time for that.
As with anything in modern society, bean counters rule and usually drive awful decision making.
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.
While not a product we’d ever build, there was always discussion amongst the doctors of how to better grade physicians and specifically surgeons. The concern is was that a lot, and I mean a LOT, of surgeons were bad at their job. They were always proposing different systems to evaluate surgeons, very close to what you described.
He asks for a level of "objectivity" that you just can't get. What do you think medicine is? Like repairing toasters? "Why don't you simply assign some objective numbers" - it's so easy! No it is not, unless you only count a set of basic and routine procedures. Even things like a broken bone vary greatly - and then add the additional variance of the people having those broken bones.
You can sort of get some objectivity when you do statistics of lots and lots of patients in many places over long periods - but the problem OP wants is to be able to make statements about individuals (doctors). Being able to say something about a population is very different from saying something about an individual within the population. "Statistics" about a single doctor are and will be full of randomness.
Besides, if they did what I quoted from OPs statement above what would probably happen is that everybody declares everything as "very difficult" (or just below) expecting colleagues to do the same for them. In Germany private insurance has a multiplier on the amounts they can charge for something. Guess what: Everything is now declared as "very difficult" (with some short fuzzy explanation), multiplier 2.3. Almost nothing is charged at the "normal difficulty" rate.
> Did they improve longevity? Did they improve quality of life?
Given that each doctor is highly specialized, and that on the other hand your GP, the one who treats you long-term, can't actually do much when there is anything serious, those numbers are mostly out of the control of individual doctors. You would have to get such numbers system-wide, not per doctor. Medicine is supplied to patients throughout their life (incl. late life) by a network, not by an individual. There also is a huge impact of ones own life choices (e.g. obesity, smoking), and no, you can't just correct for them - not individually (for populations we can). All those numbers would look terrible for doctors who treat more of the worse cases. It would lead exactly to what the article is about.
I'm not arguing against trying to measure surgeon outcomes - I'm against trying to use those measures for things they are not good for.
Most of the private surgeons are also NHS, anyway.
Most people don't have enough information to make a sensible choice; and they don't understand the information they've got.
"Okay, we won't serve you if you're just going to trash us."
"EVIL HOW DARE YOU!"
Of course someone should not go back where they don't like to go....