Giving Doctors Grades Has Backfired 245
HughPickens.com writes: Beginning in the early 1990s a quality-improvement program began in New York State and has since spread to many other states where report cards were issued to improve cardiac surgery by tracking surgical outcomes, sharing the results with hospitals and the public, and when necessary, placing surgeons or surgical programs on probation. But Sandeep Jauhar writes in the NYT that the report cards have backfired. "They often penalized surgeons, like the senior surgeon at my hospital, who were aggressive about treating very sick patients and thus incurred higher mortality rates," says Jauhar. "When the statistics were publicized, some talented surgeons with higher-than-expected mortality statistics lost their operating privileges, while others, whose risk aversion had earned them lower-than-predicted rates, used the report cards to promote their services in advertisements."
Surveys of cardiac surgeons in The New England Journal of Medicine have confirmed that reports like the Consumer Guide to Coronary Artery Bypass Graft Surgery have limited credibility among cardiovascular specialists, little influence on referral recommendations and may introduce a barrier to care for severely ill patients. According to Jauhar, there is little evidence that the public — as opposed to state agencies and hospitals — pays much attention to surgical report cards anyway. A recent survey found that only 6 percent of patients used such information in making medical decisions. "Surgical report cards are a classic example of how a well-meaning program in medicine can have unintended consequences," concludes Jauhar. "It would appear that doctors, not patients, are the ones focused on doctors' grades — and their focus is distorted and blurry at best."
Surveys of cardiac surgeons in The New England Journal of Medicine have confirmed that reports like the Consumer Guide to Coronary Artery Bypass Graft Surgery have limited credibility among cardiovascular specialists, little influence on referral recommendations and may introduce a barrier to care for severely ill patients. According to Jauhar, there is little evidence that the public — as opposed to state agencies and hospitals — pays much attention to surgical report cards anyway. A recent survey found that only 6 percent of patients used such information in making medical decisions. "Surgical report cards are a classic example of how a well-meaning program in medicine can have unintended consequences," concludes Jauhar. "It would appear that doctors, not patients, are the ones focused on doctors' grades — and their focus is distorted and blurry at best."
Seriously... (Score:5, Insightful)
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Same: "I think I'll take this class. It's an easy A".
Different: "But this is only to get my GPA up. Once I get into college, I'll take harder courses."
Re:Seriously... (Score:5, Insightful)
You attribute far too much planning and foresight to the people who implemented it.
Pretty much every metric I've seen like this leads to people trying to maximize their score instead of doing the things being measured in the score.
Think standardized testing, where suddenly teachers are only teaching what you need to pass the standardized test.
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Could you provide an example of something that teachers should teach but that cannot be tested?
Re:Seriously... (Score:4, Insightful)
The argument isn't against testing, it's against standardized testing, and over-reliance on testing. If the standardized tests for history are based on a specific curriculum, that means everyone has to teach the same parts of history, with the same emphasis (which is a great way to indoctrinate people). It also means you can't focus on assignments and on general knowledge; a kid who has a broad understanding of world history and why things happened, but who doesn't have dates memorized, could get high grades in essay assignments but tank on standardized tests. Someone who's objectively better educated can still be rated very low by tests administered by someone who doesn't know their curriculum.
Re:Seriously... (Score:4, Insightful)
The argument isn't against testing, it's against standardized testing, and over-reliance on testing.
I like the term high-stakes testing, because issuing a standardized test once a year is a fine to gain visibility into trends and patterns (and maybe figure out where extra help is needed), but once you start tying compensation and school budgets directly to the score, it's over. People are going to game the system.
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Most Standardized testing fails at the student's level. They are great for people who have no contact with students (Politicians, High Level Administrators etc), but they do NOTHING to help the kids learn anything. And because of that, they are more or less worthless for students, and everything for people getting paid stupid amounts of money to generate standards based testing.
And standards based testing is EXPENSIVE, and negatively impacts seat time in classrooms. And my experience is that by the time the
Re:Seriously... (Score:4, Insightful)
The argument isn't against testing, it's against standardized testing
If the tests are not standardized, then there is no way to compare results, which makes them meaningless for improving the schools through accountability.
If the standardized tests for history are based on a specific curriculum ...
They are not. So that is a phoney objection. However, the standardized test for reading and math ARE based on specific knowledge, like being about to add, subtract, multiply, and recognize and know the meaning of specific words. Do you also object to that as "indoctrination"?
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Actually, there is a problem. Which is why the schools with less money do worse on standardized tests than schools with more money.
And the problem is that the tests are written to a specific curriculum that is clearly identified in the text books associated with those tests.
So even if a student knows MORE about a subject than is taught in a specific text book, that student can still FAIL the standardized test because s/he does not provide the answer identified in the text book.
Such as ... what are the 3 mai
Re:Seriously... (Score:5, Insightful)
The problem, as I understand it, in standardized (CORE) testing in mathematics is not that ALL the students are made to learn how to add, subtract and multiply, but that the test makes extremely specific assumptions about PRECISELY what method that the student was taught in order to make use of those operations. For example, I believe it is common for the standardized tests to assume that students do all of their basic arithmetic by using number-lines in a very specific way. If, instead, the student was taught to do arithmetic using any of the MANY, MANY other methods out there instead of the number-line method (which I personally think is slow and stupid) they will flunk because they must show every step of the problem on a number-line, regardless of the resulting answer the student supplies.
I can't imagine a more soul-sucking task for a teacher then to have to re-teach their students how to do their math problems in an objectively WORSE manner than the one that the teacher had been, JUST so that the class doesn't fail their standardized tests and the teacher/school isn't penalized. This is exactly how you discourage passionate individuals from becoming teachers.
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Why can't the whys be tested?
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It's not a matter of can or cannot be tested, it's a matter of is or is not tested. How many pounds do you want the test booklet to weigh?
Re:Seriously... (Score:5, Insightful)
It's not always that they cannot be tested, just that they are not tested.
One reason is because using a Scantron to grade multiple choice answers costs much less than paying graders to read free-form answers.
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Could you provide an example of something that teachers should teach but that cannot be tested?
That is not the point. There are many things that can be taught and tested. However, when you test specific things and tie an infividual's renumeration to trst results teachers will focus on what is on the trst to the detriment of other things that would be useful to know. As a result the test is not a broad measure of acheivement but how well a teacher can prep students for the things on the test.
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Shouldn't those things also be on the test?
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Sure they should be. Can you write a test for them that can be graded by a Scantron?
Re:Seriously... (Score:5, Insightful)
Why can't the student's knowledge of logical fallacies be tested?
Some say creativity can in fact be tested. [wordpress.com]
Learning skills such as critical thinking and creativity? (See above.)
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Creativity in problem solving is quite different. Simple is better and simple is ALWAYS obvious in hindsight. You can't look at an answer and say it's creative, you can just look at an answer and say it works. Quality of answers for open ended problems is a fuzzy issue that cannot be easily reduced to a simple "
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Re:Seriously... (Score:5, Insightful)
Why can't the student's knowledge of logical fallacies be tested?
Because knowledge of rhetoical games is not a good measure of thinking. It'd be like a test of the rules of football and claiming it measures the ability to play the game.
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Can't critical thinking be demonstrated by identifying logical fallacies committed by a passage?
Re:Seriously... (Score:5, Insightful)
Thinking outside the box ?
That can be taught and tested. I have a meter long shelf with books full of puzzles that require "out of the box thinking" rather than conventional approaches, written by Martin Gardner, and other puzzle masters. I use problems from these books when I volunteer for after school enrichment programs. The kids love them, and they definitely get better at them with practice. The creative thinking exercises help them quickly come up with solutions in robotics and programming competitions.
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Every individual has different strengths and weaknesses.
This is an important point. Standardized tests assume everyone is like a cog coming off an assembly line. Good education should be tailored to needs of the student, not the needs of an industrial education system.
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Sorry for the messed up formatting. That should have read:
Every individual has different strengths and weaknesses.
This is an important point. Standardized tests assume everyone is like a cog coming off an assembly line. Good education should be tailored to needs of the student, not the needs of an industrial education system.
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1) Different students might need to be taught in different ways to learn the same set of skills.
2) Different students should come out of school with very different sets of skills.
I'm totally onboard with (1), but not so much with (2). "He can't add, but boy can he write!" Everybody is going to have natural aptitudes for certain things, but there's a basic level of core competence that everybody should be able to hit.
Re:Seriously... (Score:5, Interesting)
Think standardized testing, where suddenly teachers are only teaching what you need to pass the standardized test.
Poor analogy. Doctors can choose their patients. Teachers can rarely choose their students.
If what is on the test is not what you want the students to be learning, then the problem is with the design of that test, not with standardized testing in principle. Most people that object to our current system of testing, have no interest in improving it, but rather prefer no accountability at all.
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Metrics are amazingly important. However what is being measured and why are vital components of any metric and determine if the metric is useful or not. The problem with standardized testing in schools is that the purpose of the metric is ill conceived. We are testing the students to determine the quality of the teachers. Since the tests are not normalized to include the quality of the students the metrics are meaningless. Likewise unless the metric for doctors takes into account the survival risks of the p
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Except that teachers are often evaluated by the test scores of their students. Naturally, since they're rewarded by the metric, many of them do their best to game the metric.
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Poor rebuttal. Not only can teachers not choose their students, but teachers can rarely choose how they teach, as well.
The move toward standardization is not simply toward testing, but also toward scripted lessons, highly stringent time-tables, and an artificially imposed metric of "success" that leaves no room for innovating a solution. While standardized tests are performed disgustingly often in our schools, the results are so inconsistent and delivered so late that there is no opportunity for teachers
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I could have had coffee in my mouth when I read that the problem with politicians is that they aren't cynical enough, you insensitive clod!
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Simplistic solutions are attractive to bean counters, politicians, and even voters. All three groups are frequently unoccupied by unsophisticated people who may have certain degrees of tactical intelligence, but tend not be able to think through a given proposal, but rather look for things that are somehow emotionally or ideologically pleasing.
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Yes. Failure to take the patient's condition into account makes the grading useless. A doctor who loses a patient who was circling the drain on presentation should not be faulted. OTOH, losing a patient who was just in for a check-up should count HUGE.
You missed a spot (Score:3)
Suppose a patient comes in for a routine checkup and the doctor finds an advanced cancer and the patient dies. The primary care doctor who had the patient "in for a routine checkup" should not be punished for the poor outcome.
I get the feeling that is not what you meant to happen when you said "losing a patient who was just in for a check-up should count HUGE", but that is what you said. It highlights the difficulty of doing this kind of thing correctly.
--PM
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Doctor Who never loses a patient!
What about Adric?
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How could no one have foreseen the potential abuse and pitfalls of a system like this? Without even reading any further than "Giving Doctors Grades..." I immediately conjured images of a bunch of doctors huddled around each other saying, "I don't want that one." "Well I don't want that one either. My feedback is back at 85% and I can't risk another death screwing me over."
Given the enthusiasm for what is more or less exactly the same plan applied to teachers, it's hard to be too surprised that somebody would think that this is a good idea; though it doesn't shed any light on why they would have ignored the obvious pitfalls.
I can only assume that it's yet another instance of the "We want to measure stuff; but what we really want to measure is hard, so we'll settle for something that is easy to measure but not actually helpful" problem that bedevils quantification efforts o
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People Did Foresee it (Score:2)
How could no one have foreseen the potential abuse and pitfalls of a system like this? Without even reading any further than "Giving Doctors Grades..." I immediately conjured images of a bunch of doctors huddled around each other saying, "I don't want that one." "Well I don't want that one either. My feedback is back at 85% and I can't risk another death screwing me over."
People did foresee it, but that doesn't mean the decision-makers decided against it.
Doctors knew that having hospitals professionally administered as a business would be a nightmare with lots of deleterious effects on patient care, but it's still how the profession has evolved.
The fact is that unless you personally know people who are familiar with a doctor's skill from a medical perspective, it is fundamentally *impossible* to tell if they're any good. And none of those people will talk outside their prof
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Health insurance executives in secret conference "our secret plan to get rid of troublesome expensive patients is working as planned, mwa ha har.". People knew exactly what the outcome would be and that was the intention, more patients rejected, less insurance claims. Even if those patients do get accepted they will get the worst doctors and die quickly before more long term care bills can pile up.
bad metrics (Score:5, Funny)
bad metrics lead to bad results. Who would've guessed?
Gotta go, must write a million lines of code so I am "productive".
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I can usually tell the worth of a Educator (teacher) by their desire to learn. I work in a school district, and the better teachers tend to want to learn new stuff. The lessor teachers figure they are done "learning" because they finished college or similar attitude. Everything being equal, those teachers that still love to learn are better teachers, than those that don't want to learn anything else.
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You want to really screw a good thing up, set up a set of rigid metrics.
Once everything gets in the hands of the bean counters, anything that cannot be quantified as a bean gets summarily discarded, whether it's good, bad or indifferent.
And it's truly appalling how many systems get set up to measure the quantity and quality of the bathwater and ignore the fact that there's a baby in it.
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Want to know what is worse than bad metrics? No metrics.
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Not necessarily. Bad Metrics can cause problems in situations where no metrics wouldn't. As in unintended consequences. In this case, this is exactly what happened, bad metrics results in worse performance, not better.
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Well, the amount of metrics is not really at issue here. Both no metrics and bad metrics represent the same state: non-existent applicable data.
No metrics is considered "better" because it avoids putting unwarranted faith in potentially bad data. But I'd argue that bad data moves us forward as long as it can be exposed to criticism. Having no data is simply shrugging our shoulders and refusing to even attempt to measure for fear of bad data.
Data is neither bad nor good, it is merely applicable or non ap
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bad metrics lead to bad results. Who would've guessed?
Gotta go, must write a million lines of code so I am "productive".
I think the largest change (in terms of sheer number of lines that were stupid) I've ever commited was a removal of a file that had 47000 lines, each consisting of a single number (below 256) and a comma. It was a C array header file. Don't ask, I don't know, it was a xor table.
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I once bragged at a meeting about all the code I'd removed from one of our larger programs.
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Was he wrong?
The most productive coder is the coder who writes only the number of lines of code that are required (and not a line more), and who does so the quickest.
If you take three hours to develop 10 lines of code that are completely optimized, whereas the other guy just started typing and found the same solution in 1000 lines in the same amount of time, who was the most productive? You've both solved the problem, but the first person only has 10 lines of code to their name. Is he less productive? Ce
Be careful with metrics (Score:3)
I think that this Dilbert comic [dilbert.com] captures the idea quite well.
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Gamers gonna game.
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Repeat until the equation is too complex to be optimized for. The metric should reflect "do the most good" in the best way possible. A simple single KPI almost never gets the desired result.
Just like Teacher "Grades" (Score:5, Interesting)
In NY, where I live, we're now "grading" teachers based on how well their students do on standardized tests. Any teacher who strays from the "prep for the test" subject matter and uses inventive ways of helping their students learn is going to have students who might know more, but who will perform worse on the tests. Teachers who stick to the script and drill test preparation into their students will wind up with better scores even though their students will know less (except how to fill in bubbles).
Just like the Doctors example in the article, the "teacher grading" system is going to backfire. Talented teachers will be kicked out (test scores are tied to their jobs now, your students get low scores and you're out) and mediocre teachers will remain. It's almost like trying to take the jobs that teachers and doctors do and standardize their job functions across every student/patient they see doesn't work. Maybe because their jobs require using their brains and trying different techniques as opposed to an assembly line worker who just needs to perform the same task every time with no variation.
Re:Just like Teacher "Grades" (Score:5, Insightful)
It's actually much worse. Teachers who toil away in schools where the students get little or no parental or peer support for learning, get hurt very badly by these grades, because regardless of how hard they work on the students, they do less well on standardized tests (and improve less) than students who grow up in suburban environments that encourage learning.
So it becomes a terribly dis-incentive for the best teachers to go to the schools that need them the most - they'll grab all the plum assignments in the nice, rich, suburban schools, while fresh teachers get sent to the inner-city schools (perpetuating this situation).
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Which is what happens now anyways, so at least it's not making things worse.
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Well, except for crushing the desire to actually, really teach from those teachers that foolishly try to do that.
Because if you can't win, only a fool keeps trying.
Which is how young idealistic teachers become old embittered ones.
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Well some teachers are people who care more about education than making money. They want the challenge of helping inner city youth, for instance.
Such people definitely exist.
And now, they could end up fired for taking on a challenge that most of us would consider laudable, even saintly.
Don't get me wrong, there are shitty teachers who skate by and do well with good union coverage, but I am not sure the testing metric is really a good process unless we actually want our students to maximize their short term
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Except now the teachers' jobs are at stake. In New York, if a teacher's students don't do as well on their standardized tests as the state says they should, the teacher can be fired. If this happens three years in a row, the teacher IS fired. No argument is accepted to avoid termination (except fraud and good luck proving that).
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That's assuming good teachers are super-relevant. If most teachers are not-to-smart, rigorously applying what some better thinker says to is superior to them trying there best. See also, a great chef is a great chef, but any idiot can churn out a McDonald's burger or Chipotle burrito.
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While this is true, it fails to address the previous problem, which my Mom witnessed constantly while she was a school administrator. Teachers messing around playing in class and NOT teaching what they should have been teaching. And other teachers would be totally frustrated because students that had Mrs. So-And-So last year had to be re-taught everything before they could start with what they should have been learning.
When the standardized tests came out, most of these frustrating teachers were gone quic
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Maybe some of the administrators whose job it actually is to evaluate their teachers should have their feet held to the fire. The city I live in, every principal in every school must spend two hours a year in each teacher's classroom evaluating their teaching methods and performance.
Two. Hours. A year.
Since they won't do their jobs, they're falling back on ridiculous metrics to do it for them. They get paid 2-3x as much as the teachers they're supposed to be evaluating too. Seems that all of these new progr
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It might be, that the Principal doesn't have the requisite time to spend in classrooms because student discipline is out the window, and they are having do deal with rebellion in the hallways and classrooms. Or perhaps Parents of Johnny Rotten don't think Johnny is a bad seed, that it is everyone else. Or perhaps it is trying to organize the entire staff for the three weeks of Standardized Testing that needs to be completed ... or ... any number of other "urgent" matters that delay or disrupt the "important
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It seems like standardized testing is the sort of thing you'd resort to in desperation, say in schools where students aren't learning much of anything. Then at least you can increase the performance from 'abysmal' to 'mediocre'.
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"Any teacher who strays from the "prep for the test" subject matter and uses inventive ways of helping their students learn is going to have students who might know more, but who will perform worse on the tests."
Teachers may think this, but is there any reason to believe it's actually true? Near as I can tell from following the coverage, this is mostly a concern that circulates among lower-quality teachers. Really good teachers have never had any issues with their students' test scores.
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Well knowing answers is one level of learning. Analysis is another level of learning, and can be difficult to truly capture on a test.
More to the point, knowing answers that you just use to pass a tollbooth like a standardized test is not actually knowledge, because it generally does not sink in.
Yes, the students who know how to do those things will actually do well, but a test taking atmosphere is not always the most conducive to recollection of such information even for those people who do know the answe
Did TV beat this article to the punch? (Score:2, Interesting)
Wasn't this addressed by the Scrubs TV show years ago?
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At minimum it was covered in either Freakonomics or Superfreakonomics.... at least 5 years ago...
Comment removed (Score:4, Insightful)
Still A Good Idea (Score:5, Insightful)
It's still a good idea, but the metrics need to be better thought-out to account for the patients that are being seen. A proper system will also "grade" each patient based on how bad their condition is, and then combine the mortality rates to come up with a metric that reflects how well the doctor is doing at improving outcomes where it is possible to do so.
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Except patient condition is subjective, and not everything's known upfront (or needs to be for that matter). And even ignoring the problem of who'd be qualified to assess the condition of somebody else's patient, who'd be willing to spend the extra time to do the evaluation?
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1) Have a different doctor triage the patient, standardize the criteria, keep the evaluation secret. Strip privileges from doctor that leaks evaluations, and/or fine hospitals for staff caught revealing evaluations.
2) Initially round robin assign the patient to the surgeon pool. If the surgeon declines the patient, keep going to the "pool". If all available surgeons reject patient, null the evaluation value, randomly assign to available surgeon. Add death panel criteria to reject operating on patient.
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One surgeon sees mostly patients with near guaranteed death like aortic dissection and another only performs appendectomies and tonsil removal.
Is there any reasonable metric to say one is better than the other or even a reason to do so?
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It doesn't matter. The metrics/system will be determined by the state's medical board, based on national research by statisticians & epidemiologists. The important thing is to prevent hospital managers and surgeons from "gaming" the system.
High Risk + Low Success = High Cost (Score:4, Interesting)
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Re:High Risk + Low Success = High Cost (Score:5, Insightful)
I think there's a ton of money being dumped into the walking dead.
When my mom was at stage 4 of metastasized breast cancer, we had a family meeting with the oncologist to discuss my mom's situation. When asked what -- if any -- chances she had for life extension (not a cure, but more than 12 months) he was totally equivocal about it and was basically looking to start another round of chemotherapy. I felt like he was just looking for another round of payments before she died. They give you the thinnest hope to try to get you to keep using their services.
I've heard similar stories before from other people with older relatives, very sick and unlikely to every recover in any meaningful sense of the word yet the doctors insist on expensive and invasive treatments. The only explanation I can think of is that it's good business for them.
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The result of "Payment for each Service" rather than "Payment for Outcomes". Standardize on what level of hopelessness the insurance company aren't required to pay, and doctors will cease to prescribe "Hail Mary's".
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Sorry to hear about your experience regarding your mom.
That's the problem with oncologists. They peddle in hope, rather than reality.
It's a double-edged sword, really. If they say there's nothing to do and it's best to just keep her comfortable, some patients and families will think they're giving up. On the other hand, if they go all-in and keep doing round after round of therapies, some families will feel they are milking the situation.
Better to ask the patient's primary care physician their opinion.
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Absolutely none. It does however contribute greatly to the total amount spent on health care in the US. Study after study has shown that (on average) something like 50-70% of an individuals lifetime medical costs are incurred in the last three years of their life.
I propose grades to the lawyers. (Score:2)
The doctors are chumps to operate under these rules rigged by the lawyers.
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Then more lawyers will be pressuring worse settlements on their clients to get a higher win percentage.
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Which Lawyer would your rather go to, given the following two metrics (No other information available, simplistic choice) ?
We win 90% of our cases
or
We've won $900 Million dollars for our clients
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Which Lawyer would your rather go to, given the following two metrics (No other information available, simplistic choice) ?
We win 90% of our cases
or
We've won $900 Million dollars for our clients
neither, you are better choosing randomly from the phone book than choosing between two charlatans
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Tier the settlement payouts. The higher win percentage won't matter if payouts are "egregiously" lower than what could be obtained in court.
Better model? (Score:2)
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A better model is one where we assume (unless demonstrated otherwise) that everyone in the profession at hand is striving in good faith for excellence
Perhaps via a modernized version of the Hippocratic oath?
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Check out the airline industry. It works extremely well, and I'm underselling this.
Did we not just see an incident where a pilot deliberately crashed the plane, killing all? Did we not hear story after story, about how so many people knew that something was terribly wrong, but nothing was done? This sounds like a badly broken system.
Any system that can be gamed, will (Score:2)
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Corollary: Every system can be gamed.
I have the answer! (I don't really) (Score:2)
When the statistics were publicized, some talented surgeons with higher-than-expected mortality statistics lost their operating privileges, while others, whose risk aversion had earned them lower-than-predicted rates, used the report cards to promote their services in advertisements."
So just grade them on talent and/or risk aversion. The quote above implies that both are identifiable qualities.
^ sarcasm
Is it really bad to reduce aggressive treatment? (Score:5, Interesting)
"They often penalized surgeons, like the senior surgeon at my hospital, who were aggressive about treating very sick patients and thus incurred higher mortality rates," says Jauhar.
It is true, some surgeons who are willing to treat very difficult cases would be adversely graded. But shouldn't there be some mechanism to apply brakes to the aggressive treatment? Some patients, and some of the relatives will be seeking treatment even when the situation is utterly hopeless. There are incentives for the doctors and the hospitals to pursue aggressive treatment. So, under these circs, is it really bad these grades are making them reevaluate the cases and be more realistic about the prognosis?
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Sure, but what of the top cardiac surgeon who loses half of his patients but the other half go on to a high quality of life lasting years longer? Sometimes aggressive treatment does offer a fair chance for meaningful recovery.
OTOH, an expensive cancer treatment that buys an extra month of agonized delirium and never results in remission is an example of excess aggression.
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I agree that in some cases it is cruel to provide treatment beyond pain management.
Where do we draw the line between little to no hope and a "fair chance"?
I am curious to see how many people who would support not treating hopeless cases, especially for monetary reasons, also support doctor-assisted suicide laws like Oregon has.
I love these rate my doctor sites (Score:2)
Then when I finally used these sites to find our presen
Hands of Death and Destruction (Score:2)
HODAD [forbes.com]- "Hands of Death And Destruction" - A Hopkins doctor wrote a book about the subject. [amazon.com]
From the article:
"At a medical conference Dr. Marty Makary saw one of his Harvard professors who “looked out at a room of 2,000 doctors and asked ‘How many of you know of another doctor who should not be practicing because he is too dangerous?’ Every hand went up.” Yet few report bad doctors and those that do often get fired.
Hospital staff knows they are practicing bad medicine and mostly do no
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