Five Anonymous Doctors Spill Their Guts
June 14, 2007 11:39 AM Subscribe
Self-Diagnosis: Five anonymous doctors frankly discuss their patients, other doctors, American healthcare, and the inevitable mistakes doctors make, including mistakes they've personally made that jeopardized their patients' lives.
I really wonder about the way we do medical malpractice lawsuits.
First of all, there is obviously a lot of real mistakes made, even by good doctors. But the current setup is ridiculous. There is simply no way that random jurors who know nothing about the topic should be deciding these factual questions. If it were up to me, I would have an independent board evaluate the substance of the claim before proceeding to trial to determine amounts.
posted by delmoi at 11:48 AM on June 14, 2007
First of all, there is obviously a lot of real mistakes made, even by good doctors. But the current setup is ridiculous. There is simply no way that random jurors who know nothing about the topic should be deciding these factual questions. If it were up to me, I would have an independent board evaluate the substance of the claim before proceeding to trial to determine amounts.
posted by delmoi at 11:48 AM on June 14, 2007
On the other hand attitudes like this are kind of idiotic:
Dr. Heart2: Overall, malpractice has made good doctors worse rather than bad doctors better because of the fear that you’re missing something and you may be sued for missing a diagnosis. So someone has back pain. You could diagnose a stiff neck with 95 percent certainty, but there’s a 5 percent chance that he could have cancer or a serious infection, and instead of going with your gut, you order a bunch of extensive tests to rule out the improbable.
5% is a hell of a lot. Now obviously 5% of all neck pain isn't cancer, and a few extra tests are not that big of a deal, but when it comes to the individual patent, I think most would prefer that tests be done, because you don't want to be that one unlucky one when a simple test could have prevented the problem.
posted by delmoi at 11:51 AM on June 14, 2007
Dr. Heart2: Overall, malpractice has made good doctors worse rather than bad doctors better because of the fear that you’re missing something and you may be sued for missing a diagnosis. So someone has back pain. You could diagnose a stiff neck with 95 percent certainty, but there’s a 5 percent chance that he could have cancer or a serious infection, and instead of going with your gut, you order a bunch of extensive tests to rule out the improbable.
5% is a hell of a lot. Now obviously 5% of all neck pain isn't cancer, and a few extra tests are not that big of a deal, but when it comes to the individual patent, I think most would prefer that tests be done, because you don't want to be that one unlucky one when a simple test could have prevented the problem.
posted by delmoi at 11:51 AM on June 14, 2007
The only bad thing about a bunch of extensive tests is the cost, which has nothing to do with being a bad doctor. If it was all paid for by the government the way it should be, I'd sure as hell want that 5% chance of cancer looked at.
posted by DU at 12:08 PM on June 14, 2007
posted by DU at 12:08 PM on June 14, 2007
But I also feel like I hang on to it because it makes me feel like a powerful guy that I killed someone.
I think Dr. Virus is either a fucking psychopath or really needs to consider how his words can be interpreted by others.
posted by CitrusFreak12 at 12:09 PM on June 14, 2007
I think Dr. Virus is either a fucking psychopath or really needs to consider how his words can be interpreted by others.
posted by CitrusFreak12 at 12:09 PM on June 14, 2007
Dr. Virus is just being honest. We all have fleeting or deeply repressed feelings that are reprehensible.
posted by Falconetti at 12:18 PM on June 14, 2007 [2 favorites]
posted by Falconetti at 12:18 PM on June 14, 2007 [2 favorites]
and instead of going with your gut
I can't for the life of me place it, but I read a similar article recently (I think it was in Harper's) and the doctors in that article spoke about how most doctors make mistakes because they're simply trained to look for a set of common maladies. So, in a sense, they go with their gut more times than not, often with debilitating or lethal consequences.
Half of the docs in this article sounded like arrogant clowns, but that's kind of what you expect, unfortunately.
posted by The God Complex at 12:20 PM on June 14, 2007
I can't for the life of me place it, but I read a similar article recently (I think it was in Harper's) and the doctors in that article spoke about how most doctors make mistakes because they're simply trained to look for a set of common maladies. So, in a sense, they go with their gut more times than not, often with debilitating or lethal consequences.
Half of the docs in this article sounded like arrogant clowns, but that's kind of what you expect, unfortunately.
posted by The God Complex at 12:20 PM on June 14, 2007
Here's the full quote:
When I was an intern, I gave someone fluid and put them into fatal heart failure because I misunderstood what to do. He was someone who was destined to die soon—he had end-stage cancer. But I feel like a crumb about it all the time. But I also feel like I hang on to it because it makes me feel like a powerful guy that I killed someone.
He's being more honest than perhaps we give him credit for, stepping back and realizing the consequences of the care he gives and the power he has. I think I'd prefer to receive care from a doctor who can admit fallibility and has (what I read to be) a sense of humility earned from previous mistakes.
posted by Blazecock Pileon at 12:23 PM on June 14, 2007
When I was an intern, I gave someone fluid and put them into fatal heart failure because I misunderstood what to do. He was someone who was destined to die soon—he had end-stage cancer. But I feel like a crumb about it all the time. But I also feel like I hang on to it because it makes me feel like a powerful guy that I killed someone.
He's being more honest than perhaps we give him credit for, stepping back and realizing the consequences of the care he gives and the power he has. I think I'd prefer to receive care from a doctor who can admit fallibility and has (what I read to be) a sense of humility earned from previous mistakes.
posted by Blazecock Pileon at 12:23 PM on June 14, 2007
The only bad thing about a bunch of extensive tests is the cost, which has nothing to do with being a bad doctor. If it was all paid for by the government the way it should be, I'd sure as hell want that 5% chance of cancer looked at.
And... welcome to Canada. Where there are a limited number of testing spots available. So you get your tests. In 6 months. You get your new hip. Sometime.
Just because the government is paying doesn't mean things get better. The whol epoint of advocates of private-payer systems is that a lot of things get worse because the government spends, say, $2M annually on MRI machines, regardless of how many people want MRIs. Supply and demand go out the window and it's back to soviet-style lineups. (personally, I like the system, but my point is that the government doesn't really want you to have the tests because it's cheaper to let 5% of the people develop serious cancer and then treat that)
Anyway, doctors are nice and all, but asking a doctor about how to structure a nation-wide medical insurance program is like asking a plumber to design London's sewer system. The difference in scale makes it into a completely different problem.
posted by GuyZero at 12:30 PM on June 14, 2007
And... welcome to Canada. Where there are a limited number of testing spots available. So you get your tests. In 6 months. You get your new hip. Sometime.
Just because the government is paying doesn't mean things get better. The whol epoint of advocates of private-payer systems is that a lot of things get worse because the government spends, say, $2M annually on MRI machines, regardless of how many people want MRIs. Supply and demand go out the window and it's back to soviet-style lineups. (personally, I like the system, but my point is that the government doesn't really want you to have the tests because it's cheaper to let 5% of the people develop serious cancer and then treat that)
Anyway, doctors are nice and all, but asking a doctor about how to structure a nation-wide medical insurance program is like asking a plumber to design London's sewer system. The difference in scale makes it into a completely different problem.
posted by GuyZero at 12:30 PM on June 14, 2007
It's equally stupid to design a sewer system without any input from plumbers at all. Doctors shouldn't structure it, GuyZero, but they should be heavily consulted, especially in a way that allows them to be candid without professional risk. And patients should be consulted too, because at one point or another everyone becomes one.
The "engineers" we are relying on in this case can't be counted on to produce results as long as the fortune they're making off of us affords them the very best of care.
posted by hermitosis at 12:57 PM on June 14, 2007
The "engineers" we are relying on in this case can't be counted on to produce results as long as the fortune they're making off of us affords them the very best of care.
posted by hermitosis at 12:57 PM on June 14, 2007
I'm inclined to agree with Blazecock Pileon about the whole "feel like a powerful guy that I killed someone" bit. Having the honesty and self-awareness to say that kind of thing is quite admirable. Obviously in a lot of situations doctors possess the power of life and death in a very real, raw way that the vast majority of the population will never experience. To dismiss the suggestion that this power could have any effect on someone, and describe someone honestly describing their understandable reaction to it as a psychopath, doesn't make sense.
posted by Aloysius Bear at 1:04 PM on June 14, 2007
posted by Aloysius Bear at 1:04 PM on June 14, 2007
The God Complex: was this the article you meant?
posted by The corpse in the library at 1:22 PM on June 14, 2007
posted by The corpse in the library at 1:22 PM on June 14, 2007
The OB/GYN's confession of having dropped a baby will stick with me for a long time.
That's what stuck with you? I'm more impressed with the admissions of killing people accidentily.
posted by agregoli at 1:29 PM on June 14, 2007
That's what stuck with you? I'm more impressed with the admissions of killing people accidentily.
posted by agregoli at 1:29 PM on June 14, 2007
And... welcome to Canada. Where there are a limited number of testing spots available. So you get your tests. In 6 months.
...a lot of things get worse because the government spends, say, $2M annually on MRI machines, regardless of how many people want MRIs.
That's not quite accurate. In the Canadian single payer system it's true that there is a limited amount of money spent on MRI scanners, to use your example. But that means that although fewer MRIs are done they tend to be done on the patients who genuinely need them, rather than those who "want" them. In this climate a physician doesn't have to be afraid of being sued for not ordering an MRI in a situation where all the evidence suggests it's unwarranted, because there's a general understanding that you can't MRI everybody.
In both countries there is, ultimately, a finite amount of money available to be spent on medical care. The advantage of a single payer system is, in my opinion, that decisions can be made to rationally allocate resources. This is in contrast to the US system in which resources appear to be allocated according to a bewildering patchwork of widely varying insurance coverage levels and the cover-your-ass reflexive response to the fear of being sued for malpractice.
posted by Turtles all the way down at 1:37 PM on June 14, 2007
...a lot of things get worse because the government spends, say, $2M annually on MRI machines, regardless of how many people want MRIs.
That's not quite accurate. In the Canadian single payer system it's true that there is a limited amount of money spent on MRI scanners, to use your example. But that means that although fewer MRIs are done they tend to be done on the patients who genuinely need them, rather than those who "want" them. In this climate a physician doesn't have to be afraid of being sued for not ordering an MRI in a situation where all the evidence suggests it's unwarranted, because there's a general understanding that you can't MRI everybody.
In both countries there is, ultimately, a finite amount of money available to be spent on medical care. The advantage of a single payer system is, in my opinion, that decisions can be made to rationally allocate resources. This is in contrast to the US system in which resources appear to be allocated according to a bewildering patchwork of widely varying insurance coverage levels and the cover-your-ass reflexive response to the fear of being sued for malpractice.
posted by Turtles all the way down at 1:37 PM on June 14, 2007
Interesting read. Thanks.
posted by HighTechUnderpants at 1:48 PM on June 14, 2007
posted by HighTechUnderpants at 1:48 PM on June 14, 2007
Very informative. Thanks for pointing it out.
posted by Dave Faris at 2:12 PM on June 14, 2007
posted by Dave Faris at 2:12 PM on June 14, 2007
Slimy, slimy people this lot.
That's not the impression I had at all. Five people being honest about their profession, is much more the take-away I had. Why is it surprising that doctors make mistakes, that they consider human factors when making decisions, that they they think hospitals are cold and depersonalizing too, that they want people they like to do well? I'm sure that if you talked to auto mechanics, for instance, you would hear similar things. The lack of arrogance and self-serving answers made for an interesting view into the doctors' perspectives. Nice interview.
One of the more amusing things from the bottom of the 50 nurses poll, linked on the page:
Do doctors and nurses flirt in the operating room?
Often…. 8
Sometimes…. 10
Never…. 15
No response…. 17
Do they ever have affairs?
Often…. 8
Sometimes…. 17
Never…. 15
No response…. 10
A lot of "no comments" there.
posted by bonehead at 2:38 PM on June 14, 2007 [1 favorite]
That's not the impression I had at all. Five people being honest about their profession, is much more the take-away I had. Why is it surprising that doctors make mistakes, that they consider human factors when making decisions, that they they think hospitals are cold and depersonalizing too, that they want people they like to do well? I'm sure that if you talked to auto mechanics, for instance, you would hear similar things. The lack of arrogance and self-serving answers made for an interesting view into the doctors' perspectives. Nice interview.
One of the more amusing things from the bottom of the 50 nurses poll, linked on the page:
Do doctors and nurses flirt in the operating room?
Often…. 8
Sometimes…. 10
Never…. 15
No response…. 17
Do they ever have affairs?
Often…. 8
Sometimes…. 17
Never…. 15
No response…. 10
A lot of "no comments" there.
posted by bonehead at 2:38 PM on June 14, 2007 [1 favorite]
The whole bit about the best doctors being at the more prestigious hospitals or coming from the highest-tier schools reeks of total elitist bullshit.
posted by secret about box at 3:09 PM on June 14, 2007
posted by secret about box at 3:09 PM on June 14, 2007
Note: The general tone of the article was still good, just that bit bothered me.
posted by secret about box at 3:14 PM on June 14, 2007
posted by secret about box at 3:14 PM on June 14, 2007
...a lot of things get worse because the government spends, say, $2M annually on MRI machines, regardless of how many people want MRIs.
If the government is actually buying the MRI machines or even providing a budget to physicians for them, then the Canadian system is different from single-payer as I understand it.
I was thinking the way it worked was that private or regional clinics bought the machines, and billed the payer for each patient who received service, recovering costs on these fees. Not true?
posted by weston at 3:14 PM on June 14, 2007
If the government is actually buying the MRI machines or even providing a budget to physicians for them, then the Canadian system is different from single-payer as I understand it.
I was thinking the way it worked was that private or regional clinics bought the machines, and billed the payer for each patient who received service, recovering costs on these fees. Not true?
posted by weston at 3:14 PM on June 14, 2007
Slimy, slimy people this lot.
Nice. I wonder why we don't hear doctors' honest opinion more often.
posted by Slarty Bartfast at 3:27 PM on June 14, 2007
The whole bit about the best doctors being at the more prestigious hospitals or coming from the highest-tier schools reeks of total elitist bullshit.
If, God forbid, I ever found myself at the tender mercies of the American healthcare system and had the required money, I would damn well want a doctor who'd gone to one of the most prestigious medical schools. Sure, it's not a guarantee of competence, and there's no substitute for local knowledge, as the doctor in the article says himself. But you'd have to be an idiot to think that the average doctor who graduated from Johns Hopkins or wherever is no better than the average University of Nowheresville graduate.
There's bad elitism and good elitism; social elitism is bad, and academic medical elitism is good.
posted by Aloysius Bear at 3:28 PM on June 14, 2007
If, God forbid, I ever found myself at the tender mercies of the American healthcare system and had the required money, I would damn well want a doctor who'd gone to one of the most prestigious medical schools. Sure, it's not a guarantee of competence, and there's no substitute for local knowledge, as the doctor in the article says himself. But you'd have to be an idiot to think that the average doctor who graduated from Johns Hopkins or wherever is no better than the average University of Nowheresville graduate.
There's bad elitism and good elitism; social elitism is bad, and academic medical elitism is good.
posted by Aloysius Bear at 3:28 PM on June 14, 2007
regarding the unlimited MRIs for everyone question:
The true number of sore necks due to cancer is certainly much less than 5%. However, the number of questionable findings that do not need clinical followup found on MRI is probably about 5%.
So you strained your neck moving boxes over the weekend. You get an MRI from your doctor the next day, because hey, you have insurance, right? But your risk of having cancer is like 1 in 10,000. But your risk of having a "mysterious spot" is 500 in 10,000. So you get the MRI and now you have a spot. What are you going to do now? Because I bet your doctor, who knows in his heart this isn't cancer, is going to want to perform spinal surgery because this is now an indefensible lawsuit to do nothing.
This scenario happens *all the time* and is applicable to almost every medical test that is available.
posted by Slarty Bartfast at 3:35 PM on June 14, 2007
The true number of sore necks due to cancer is certainly much less than 5%. However, the number of questionable findings that do not need clinical followup found on MRI is probably about 5%.
So you strained your neck moving boxes over the weekend. You get an MRI from your doctor the next day, because hey, you have insurance, right? But your risk of having cancer is like 1 in 10,000. But your risk of having a "mysterious spot" is 500 in 10,000. So you get the MRI and now you have a spot. What are you going to do now? Because I bet your doctor, who knows in his heart this isn't cancer, is going to want to perform spinal surgery because this is now an indefensible lawsuit to do nothing.
This scenario happens *all the time* and is applicable to almost every medical test that is available.
posted by Slarty Bartfast at 3:35 PM on June 14, 2007
weston: I was thinking the way it worked was that private or regional clinics bought the machines, and billed the payer for each patient who received service, recovering costs on these fees.
Yep, that's right. Health care in Canada is operated on a fee for service basis. Fees are set by provincial medical associations and health care professionals bill on their scales.
To expand out a bit on funding: the federal government transfers money to each of the provinces to run its health care program and then the province--in consultation with its health regions, health care professionals, and policy makers (who most certainly take into account public opinion--spends the money as it sees fit. There will be province-wide targeted investment when it is clear that the need exists. For example, this could be in the form of earmarking money for more MRI machines where waiting lists are long or decreasing waiting times across the province for specific procedures. In Alberta (and I'm pretty sure this is the case in other provinces, too), money is then transferred to smaller health regions/authorities and they manage their own affairs. In other words, the province is charged with setting broad policy goals and priorities and health care regions are then empowered to implement them. It's a surprisingly mobile and responsive system--I find the Soviet-style central planning accusations a bit far fetched.
(Of course, there are times when the Canadian health care system fails and everyone's heard stories about horrific waiting times or unavailable treatment or the impossibility of finding a doctor who's taking new patients etc. I certainly don't deny this and think that this is truly a shame. It's anecdotal, sure, but my family and I have always received exemplary care for trivial and serious medical situations.)
posted by lumiere at 3:52 PM on June 14, 2007
Yep, that's right. Health care in Canada is operated on a fee for service basis. Fees are set by provincial medical associations and health care professionals bill on their scales.
To expand out a bit on funding: the federal government transfers money to each of the provinces to run its health care program and then the province--in consultation with its health regions, health care professionals, and policy makers (who most certainly take into account public opinion--spends the money as it sees fit. There will be province-wide targeted investment when it is clear that the need exists. For example, this could be in the form of earmarking money for more MRI machines where waiting lists are long or decreasing waiting times across the province for specific procedures. In Alberta (and I'm pretty sure this is the case in other provinces, too), money is then transferred to smaller health regions/authorities and they manage their own affairs. In other words, the province is charged with setting broad policy goals and priorities and health care regions are then empowered to implement them. It's a surprisingly mobile and responsive system--I find the Soviet-style central planning accusations a bit far fetched.
(Of course, there are times when the Canadian health care system fails and everyone's heard stories about horrific waiting times or unavailable treatment or the impossibility of finding a doctor who's taking new patients etc. I certainly don't deny this and think that this is truly a shame. It's anecdotal, sure, but my family and I have always received exemplary care for trivial and serious medical situations.)
posted by lumiere at 3:52 PM on June 14, 2007
So you strained your neck moving boxes over the weekend. You get an MRI from your doctor the next day, because hey, you have insurance, right? But your risk of having cancer is like 1 in 10,000. But your risk of having a "mysterious spot" is 500 in 10,000. So you get the MRI and now you have a spot. What are you going to do now? Because I bet your doctor, who knows in his heart this isn't cancer, is going to want to perform spinal surgery because this is now an indefensible lawsuit to do nothing.
Well where's the patient in all of this? Can't the doctor explain that there's only a small chance that the spot is a problem? And that there could be consequences to unnecessary surgery?
posted by delmoi at 4:29 PM on June 14, 2007
Well where's the patient in all of this? Can't the doctor explain that there's only a small chance that the spot is a problem? And that there could be consequences to unnecessary surgery?
posted by delmoi at 4:29 PM on June 14, 2007
And how many patients will end up making the right decision, not just for them but also for the system as a whole, based on that information? Most people would not be reassured by their doctor telling them 'there's only a small chance of cancer.' They probably know someone who has died of cancer, but probably don't know anyone who's died of complications from a biopsy. The assumption that, even given the information and advice of their doctor, most patients will take the rational, considered choice that ends up benefiting the healthcare system as a whole is just wrong.
posted by Aloysius Bear at 5:06 PM on June 14, 2007
posted by Aloysius Bear at 5:06 PM on June 14, 2007
This is a small issue, but how exactly did this make it past their editors:
What’s your approximate annual salary?
>$50k….
$50k–$99k…
$100k–$149k….
$150k–$249k….
$250k–$499k….
$500k–$999k….
< $2m…. no response…. /i>
posted by Rictic at 5:55 PM on June 14, 2007
What’s your approximate annual salary?
>$50k….
$50k–$99k…
$100k–$149k….
$150k–$249k….
$250k–$499k….
$500k–$999k….
< $2m…. no response…. /i>
posted by Rictic at 5:55 PM on June 14, 2007
Well where's the patient in all of this? Can't the doctor explain that there's only a small chance that the spot is a problem? And that there could be consequences to unnecessary surgery?
Incidentaloma. I can't tell you how many unnecessary surgical resections I've seen for these. But patients are exposed to surgical/anesthesia risk all the time when they could easily be monitored.
This article is pretty spot on. Very candid discussion. I've got all kinds of great stories like these.
Forget the socialized medicine vs. privatized insurance discussion. That's a smoke-screen for the real issue which is why our health-care system is not being restructured. Our current health-care infrastructure is directed against acute-care/emergent-care delivery. It needs to be reorganized to deliver decent primary care/primary prevention of chronic disease (diabetes, heart disease, cancer prevention, etc). Fighting chronic illness is where about 85% of our healthcare dollars are spent these days.
posted by i_am_a_Jedi at 6:02 PM on June 14, 2007
Incidentaloma. I can't tell you how many unnecessary surgical resections I've seen for these. But patients are exposed to surgical/anesthesia risk all the time when they could easily be monitored.
This article is pretty spot on. Very candid discussion. I've got all kinds of great stories like these.
Forget the socialized medicine vs. privatized insurance discussion. That's a smoke-screen for the real issue which is why our health-care system is not being restructured. Our current health-care infrastructure is directed against acute-care/emergent-care delivery. It needs to be reorganized to deliver decent primary care/primary prevention of chronic disease (diabetes, heart disease, cancer prevention, etc). Fighting chronic illness is where about 85% of our healthcare dollars are spent these days.
posted by i_am_a_Jedi at 6:02 PM on June 14, 2007
They probably know someone who has died of cancer, but probably don't know anyone who's died of complications from a biopsy.
I'll bet they do.
posted by Slarty Bartfast at 6:15 PM on June 14, 2007
I'll bet they do.
posted by Slarty Bartfast at 6:15 PM on June 14, 2007
There's a lot of stuff here that's interesting, encouraging, scary or just plain amazing, but this is what I found, by far, the most surprising:
Dr. Lung: Research is a real problem. Doctors just make up the data. They don’t report negative side effects, no question about it. I used to write the results on my reports that were negative and nobody printed them. Only if it’s positive does it get published in a journal. A doctor I know used to publish papers like nobody’s business, and all the doctors who came and left told me he made up data to satisfy NIH grants and pharmaceutical grants. He was and still is very popular.
posted by Clay201 at 6:30 PM on June 14, 2007
Dr. Lung: Research is a real problem. Doctors just make up the data. They don’t report negative side effects, no question about it. I used to write the results on my reports that were negative and nobody printed them. Only if it’s positive does it get published in a journal. A doctor I know used to publish papers like nobody’s business, and all the doctors who came and left told me he made up data to satisfy NIH grants and pharmaceutical grants. He was and still is very popular.
posted by Clay201 at 6:30 PM on June 14, 2007
The assumption that, even given the information and advice of their doctor, most patients will take the rational, considered choice that ends up benefiting the healthcare system as a whole is just wrong.
You're missing the point. Being a physician is not about knowing the name of a test to order for a given set of symptoms. Being a physician is about having the judgment to know which test, if any, is likely to help the patient.
There is literally no end to the number of tests you could do. In the sore neck example, what if the MRI is normal? Does that mean the patient is 100% guaranteed not to have anything serious? Maybe he has ankylosing spondylitis. Better do a test. Maybe he has Rheumatoid Arthritis. Better do a test. Maybe he has osteomyelitis that hasn't had an opportunity to light up on MRI yet. Better do another MRI next week.
We play the odds *all the time* and it's a complicated balance because people are emotional, anxious, and some of the time there isn't good evidence to guide us. None of us wants anything except the best outcome for our patients. Fortunately, some of the time, like in the sore neck example, someone has done the study so the doctor can tell the patient what is a safe, reasonable approach to take instead of making emotional decisions that don't actually help them and lead them down the wrong path.
posted by Slarty Bartfast at 6:30 PM on June 14, 2007
You're missing the point. Being a physician is not about knowing the name of a test to order for a given set of symptoms. Being a physician is about having the judgment to know which test, if any, is likely to help the patient.
There is literally no end to the number of tests you could do. In the sore neck example, what if the MRI is normal? Does that mean the patient is 100% guaranteed not to have anything serious? Maybe he has ankylosing spondylitis. Better do a test. Maybe he has Rheumatoid Arthritis. Better do a test. Maybe he has osteomyelitis that hasn't had an opportunity to light up on MRI yet. Better do another MRI next week.
We play the odds *all the time* and it's a complicated balance because people are emotional, anxious, and some of the time there isn't good evidence to guide us. None of us wants anything except the best outcome for our patients. Fortunately, some of the time, like in the sore neck example, someone has done the study so the doctor can tell the patient what is a safe, reasonable approach to take instead of making emotional decisions that don't actually help them and lead them down the wrong path.
posted by Slarty Bartfast at 6:30 PM on June 14, 2007
Actually, I don't think you are missing the point Aloysius. That was rude. My point however is that a good doctor has a dialogue with his or her patient about why or why not do a particular treatment or test and hopefully steer them away from the expensive, sexy test if it is not a helpful thing to do.
I am probably perseverating on this to an unhealthy degree because it's something that causes me unending grief in my professional life and it is one of the things that is killing a profession I love.
And I am guilty myself of performing an expensive, sexy test that wasn't indicated and then having to explain to my patient why I wouldn't recommend doing anything about the positive finding.
posted by Slarty Bartfast at 6:50 PM on June 14, 2007
I am probably perseverating on this to an unhealthy degree because it's something that causes me unending grief in my professional life and it is one of the things that is killing a profession I love.
And I am guilty myself of performing an expensive, sexy test that wasn't indicated and then having to explain to my patient why I wouldn't recommend doing anything about the positive finding.
posted by Slarty Bartfast at 6:50 PM on June 14, 2007
Slarty Bartfast, about 600,000 people die of cancer every year in the US. An estimated 200,000 die of medical errors, the majority of which surely occur in (non-testing) surgery.
As for your second comment, I agree with all of it so I'm not sure what point I have missed. Delmoi seemed to be saying that doctors could solve the problem of excessive testing due to fear of litigation by merely "explain[ing] that there's only a small chance that the spot is a problem." I could be wrong, but I don't think the average patient is particularly willing to say, "OK, I trust you doc, I probably don't have cancer so you don't need to run all the tests on me," even when that would be the most rational, best choice for them to make for their own good and that of the system as a whole.
posted by Aloysius Bear at 6:53 PM on June 14, 2007
As for your second comment, I agree with all of it so I'm not sure what point I have missed. Delmoi seemed to be saying that doctors could solve the problem of excessive testing due to fear of litigation by merely "explain[ing] that there's only a small chance that the spot is a problem." I could be wrong, but I don't think the average patient is particularly willing to say, "OK, I trust you doc, I probably don't have cancer so you don't need to run all the tests on me," even when that would be the most rational, best choice for them to make for their own good and that of the system as a whole.
posted by Aloysius Bear at 6:53 PM on June 14, 2007
Failure to preview claims another victim!
posted by Aloysius Bear at 6:54 PM on June 14, 2007
posted by Aloysius Bear at 6:54 PM on June 14, 2007
But you'd have to be an idiot to think that the average doctor who graduated from Johns Hopkins or wherever is no better than the average University of Nowheresville graduate.
No, you wouldn't. Not if the Johns Hopkins doc had spent most of his professional life in his research lab doing gas chromatography on liquefied amphioxus notochords, emerging twice a week for a month every year, blinking dazedly in the sunlight, to preside over a clinic run by his residents and fellows. While the Nowheresville U. graduate has personally examined and treated thousands of patients, followed them over years, and kept up with the current clinical literature in his specialty.
Famous academics who have graduated from famous schools and are employed by famous schools may or may not be good clinicians.
posted by Slithy_Tove at 7:51 PM on June 14, 2007
No, you wouldn't. Not if the Johns Hopkins doc had spent most of his professional life in his research lab doing gas chromatography on liquefied amphioxus notochords, emerging twice a week for a month every year, blinking dazedly in the sunlight, to preside over a clinic run by his residents and fellows. While the Nowheresville U. graduate has personally examined and treated thousands of patients, followed them over years, and kept up with the current clinical literature in his specialty.
Famous academics who have graduated from famous schools and are employed by famous schools may or may not be good clinicians.
posted by Slithy_Tove at 7:51 PM on June 14, 2007
Like Clay201, I was most stunned and scared by the description of doctors inventing data and leaving the bad results out of their research reports. The other points in the article are just admissions that doctors are humans who make mistakes and have accidents. Fabricating and twisting results that will be used to guide patient care in the future, on the other hand, is an inexcusable decision made by people who must have forgotten that their first mandate is to do no harm. Sure, we can condemn the culture that won't publish honest research, but I think those doctors who are making stuff up deserve at least as much condemnation.
posted by vytae at 7:58 PM on June 14, 2007
posted by vytae at 7:58 PM on June 14, 2007
I hope I never get seriously ill or badly hurt. It's not just that have to rely on Medicaid and an HMO, but that I have to be treated by arrogant doctors and overworked nursing staff in germy hospitals.
Y'all believers are welcome to pray for my health and safety.
posted by davy at 11:42 PM on June 14, 2007
Y'all believers are welcome to pray for my health and safety.
posted by davy at 11:42 PM on June 14, 2007
"Our current health-care infrastructure is directed against acute-care/emergent-care delivery."
Could somebody please translate this into ordinary English?
posted by davy at 11:45 PM on June 14, 2007
Could somebody please translate this into ordinary English?
posted by davy at 11:45 PM on June 14, 2007
The medical system in the US is designed mostly around long-term treatment of existing conditions; cancer, heart disease, diabetes etc.
Not enough time and money is spent on prevention by catching warning signs early and encouraging life style changes. Thus the problems with smoking, excessive drinking, lack of exercise and diet that often lead to things like cancer and heart disease or diabetes that could have been avoided.
Its the 'a penny of prevention saves a pound of cure' problem. There's also a problem of not enough focus on emergency, immediate care - faster, better care at the sharp end may lead to better outcomes and fewer long term care problems. E.G. catching and treating a heart attack quickly reduces the damage to the heart muscle, thus potentially making the difference between someone who can largely recover compared to someone needing substantial care for the rest of his life.
That's what I understood i_am_a_jedi to mean anyway.
posted by ArkhanJG at 12:53 AM on June 15, 2007
Not enough time and money is spent on prevention by catching warning signs early and encouraging life style changes. Thus the problems with smoking, excessive drinking, lack of exercise and diet that often lead to things like cancer and heart disease or diabetes that could have been avoided.
Its the 'a penny of prevention saves a pound of cure' problem. There's also a problem of not enough focus on emergency, immediate care - faster, better care at the sharp end may lead to better outcomes and fewer long term care problems. E.G. catching and treating a heart attack quickly reduces the damage to the heart muscle, thus potentially making the difference between someone who can largely recover compared to someone needing substantial care for the rest of his life.
That's what I understood i_am_a_jedi to mean anyway.
posted by ArkhanJG at 12:53 AM on June 15, 2007
No, you wouldn't. Not if the Johns Hopkins doc had spent most of his professional life in his research lab ...
I don't think you understand the difference between "the average graduate" and "every single graduate".
posted by Aloysius Bear at 1:40 AM on June 15, 2007
I don't think you understand the difference between "the average graduate" and "every single graduate".
posted by Aloysius Bear at 1:40 AM on June 15, 2007
'a penny of prevention saves a pound of cure'
That's certainly part of it, and important part too, but it's not the whole picture.
-The US insurance infrastructure encourages the underinsured and non-insured to use the critical care resources, emergency and clinic, for routine health care. Worse, they have incentive to wait before seeking care, so that when they do, things are worse and cost more to treat.
-The people at the thin edge of the wedge for prevention are undervalued: GPs and nurse-practitioners. Specialists make a pile more money than family doctors. It's hard to blame med students from picking the higher status, higher paid specialist career paths. Right now, there are few rewards professionally or monetary for choosing to become a primary care physician. I've had friends and relatives who would make great GPs, kind, caring people, choose career paths they ended up being less happy with because GPs are "second raters".
posted by bonehead at 5:27 AM on June 15, 2007
That's certainly part of it, and important part too, but it's not the whole picture.
-The US insurance infrastructure encourages the underinsured and non-insured to use the critical care resources, emergency and clinic, for routine health care. Worse, they have incentive to wait before seeking care, so that when they do, things are worse and cost more to treat.
-The people at the thin edge of the wedge for prevention are undervalued: GPs and nurse-practitioners. Specialists make a pile more money than family doctors. It's hard to blame med students from picking the higher status, higher paid specialist career paths. Right now, there are few rewards professionally or monetary for choosing to become a primary care physician. I've had friends and relatives who would make great GPs, kind, caring people, choose career paths they ended up being less happy with because GPs are "second raters".
posted by bonehead at 5:27 AM on June 15, 2007
This is horrifying.
Yes. That story should end with people scrubbing bathroom floors in prison.
posted by pracowity at 5:45 AM on June 15, 2007
Yes. That story should end with people scrubbing bathroom floors in prison.
posted by pracowity at 5:45 AM on June 15, 2007
Davy: "Our current health-care infrastructure is directed against acute-care/emergent-care delivery." Can you translate this?
It means the clinical focus is toward ER visits, or acute-care (sub-emergency, not necessarily less serious, but maybe minus the ER visit--- you know, maybe one of those 'Doc-in-a-box' establishments)... Thats where the immediate money is, whether it comes out of the patients pockets, or from their copay+an insurance payoff---- It doesn't mean they're getting better care, just faster care, in most cases.
posted by SeanMac at 6:08 AM on June 15, 2007
It means the clinical focus is toward ER visits, or acute-care (sub-emergency, not necessarily less serious, but maybe minus the ER visit--- you know, maybe one of those 'Doc-in-a-box' establishments)... Thats where the immediate money is, whether it comes out of the patients pockets, or from their copay+an insurance payoff---- It doesn't mean they're getting better care, just faster care, in most cases.
posted by SeanMac at 6:08 AM on June 15, 2007
^^
Pretty much. There's a significant proportion of the chronically-ill population that gets no regular medical care. And it's incredibly expensive to take care of them when they're overwhelmed by their illness.
Primary care is broken in the US. Primary care docs are working a lot longer hours, seeing more patients for shorter clinic visits and getting paid less. Not only does that mean shitty care for the patients, in the long run we're all going to have shitty primary care docs too.
In my graduating class at medical school, no one in the top 25% went into primary care -- no one. We all went into surgical sub-specialties or the 'lifestyle' specialties (radiology, pathology, radiation oncology). Almost everyone in the bottom 25% went into a primary care specialty (because those were the types of residencies that they could secure). That is a trend that is not going to be reversing anytime soon. You can talk about altruism and helping people all day long, but that ain't going to pay off my 175k in school loans.
posted by i_am_a_Jedi at 10:47 AM on June 15, 2007
Pretty much. There's a significant proportion of the chronically-ill population that gets no regular medical care. And it's incredibly expensive to take care of them when they're overwhelmed by their illness.
Primary care is broken in the US. Primary care docs are working a lot longer hours, seeing more patients for shorter clinic visits and getting paid less. Not only does that mean shitty care for the patients, in the long run we're all going to have shitty primary care docs too.
In my graduating class at medical school, no one in the top 25% went into primary care -- no one. We all went into surgical sub-specialties or the 'lifestyle' specialties (radiology, pathology, radiation oncology). Almost everyone in the bottom 25% went into a primary care specialty (because those were the types of residencies that they could secure). That is a trend that is not going to be reversing anytime soon. You can talk about altruism and helping people all day long, but that ain't going to pay off my 175k in school loans.
posted by i_am_a_Jedi at 10:47 AM on June 15, 2007
Regarding "bad results" getting left out of publications-- what the person really meant was "null results" and they aren't left out of the paper, the paper is left out of the journal.
This is known as publication bias or the "file drawer" problem: who wants to publish a study that finds that X *doesn't work*? no, you want to publish X does work.
Fortunately, there's now actually a whole journal devoted to negative results-- and there is a movement to force registration of all pharmaceutical clinical trials so that if you know one was started and you don't find it published, you can determine that it exists somewhere and probably shows negative results (and it has to be made available to places like the FDA etc).
posted by Maias at 12:08 PM on June 15, 2007
This is known as publication bias or the "file drawer" problem: who wants to publish a study that finds that X *doesn't work*? no, you want to publish X does work.
Fortunately, there's now actually a whole journal devoted to negative results-- and there is a movement to force registration of all pharmaceutical clinical trials so that if you know one was started and you don't find it published, you can determine that it exists somewhere and probably shows negative results (and it has to be made available to places like the FDA etc).
posted by Maias at 12:08 PM on June 15, 2007
In my graduating class at medical school, no one in the top 25% went into primary care -- no one.
I just popped back into this thread late and I am sure no one's reading anymore...
I wanted to say I agree with almost everything i_am_a_Jedi says but I wanted to clarify that some of us did graduate at the top of our class and went into primary care because we were intensely committed to it and cared more about taking care of people than making money or having prestige. I admit there's not enough primary care doctors like this and I think the shitty working conditions has a lot to do with it.
posted by Slarty Bartfast at 6:52 PM on June 15, 2007
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Yeah, I know. Normally I loathe, despise and abominate NYMag, but by getting out of the way and letting the doctors say it all, they have produced something quite penetrating here. The OB/GYN's confession of having dropped a baby will stick with me for a long time.
posted by hermitosis at 11:40 AM on June 14, 2007