Ootrazh du Jour

[Orestes Munn]

Because the aviation system was put in place a long time ago.

The modern hospital is about the same age, as an institution.

[BeauV]

Again, this isn't about judgment, skill, or the monumental fuckup, but procedural glitches and omissions by competent, good faith, actors that end up damaging or killing people. The big question for me is why we can (or, maybe even, want to) fix this for aviation, but not medicine.

I believe that aviation started out as a fairly terrifying prospect for most folks. Commercial aviation couldn't succeed without astoundingly good safety. The same is true of the bar to which we hold NASA. We shut down the entire project due to the death of a group of people who numbered fewer than those that die on the streets of San Francisco over a weekend. But, airlines wouldn't have customers and NASA wouldn't have funding if it killed people (publically).

The art and practice of medicine has developed over a long time, and people have slowly begun to trust it, but it has no real competition. If you don't like what the doc says or what the system does go someplace else.... there isn't an option other than no care. Like all true monopolies, medicine is terribly hard to regulate for quality. Imagine McDonnalds as the only restaurant in the world, or even the only source of food, do you think the quality would be Michelin 3 star? Genuine competition drove airline quality, no one "needed to fly".

Frankly, around here, folks think that Kaiser has the best quality of care. They might not have the rock-star docs, but the general impression is that the system keeps you alive longer. So even really rich folks use Kaiser. I'd put that forth of evidence that genuine competition can even improve the medical system.

[LarryHoward]

Interesting summary of the no fault compensation process, from the Oz perspective.

No clear link from this to quality assurance programs at the moment, but reliable data should provide a path to QA systems.

https://www.mja.com.au/journal/2012/197 ... ng-overdue

If memory serves: New Zealand voters agree to give up the right to sue for personal injury in exchange for a universal public health system.

It seems that one can pay for universal public healthcare by getting rid of the added expense of everyone suing everyone over personal injust.... who knew??

Seems like a good idea to me!!

As long as the AMA will support identifying and eliminating bad doctors. In other words you need a robust and effective quality program. Aviation does. A pilot who has repeated incidents or fails periodic check rides doesn't getting keep flying.

The AMA, to the extent that it has any teeth as a lobby anymore, does support this in principle. Getting rid of bad docs is a function of state medical boards, many of which, including mine in Massachusetts, are very strict.

Assuming it gets to the board. How many hospitals merely don't renew a doctor's privileges but give him or her a somewhat glowing referral to another service to avoid an ugly fight, a wrongful termination suit and perhaps publicity that they had a "bad doc" on staff who killed a few patients? Better to call it "heart failure" on the DC than compromise their reputation. It's easier than it used to be but getting objective stats on outcomes by hospital, service and doctor is still too hard. Plenty of subjective "my doc is a god" or "this doc sucks" online but little hard data for the layman.

[Orestes Munn]

Again, this isn't about judgment, skill, or the monumental fuckup, but procedural glitches and omissions by competent, good faith, actors that end up damaging or killing people. The big question for me is why we can (or, maybe even, want to) fix this for aviation, but not medicine.

I believe that aviation started out as a fairly terrifying prospect for most folks. Commercial aviation couldn't succeed without astoundingly good safety. The same is true of the bar to which we hold NASA. We shut down the entire project due to the death of a group of people who numbered fewer than those that die on the streets of San Francisco over a weekend. But, airlines wouldn't have customers and NASA wouldn't have funding if it killed people (publically).

The art and practice of medicine has developed over a long time, and people have slowly begun to trust it, but it has no real competition. If you don't like what the doc says or what the system does go someplace else.... there isn't an option other than no care. Like all true monopolies, medicine is terribly hard to regulate for quality. Imagine McDonnalds as the only restaurant in the world, or even the only source of food, do you think the quality would be Michelin 3 star? Genuine competition drove airline quality, no one "needed to fly".

Frankly, around here, folks think that Kaiser has the best quality of care. They might not have the rock-star docs, but the general impression is that the system keeps you alive longer. So even really rich folks use Kaiser. I'd put that forth of evidence that genuine competition can even improve the medical system.

I am a certified rockstar doc and you're better off at Kaiser.

[Orestes Munn]

Interesting summary of the no fault compensation process, from the Oz perspective.

No clear link from this to quality assurance programs at the moment, but reliable data should provide a path to QA systems.

https://www.mja.com.au/journal/2012/197 ... ng-overdue

If memory serves: New Zealand voters agree to give up the right to sue for personal injury in exchange for a universal public health system.

It seems that one can pay for universal public healthcare by getting rid of the added expense of everyone suing everyone over personal injust.... who knew??

Seems like a good idea to me!!

As long as the AMA will support identifying and eliminating bad doctors. In other words you need a robust and effective quality program. Aviation does. A pilot who has repeated incidents or fails periodic check rides doesn't getting keep flying.

The AMA, to the extent that it has any teeth as a lobby anymore, does support this in principle. Getting rid of bad docs is a function of state medical boards, many of which, including mine in Massachusetts, are very strict.

Assuming it gets to the board. How many hospitals merely don't renew a doctor's privileges but give him or her a somewhat glowing referral to another service to avoid an ugly fight, a wrongful termination suit and perhaps publicity that they had a "bad doc" on staff who killed a few patients? Better to call it "heart failure" on the DC than compromise their reputation. It's easier than it used to be but getting objective stats on outcomes by hospital, service and doctor is still too hard. Plenty of subjective "my doc is a god" or "this doc sucks" online but little hard data for the layman.

The main source of resistance there is the hospitals themselves and mainly because the bad docs are often profit centers, not because they like them. The lack of data for the layman or, indeed, the expert is a very bad thing. The metrics are tricky and those who take care of sicker patients have more bad outcomes for a given diagnosis, but it can be done. Simply issuing national provider numbers, as happened some years ago, is a big step, so adverse actions on a bad actor's record can follow him or her from state to state.

But, again, what kills you will be an "innocent" error not the action of an egregious dickhead.

[LarryHoward]

Interesting summary of the no fault compensation process, from the Oz perspective.

No clear link from this to quality assurance programs at the moment, but reliable data should provide a path to QA systems.

https://www.mja.com.au/journal/2012/197 ... ng-overdue

If memory serves: New Zealand voters agree to give up the right to sue for personal injury in exchange for a universal public health system.

It seems that one can pay for universal public healthcare by getting rid of the added expense of everyone suing everyone over personal injust.... who knew??

Seems like a good idea to me!!

As long as the AMA will support identifying and eliminating bad doctors. In other words you need a robust and effective quality program. Aviation does. A pilot who has repeated incidents or fails periodic check rides doesn't getting keep flying.

The AMA, to the extent that it has any teeth as a lobby anymore, does support this in principle. Getting rid of bad docs is a function of state medical boards, many of which, including mine in Massachusetts, are very strict.

Assuming it gets to the board. How many hospitals merely don't renew a doctor's privileges but give him or her a somewhat glowing referral to another service to avoid an ugly fight, a wrongful termination suit and perhaps publicity that they had a "bad doc" on staff who killed a few patients? Better to call it "heart failure" on the DC than compromise their reputation. It's easier than it used to be but getting objective stats on outcomes by hospital, service and doctor is still too hard. Plenty of subjective "my doc is a god" or "this doc sucks" online but little hard data for the layman.

The main source of resistance there is the hospitals themselves and mainly because the bad docs are often profit centers, not because they like them. The lack of data for the layman or, indeed, the expert is a very bad thing. The metrics are tricky and those who take care of sicker patients have more bad outcomes for a given diagnosis, but it can be done. Simply issuing national provider numbers, as happened some years ago, is a big step, so adverse actions on a bad actor's record can follow him or her from state to state.

But, again, what kills you will be an "innocent" error not the action of an egregious dickhead.

I get that but it doesn't help the patients of Doctor Billing.

My experience with my mother is that doctors seem to be trained that they alone are experts and other doctors are particularly flawed. Each and every time she visited the ER or was admitted, she started at T-) as to condition and meds, even when handed a copy of her history, current meds and a phone number for her primary, cardio, nephrologist, etc. The "hospitalists" and specialists routinely failed to respond to designated family members even when her HC POA was part of her file. It seemed that the system was that neither a previous doctor nor her designated HC POA was worthy of an opinion - even those who had been treating her for years. That treatment usual resulted in her being back on her original dosages within 10 days after her test results proved the original dosages were appropriate for her.



Portable records are great. They will be actually helpful when they get used in evaluation and treatment.

[Orestes Munn]

I get that but it doesn't help the patients of Doctor Billing.

My experience with my mother is that doctors seem to be trained that they alone are experts and other doctors are particularly flawed. Each and every time she visited the ER or was admitted, she started at T-) as to condition and meds, even when handed a copy of her history, current meds and a phone number for her primary, cardio, nephrologist, etc. The "hospitalists" and specialists routinely failed to respond to designated family members even when her HC POA was part of her file. It seemed that the system was that neither a previous doctor nor her designated HC POA was worthy of an opinion - even those who had been treating her for years. That treatment usual resulted in her being back on her original dosages within 10 days after her test results proved the original dosages were appropriate for her.



Portable records are great. They will be actually helpful when they get used in evaluation and treatment.

Yes. This is what very often happens and is particularly infuriating and dangerous. Portable records are great and the military treatment centers are among the few places where they exist, but someone has to read them and bad info has to be removable. Machines could do better.

[Olaf Hart]

Kaiser is not for profit.

Continuity of care is the key to quality and cost management.

The airline vs medicine thing, such as moving to a New Zealand " no fault" system, boils down to doctors vs lawyers.

Round here, Parliament is full of lawyers.

[BeauV]

I get that but it doesn't help the patients of Doctor Billing.

My experience with my mother is that doctors seem to be trained that they alone are experts and other doctors are particularly flawed. Each and every time she visited the ER or was admitted, she started at T-) as to condition and meds, even when handed a copy of her history, current meds and a phone number for her primary, cardio, nephrologist, etc. The "hospitalists" and specialists routinely failed to respond to designated family members even when her HC POA was part of her file. It seemed that the system was that neither a previous doctor nor her designated HC POA was worthy of an opinion - even those who had been treating her for years. That treatment usual resulted in her being back on her original dosages within 10 days after her test results proved the original dosages were appropriate for her.



Portable records are great. They will be actually helpful when they get used in evaluation and treatment.

Yes. This is what very often happens and is particularly infuriating and dangerous. Portable records are great and the military treatment centers are among the few places where they exist, but someone has to read them and bad info has to be removable. Machines could do better.

Eric: when you say Machines could do better my memory flashed back to my youth when, as a newly minted programmer in 1974, I got to help Ted Shortliffe with a piece of software called MICYN at Stanford. It was PROVABLY better than the doctors of the time. Proven in tests mind you. But there was NFW that any doctor at Stanford Hospital would use it. My first encounter with people who, while appearing intelligent and ethical, were utterly and completely self-serving. This was very very early in the development of AI sofware. Today, I've no doubt that a modern version of MICYN would utterly and competely out perform humans in every situation. In fields like marketing we now process billions of interactions, extract the data and make decisions that are about five decimal orders of magnitude more complex than anything performed by MICYN. These extractions and decisions are literally orders of magnitude more complex than a human can deal with, no matter how well trained or schooled.

For those who don't want to read the history, a quote: "Research conducted at the Stanford Medical School found MYCIN to propose an acceptable therapy in about 69% of cases, which was better than the performance of infectious disease experts who were judged using the same criteria."

More background: https://en.wikipedia.org/wiki/Mycin

[Orestes Munn]

Yeah, machines certainly ought to be able to make clinical decisions better than humans--decisions, that is, not requiring knowledge of the patient's state of mind or other social data. When I was an intern, back in the days before troponin levels, a big journal published an article on how a little algorithm taking into account a few key categorical data did just as well as, or better than, experts in evaluating the probability that a patient with chest pain was having a heart attack. As far as I know, no one ever used it.

As you note, humans are too subject to bias and don't like doing apparently counterintuitive things. My favorite clinical aphorism is that the three most dangerous words in medicine are in my experience.

This is one reason I have pretty much given up doing clinical stuff except as it relates directly to my little science projects. I bet you couldn't design an algorithm to be as useless as I am.

[kdh]

Beau, "acceptable therapy in 69% of cases?"

That doesn't sound great to me, no matter what it's compared to.

I'm going to give you some E coast parochialism. You W coast guys seem to think you can do anything.

When I look carefully at artificial intelligence/expert systems/neural nets/non-parametric statistics, whatever you want to call it--and in my experience in finance using statistical/systematic approaches, I'm not that enamored.

Guys like me tend not to say this, but there's a whole lot of room for humans, especially when it comes to common sense (please don't give me the speech on including this in a prior distribution in a Bayes formulation).

[BeauV]

Beau, "acceptable therapy in 69% of cases?"

That doesn't sound great to me, no matter what it's compared to.

I'm going to give you some E coast parochialism. You W coast guys seem to think you can do anything.

When I look carefully at artificial intelligence/expert systems/neural nets/non-parametric statistics, whatever you want to call it--and in my experience in finance using statistical/systematic approaches, I'm not that enamored.

Guys like me tend not to say this, but there's a whole lot of room for humans, especially when it comes to common sense (please don't give me the speech on including this in a prior distribution in a Bayes formulation).

Keith, I agree that 69% is pretty crumby! But, that number was 20 percentage points better than a large pool of humans working from the same data! Which is even more crumby!

I don't really think we W coast guys think we can do "anything", but we do think that we can do stuff that most people don't believe will work. We've also got a little bit of a track record of actually doing it - like the SpaceX rocket landing itself. That said, I actually agree that there is a giant opportunity for humans.

Here's what I think we humans need to accept: We can do a LOT better job at a lot of things if we let technology augment our decision making.

As both you and Eric point out, there are plenty of places where humans can contribute in ways that the machines can't. I agree with that. But, what should not be discounted is how useful the machine can be at lending a hand. Everywhere from Uber software augmenting a human driver by making her as good as the best taxi driver in town at getting around, to the current versions of diagnostic software which really do outperform humans almost all the time, through machines that can trivially out-fly a human pilot in a dogfight, we've got lots of places where the person who wins will be the one who can use tools (including computers) to augment their own skills.

So, you E coast guys need to avoid believing that computers aren't good for anything. That and you have to stop wearing bow ties

[Orestes Munn]

I was cynical enough to guess that the humans didn't perform at 69%. Since 1965, the bow tie has been an idiopathic sign that a physician is a conceited asshole.

[kdh]

I agree with you, Beau.

Well, I certainly don't believe computers aren't good for anything, and I've never worn a bow tie.

[BeauV]

I agree with you, Beau.

Well, I certainly don't believe computers aren't good for anything, and I've never worn a bow tie.

Thank heavens - bow ties and Ferraris are not a good look together

[Jamie]

I was cynical enough to guess that the humans didn't perform at 69%. Since 1965, the bow tie has been an idiopathic sign that a physician is a conceited asshole.

Ties are also great vectors for infection.

[Orestes Munn]

I was cynical enough to guess that the humans didn't perform at 69%. Since 1965, the bow tie has been an idiopathic sign that a physician is a conceited asshole.

Ties are also great vectors for infection.

Fomites

I have only worn a bow tie with a Dinner Dress uniform and that was in the presence of a sitting president and God knows who-all.