Increased Physician Survey Signup Bonuses

Many survey companies don’t have great offerings for residents, but two do offer bonuses for signing up/when you complete a survey or two, and MDforLives has doubled theirs as of this month:

I maintain an up-to-date list of healthcare survey companies here–and some links are referrals that also support this site–so if signing up meets your needs/desires, thank you.

Munger on Incorrect Approaches to Medicine

In 2003, Charlie Munger gave a lecture titled ‘Academic Economics: Strengths and Weaknesses, after Considering Interdisciplinary Needs,’ at the University of California at Santa Barbara.

It’s a pretty good read.

He mostly discusses problems with economics as a soft science that desperately wants to be a hard science.

Medicine is also surprisingly soft. I’ve replaced some words with medicine in several paragraphs to illustrate how cross-domain problems with medical practice can be:

The Man with a Hammer Syndrome

Yet medicine, like much else in academia, is too insular.

The nature of this failure is that it creates what I always call, “man with a hammer syndrome.” And that’s taken from the folk saying: To the man with only a hammer, every problem looks pretty much like a nail. And that works marvelously to gum up all professions, and all departments of academia, and indeed most practical life. The only antidote for being an absolute klutz due to the presence of a man with a hammer syndrome is to have a full kit of tools. You don’t have just a hammer. You’ve got all the tools. And you’ve got to have one more trick.

This is an argument for a broad foundation in medicine before specialization. The more siloed we are, the less we can draw on different toolsets to help patients.

This is also an argument against fee-for-service. If doctors and hospitals can generate the most money with a certain hammer, that hammer is likely to be used disproportionately.

Overweighing what can be counted

A special version of this “man with a hammer syndrome” is terrible, not only in economics but practically everywhere else, including medicine. It’s really terrible in medicine. You’ve got a complex system and it spews out a lot of wonderful numbers that enable you to measure some factors. But there are other factors that are terribly important, [yet] there’s no precise numbering you can put to these factors. You know they’re important, but you don’t have the numbers. Well practically everybody (1) overweighs the stuff that can be numbered, because it yields to the statistical techniques they’re taught in academia, and (2) doesn’t mix in the hard-to-measure stuff that may be more important. That is a mistake I’ve tried all my life to avoid, and I have no regrets for having done that.

This gives rise to the classic Goodhart’s Law: when a measure becomes a target, it ceases to be a good measure.

We shouldn’t confuse measurability with importance. In many cases, the measure is a poor surrogate for what we really care about or can be gameable to ultimately negative downstream effects. An example? Patient satisfaction.

The first-order short-term focus

Too little attention in medicine to second-order and even higher-order effects. This defect is quite understandable, because the consequences have consequences, and the consequences of the consequences have consequences, and so on. It gets very complicated. When I was a meteorologist I found this stuff very irritating. And medicine makes meteorology look like a tea party.

Extreme economic ignorance was displayed when various experts, including Ph D. economists, forecast the cost of the original Medicare law. They did simple extrapolations of past costs. Well the cost forecast was off by a factor of more than 1000%. The cost they projected was less than 10% of the cost that happened. Once they put in place all these new incentives, the behavior changed in response to the incentives, and the numbers became quite different from their projection. And medicine invented new and expensive remedies, as it was sure to do. How could a great group of experts make such a silly forecast? Answer: They over simplified to get easy figures, like the rube rounding Pi to 3.2! They chose not to consider effects of effects on effects, and so on.

Short-term thinking is bad at both micro and macro levels.

On the micro level, the patient’s care doesn’t end when they leave the clinic or hospital. It keeps going throughout their life. And each episode of care from each different provider doesn’t exist in a vacuum. It interfaces with every other bit of care they get. The combination of direct patient care, socioeconomic factors, and education is a complicated mess at baseline.

But decisions lead to decisions, and outcomes further affect outcomes. We treat at the n of 1 and often at the timepoint of right this second. Missing the forest for the trees is easy to do when your patient is usually coming to you for a tree and you are also paid to look at the tree.

On the macro level, Munger’s Medicare example above. Or, the more recent news, approving a multibillion-dollar a year Alzheimer’s drug with no evidence that it works: It won’t just cost billions of upfront, it will result in other companies diverting resources in a rush for me-too drugs that also may not work to get a slice of a massive market and likely cost still billions more while potentially resulting in less novel drug development. We think in linear terms but systems often work exponentially.

Semiannual Social Media is Terrible PSA

Here’s a little exercise adapted from “You Really Need to Quit Twitter” in The Atlantic:

Step 1: Take the Simone Weil essay  “On the Abolition of All Political Parties” and replace the word “parties” with something that maybe shouldn’t exist, like social media:

The mere fact that social media exists today is not in itself sufficient a reason for us to preserve it. The only legitimate reason for preserving anything is its goodness. The evils of social media are all too evident; therefore, the problem that should be examined is this: Does it contain enough good to compensate for its evils and make its preservation desirable?

Step 2: (Oh well I still have my Twitter account).

To STAT or not to STAT

A passage about limited resources and optimizing imaging from The Emergency Mind: Wiring Your Brain for Performance Under Pressure by Dan Dworkis MD PhD:

Within the broader context of your responsibility however, there frequently will be significant variability in the relative urgencies of individuals being imaged. Some patients—like a person seemingly experiencing an acute stroke—do need to be scanned immediately. Others—such as a patient with abdominal pain, stable vitals, and a reassuring physical exam—while no less “deserving” of those resources, would receive nearly equal benefit from being scanned now as in an hour from now. Optimizing care across the field in this context would involve prioritizing CT scans for those patients who would receive outsized benefits from immediate imaging, even if this makes some other patients wait longer.

Put a different way: If everything is stat, nothing is stat.

Stat abuse is one of those crimes especially tempting to inpatient teams in busy hospitals. It’s natural to want answers (and dispo) as soon as possible, and we assume that we will get them faster if we increase the priority of the exam.

All a clinician knows is that sometimes something ordered routine takes forever and that ordering stat should generally result in it being performed faster. They may not even care if the read is prioritized in all cases so long as the patient is freed from the waiting and future transport.

It’s also human nature for there to be a distribution with certain individuals ordering an outsize proportion of “stat” exams. The negatives of over-ordering or inappropriate priority are almost always placed on other staff. In a zero-sum game, selfish behavior may be an optimal choice for individual success even if it makes the system less efficient overall. Hospitals very rarely scold their staff for such abuses.

I don’t think most clinicians even have any idea where along the spectrum their behavior falls. Knowledge of outlier performance one hopes might curb excesses, and that data would certainly be helpful for individuals to know (presuming those individuals are capable of feeling shame and said shame functions as a deterrent). Such information would have to be long-term and stratified well to be meaningful (we should expect different levels of stat exams as a fraction of orders from different hospital units, for example). Otherwise, data are dismissible.

Ultimately, pleading and punishment are often ineffective and/or undesirable.

A more helpful approach would include data to guide decision-making on a case by case basis:

The EMR should show in real-time the expected wait for different study types based on the current queue and exam types pending, both inpatient and outpatient (i.e. how many unnecessary exams are obtained during an inpatient stay due to fears of long delays for outpatient follow-up?). Yes, a routine study may unexpectedly get bumped further down the line, but a smart system would incorporate predictions based on the current patient census, admission diagnoses, time of year, and whatever else some machine learning algorithm would include its impenetrable black box of Skynet code.

It would be extremely helpful for all parties to know if an MRI should be expected today or tomorrow, sometime this afternoon or more likely at 3 am.

And so, yes, of course, people are working on this in the machine learning world. But hurry up. I for one will continue to welcome our AI overlords and their promised efficiency gains, but I’m still waiting.

The Lesser “Personal” Side of Medicine

A century-old tidbit of wisdom from the Book on the Physician Himself by DW Cathell MD (published way back in 1902, so ignore the pronouns):

EVERY Medical Man discovers sooner or later that The Practice of Medicine has two sides: A Greater Scientific Side, and a Lesser, but important, Personal Side, and that to fight the battles of life successfully it is as necessary for even the most scientific physician to possess a certain amount of professional tact and business sagacity as it is for a ship to have a rudder.

Only one of these sides is meaningfully taught or modeled in school, and I think we’ve all met physicians who do not seem to possess “professional tact” or “business sagacity” and been worse for it. Cathell was writing during a time when most physicians literally were one-man shops, but if anything the “lesser” side of the Practice of Medicine is more important than ever.

Discussing the ancient pro/cons of specialization that led to ever-increasing specialization over the next 120 years:

You may also ask the question: Shall I adopt a specialty? Would it pay me to do so? The adoption of a specialty, to the exclusion of other varieties of practice, is successful with but a few of those who attempt it. It should never be undertaken without first studying the whole profession and attaining a few years’ experience among the people as a general practitioner.

A successful specialist has many advantages over the hurly-burly life of the general practitioner: He is independent of general practice. He has short hours and is seldom or never called out at night. He can escape the expenses of horses, carriages, stables, and drivers. His Sundays are his own if he chooses. His fees are always good, sometimes fat. He can tell his terms and arrange about the payment of his fees at the beginning of each case, and usually gets them cash, and after a much easier life he generally dies a great deal better off pecuniarily than the general practitioner.

On the other hand, the specialist must be better equipped in instruments, etc., and more dextrous and masterful in their use and also more concise in the details of treatment; should possess a faultless manner and must foster his practice more carefully; in other words, if you put all your eggs in one special basket you must watch that basket much more closely.

So much energy has been spent fighting in the turf wars of watching and growing those special baskets that doctors dropped the ball on the broader healthcare basket entirely.

Dying rich after an easy life sounds nice, but he did miss the part where the physician became an employee and stopped being able to choose those short hours and Sundays “as his own.”

(Hat tip @archives_Rx.)