They hadn’t bothered to consider statistically far more likely causes of an irregular heartbeat. In Redelmeier’s experience, doctors did not think statistically.
Statistics assumes independence, something that may be hard to come by in the ER. Even when you start factoring in the covariance between conditions, there's so many confounding factors it's probably difficult to tease out any sort of significant r^2 for an individual patient
Instead, I would advocate for a pattern recognition method. Given a database of x million patients, it's likely someone has had the same type of case before, if not very similar. A sample would provide much less variable results than the individual patient,making diagnosis more confident.
Such a system could be used to predict symptoms before they become symptoms, saving time and preventing pain while serving to reduce hospital workload. Figure out a way to standardize it in the intake, and let the system predict what's wrong. It'll solve most of the cases, and identify new trends, leaving human doctors to focus on the edge cases like the one in the article.
I had a professor in undergrad who worked on order entry research. He talked about one of the problems facing Vanderbilt as far as scanning costs.
CT scans and MRI are crazy expensive. Trauma patient comes in, doc orders a CT scan, it comes back and he says, "shit, this doesn't tell me what I need to. I knew I should have ordered an MRI instead."
They used a decision tree learning algorithm and trained it using attributes of incoming patients and which type of scan would have been the most useful. Then they did a trail where ER docs would enter in patient information and what they would have picked, but then defer to the algorithm's judgement instead.
I can't remember the number, but they significantly reduced the number of unnecessary scans.
As a side note, MRIs do not have to be expensive: grad students at research universities do them (for research, not on real patients) and the costs are nothing like at the numbers you see on medical bills.
And this is just one of the many problems with the US medical system, even if it went to a single payer system taking the individual off the hook, the cost of delivery is completely out of control due to (in my opinion) a lack of "proper" capitalism.
Perhaps any acquisitions in the field of medicine should be subject to antitrust laws?
I think there is an important point for people to remember: The cost of a procedure, like a CT scan, is not the cost of the procedure. The amount you are getting charged is the Chargemaster rate.
The Chargemaster rate is the same no matter who you are, the different is what people pay from the chargemaster bill. Let's say you are given tylenol and the charge master is $50. The reason why this is so high is because medicare will then say that they pay , say, 20% the chargemaster rate, and thus elderly patients pay $10. This is why elderly patients are seen as great patients for revenue: They all actually can pay something, even if its only a fraction of the chargemaster. A gold plated insurance patient will pay Medicare+30%, and thus the gold plate insurance pays $20. The patient with no insurance then is also billed $50 because they don't have an agreement with the hospital. Thus, what likely happens is that they pay $0 and goes bankrupt, or more likely, these patients don't have any net worth at all. This creates a weird situation where the homeless, destute, and people with no net worth essentially get infinitely free healthcare. These patients tend to be very high volume healthcare users (homeless patients that take $5000 ambulance rides as taxis because they know they will never actually pay a penny, despite having millions of dollars of charges.). This is what the Affordable Care act tried to prevent: by making people pay something, you were actually decreasing costs for all because you remove free riders who present the majority of sunk costs in the healthcare system. Very few people if ever pay for the full cost of a procedure or chargemaster. The chargemaster is a negotiation tactic. Not a final bill.
That is why a CT Scan costs thousands of dollars. Because everyone knows you'll only end up paying a fraction of that if you have insurance. And if you pay cash, its only a few hundred bucks, because thats how much people get paid anyways.
Source: I'm an ER Doc.I do research in healthcare and billing
What do, for example, tourists pay? When I buy a plane ticket to the US, there is travel insurance, but I have never needed to use it and do not know how it would work.
Cost inflation in the US is huge due to a combination of red tape, CYA, customers with good insurance subsidizing people with bad/no insurance, and many other factors. There's no simple answer, unfortunately. No one is entirely sure why medical costs are so high in the US. It doesn't appear to be any one factor that people commonly blame.
Fundamentally, they don't need to be expensive; via private medical tourism, you can get any sort of scan at a fraction of the US cost.
The problem is everyone gets paid too much. Our doctors salaries are far out of line with most countries , we have the strictest drug pricing laws in the world, and people love to sue. We also have a significant portion of the population paying no medical bills while the rest is overcharged to compensate. On top of that our health insurance is full of middle men like "PBM's" that do nothing but raise costs.
The combo means docs, drugs, treatment, and insurance are all more costly.
A fix is hard to come by but would work something like this.
1)subsidize the cost of medical school increasing supply of MDS
2)pass laws to protect physicians from frivolous lawsuits or at least limit damages.
3)disallow drug companies from advertising, ban rampant kickbacks to doc's that prescribe their drugs
4)ban anti competitive practices that prevent insurance companies from negotiating prices directly with manufacturers.
5) provide healthcare centers of last resort(the ER) compensation for patients unable to pay.
My last point is state specific and really controversial but it's based on what I've personally seen.
States with a lot of illegal immigrants spend an enormous amount for healthcare at the ER for these people. Around 1/4 of the people that came into the ER I was familiar with were likely illegal
and over 90% either gave a fake name or never paid. The majority of those costs are passed on to those with insurance. I lived in an area with probably 3% of the population were undocumented.
Since the ER is healthcare of last resort they are forced to treat you even if you give them completely false info with no intention of paying. Illegal immigrants know this and preferentially go to the ER because they get treated without probing questions or need to pay. They also already have fake ID's in most cases so giving one to the hospital isn't a big deal. This enomous cost gets buried because it's politically unpopular to say and because the hospital just raises prices in everyone else to compensate.
I'm an ER Doc. The focus on illegal immigrants is way off base.
There's a law called EMTALA which is basically an unfunded mandate that says, in part, we can't just turn away patients because they can't pay. This was because slot of hospitals (university of Chicago in particular) were dumping or transferring patients to other hospitals who couldn't pay and making huge news stories. As you mention, this means people who can’t pay get free health care.
Who does this end up being? Almost 100% alcoholics and homeless patients, often with severe mental illnesses. When there are no resources for them, they end up taking ambulance rides to the ED, say they have Chest pain, and then we give them thousand dollar workups that you end up paying for. Illegal immigrants at large county hospitals are often grateful for any care and usually actually do end up paying at least some portion of their bill, and often are not super high utilizers.
For example, do you know who the number #1 utilizer of NY state medicare dollars is?
Trust me, if hospitals could sort out paying from non paying patients they'd do that in a heartbeat (if they have one). There's lots of programs that try to draw those sorts of patients in, like international elective procedure patients and elderly patients who are universally paid for by Medicare.
Alternatively, increased free clinics for basic healthcare (flu, checkups, non-emergency procedures) could eliminate a large percentage of wasted effort and time. Free regular checkups just a few times a year would catch so many issues before they became big expensive issues and it would eliminate the use of the ER as a general physician visit.
We're already paying out crazy amounts for doctors time and for expensive visits, might as well make the basic health checks free. No need to bring insurance in on matters like just having a doctor write "you have the flu. Rest 4 days and take this" when the entire operation is 15 minutes for a quick culture.
Doctors salaries don't tell the whole story. I've read that roughly half of doctors are self employed. They are also the owners, or major shareholders, in medical related businesses such as provider networks and malpractice insurance companies. Being a doctor means that you can make what I call "insider investments" that aren't available to the public, and the cost of training ensures that the only people who are doctors, have family money available to invest in those businesses.
The rat's nest of business entities makes it impossible to figure out where the money is going, or who is making how much. That way, everybody can point the finger at somebody else. I suspect a reason why medicine costs less in countries with nationalized systems is that it's possible to figure out where the costs are going.
I'd favor a system where medical school is free, and doctors work as employees of the government.
One brief clarification. Doc salaries are higher, but cost and length of training is higher too. Four years of college and four years of med school dig the hole very deep. Then three to eight more years often working below minimum wage as the interest on the debt compounds.
Medical school definitely needs to be less expensive to lower salaries. It's also pushing doctors towards specialities that pay more and leaving us with a thortage of GP's
pass laws to protect physicians from frivolous lawsuits or at least limit damages
Several US states have harsh caps on medical malpractice damages. They still see massively-rising medical costs. And in uncapped states the rate of growth in malpractice damage awards hovers very close to the rate of inflation of the US dollar.
Which sort of destroys the argument that "frivolous lawsuits" and massive damage awards drive medical costs in any significant way.
It's less the actual damages as much as it the defensive medicine that occurs because of the constant risk. If you show up with the flu, but it could be some weird disease that shows up in an MRI, the incentive for the doctor is to get you an MRI.
I used to believe in caps, but I think we could do better than that. Create a no-fault insurance market that pays people without the hassle of civil trials. That has the potential to allow medical professionals to be more open and honest about mistakes they make (similar to the aviation industry). That, in turn, would allow for data-driven decisions about how to make the biggest improvements for the lowest dollar amount.
Oh, and while we're at it, how about a self-driving unicorn that runs on rainbows...
100% agreed with this. This is an insightful comment. people have no idea how much practice patterns would change if less defensive medicine could be practiced. So much of the inconvenience of medicine exists because the standard of care is extremely conservative to ensure minimal risk of litigation. The few states that have malpractice caps really doesnt change anything--those states just provide a good practice environment in rare situations, but doesn't change the way that standard medicine is practiced because that is developed out of state as a national consensus.
If MRIs were priced at what most people would call reasonable, then that defensive practice wouldn't be as big of a problem. We've seen prices of $100 to 300 mentioned for some other countries.
Its not about frivolous lawsuits as much as defensive medicine which is the standard of care. For example if you come in to the Emergency department with a traumatic brain bleed (even a tiny spec on your scan), then you end up getting another scan at 6 hours, likely platelets since you took a baby aspirin that day, a very expensive neurosurgery evaluation, keppra for 2 weeks, and continuous monitoring, even though by all metrics you have a very benign pathology. Why? Because this is the standard of practice. Not because it makes any sense.
also, keep in mind that the factor that matters the most for practice patterns (especially defensive ones which drive up cost) is not where a doctor practices, its where a doctor trains. Since most doctors train in high risk litigation environments, and most standard of care procedures are developed with defensive practices in mind, the standard of care is high cost high utilization medicine.
I don't need to make an argument. Call your doctor and ask him how much he pays for his malpractice insurance.
I used to know some people in healthcare tangentially and the answer is $50,000 to $250,000 A YEAR depending on specialty etc.
Sometimes the practice will pay these costs for you, so the doctor might not be paying it directly but the money is coming from somewhere.
My friends told me malpractice insurance was generally about a third of your salary. And this includes people like pharmacists and physicians assistants too. So if much higher than world average doctor salaries in the US are any part of the reason for high medical costs, lawsuits are a third of that
I used to know some people in healthcare tangentially and the answer is $50,000 to $250,000 A YEAR depending on specialty etc.
And... inflates at a rate which appears to be completely unrelated to malpractice damage awards. So calling for caps and limits on malpractice suits would not solve it.
Consumers need protection from doctor's mistakes, plain and simple. I don't need to make an argument either. Call someone who has lost their child to a doctor's mistake.
They are hugely complex pieces of kit, manufactured in relatively low volumes and requiring lots of specialized materials and development. Not an easy thing to cost-reduce. (That said, each scan has very low marginal cost).
I agree that they're highly complicated, but they're made in surprisingly large volumes. There are 5,564 hospitals in the US, and each one will likely have several. A manufacturer will probably ship 500 units/year. This is decent enough volume where you can drive good cost reductions.
Source? Because I'm pretty sure that's completely untrue. Nervous tissue like the brain is the most resistant to radiation of any cell types in the body. Radiation affects faster growing cells the most, and nerve cells grow the slowest of any in the body. The brain is also the best shielded part of the body against x-rays, and the x-rays in a CT machine are necessarily highly collated, so unless your brain is getting scanned your brain is receiving almost zero dose.
If CT scans damaged the body, it would be visible in the lymphatic and immune system first, and way before any other systems.
I think they mean most statistics are simply "you have x% chance of y" when the chance of having y given the prior that you're in the ER may be different
This article seems mostly a glorified praise of a top-med-school-doc, who in fact is probably in no way exceptional.
Some points:
- the cardiac arrhythmia and pneumothorax anecdote absolutely screams "inexperienced staff on scene". Not performing basic imaging for car crash victims, and furthermore thinking of a medical (vs. surgical) cause first, would be absolutely laughable for any trauma/ER doc, and does not respect standard care guidelines. Big trauma centers also means lots of resident docs, more or less supervised. Additionally, the article does not give a lot of details about the case, so judgment of this particular case from an armchair is presumptuous.
- Many medical professionals not only do not think statistically, they also believe statistical studies to be less reliable than their own clinical experience-based judgment, and often rightly so. People outside of the field often miss how catastrophic the quality of medical statistics are. The end result is that professors will cite the literature when it supports their opinion, and will say something on the order of: "in my experience as a clinician, it would be better to do such and such..." when it does not.
- a serious and reliable approach to statistics is a priority concern of today's medical system. The main problems are 1) inability to collect reliable data, and 2) professionals with no statistical education analyzing said data. This is changing, albeit very slowly.
> Big trauma centers also means lots of resident docs, more or less supervised.
Yep, that was my thought as well. That sounds a lot like a resident who started heading down the wrong path before the attending pointed them back in the right direction. A 'teachable moment' of the sort that occurs hundreds of times a day at teaching hospitals across the continent.
As a completely trivial takeaway from this, now I want to start using tissues to press elevator buttons in hospitals, and possibly bring along surface disinfecting wipes to use on them as well.
Unfortunately, just being metal isn't enough. Most metal surfaces in hospitals are stainless steel, which can hold viable pathogens for a week or more. Silver plating would sterilize some pathogens in as little as 5 minutes.
> Silver plating would sterilize some pathogens in as little as 5 minutes
That would be very expensive for very little benefit - five minutes is more than long enough for multiple people to use the same buttons at a busy hospital during the day.
It's much better to promote behaviors like washing hands before touching food or mucous membranes (like rubbing your eyes) and using alcohol-based hand sanitizers when that isn't practical. That's why you see hand sanitizer dispensers every few feet at (good) hospitals, and why infection rates plummeted when hospitals introduced them.
In addition, never touch those buttons with the tips of your fingers. Use the knuckle of your pinky instead - it's much less common to accidentally use that to touch a mucous membrane later on, so it's slightly better.
The importance of handwashing can't be overstated, it is one of the keystones of sanitation and public health! Hospital transmitted infections would go way down if staff followed all checklists to a T.
It's a matter of defense-in-depth. When the traffic is heavy enough to have less than 5 minutes between contacts, how many more people would be infected after a week?
As for cost, it would be more expensive but less so than you might think. With how thin the plating layer is, even for heavy wear, the material cost is under $500 per square meter. For small objects like buttons, door knobs, and hand rails it's negligible compared to installation and other costs. By switching to a cheaper base material it could even be cheaper over all.
I agree with your assessment. Considering the constant work hospitals put towards maintaining a clean environment, it seems only natural to use self-sterilizing surfaces whenever possible, just as part of the overall system.
> That's why you see hand sanitizer dispensers every few feet at (good) hospitals, and why infection rates plummeted when hospitals introduced them.
Alcohol hand gels give a false sense of cleanliness though. Some hospitals have problems with Norovirus, and it's likely members of the public who've recently had vomiting think it's okay for them to visit a relative because of all the handgel.
While this has nothing directly to do with the OP, but there's an assumption of cleanliness amongst everyone I know. If it looks clean, it must be clean, right?
100% completely wrong. Simple casual observation of people exiting restrooms is proof that if anything is touched, it cannot be clean. I have seen far too many people not washing after going #2 that I simply do not trust a single damn thing that I touch in public. I'm not OCD, but the general piggishness of a large portion of the population is quite disgusting.
I operate on the assumption of filth, and it has kept me from getting sick for nearly 7 years. I avoid public restrooms unless nature is screaming at me, and I carry safety wipes and use them all the time. I use them the moment when I get into my car from visiting anything, anywhere.
I filled in for the building manager at a higher end office building, and the things I have seen were shocking. I have seen non-public bathrooms defiled in disgusting ways...all on touch surfaces. Feces, blood, ejaculate, and who knows what type of drippy bile. This in an upscale business building, mind you. Imagine what horrors are visited upon your common public restroom.
I even wash my soda cans. Probably a bit overkill, and my dad used to give me stick about it until he got sick from drinking from a can that had mouse pee on it.
The neat thing is that being fastidious doesn't take much time or effort. And, it's not like my immune system became Superman overnight 7 years ago, it's that I started being careful with what I did with my hands.
Same. You were not just born into a filthy world. You evolved with the rest of us in a world incredibly densely populated with microbes, and in fact by weight you are more microbes than human.
I think there's more factors than that. Air traffic controllers are very overworked and they don't often cause collisions[1].
I think this part of the article is what the big problem is:
“Eighty percent of doctors don’t think probabilities apply to their patients,”
I've recently gone through 4 years of medical treatment, and it's still ongoing. Only to find out this week that I have Lyme disease. Given that the chances of getting Lyme where I live is relatively small, it was overlooked for many years. I even asked doctors to test for it, but they refused. Meaning I'm a direct example of doctors not considering non-regular cases. It cost me over $20,000 out of pocket. Not to mention the other things it cost me.
I don't know if its a form of arrogance or how they are trained or a combination of both. But can be life-destroying for patients to say the least. The leading cause of death in Lyme patients is suicide.
As a matter of fact, their training could indeed have motivated their refusal to test.
The Lyme test not being perfect and the disease not being that frequent in your area makes testing dubious, depending on the particular numbers. In more scientific words: if the prevalence of the disease goes down, then the positive predictive value of the test decreases as well [1][2].
Lyme is the new fibromyalgia, which replaced ME, which replaced the "Victorian lady took to her bed for a number of years" trope. Be very careful of jumping down this rabbit hole. The tests you'll have had are not validated.
> I think there's more factors than that. Air traffic controllers are very overworked and they don't often cause collisions[1].
Seems like they're getting pretty close. Air traffic and medicine are not the same field, I wouldn't expect the probabilities and risks to be the same.
> The study found that nearly 2 in 10 controllers had committed significant errors in the previous year — such as bringing planes too close together — and over half attributed the errors to fatigue. A third of controllers said they perceived fatigue to be a "high" or "extreme" safety risk. Greater than 6 in 10 controllers indicated that in the previous year they had fallen asleep or experienced a lapse of attention while driving to or from midnight shifts, which typically begin about 10 p.m. and end around 6 a.m.
also, a case of "hearing hoof prints and thinking horses, not zebras."
a pneumothorax (collapsed lung) that didn't show up on an x-ray is what would concern me. They were focused on the most common causes of the issue they had at hand, and likely with all of the information available at the time. when the new information was available, the treatment course changed.
That's often how things work in emergency medicine.
I find it pretty surprising that a trauma center would miss a pneumo in a multi-system trauma pt...
Perhaps the only saying more common in trauma than "if you hear hoofbeats think horses not zebras" is "the problem is caused by the trauma until proven otherwise".
The number of people killed by medical errors thing is a little controversial. People who are about to die anyway get a lot of medical interventions (which is more opportunity for errors, big small). If a patient accidentally gets an extra dose of their antacid 48 hours before they die, is it really likely that error led to their death? Because it would be counted in that 250k/yr number...
Preventable medical errors are certainly something we should continue to work to reduce (significant progress has been made over the past few decades in that regard).
I'm not advocating complacency, just pointing out that many people think the 250k/yr number is substantially inflated.
There's a book called "Thinking Fast and Slow" by Daniel Kahneman that talks about systematic bias in human heuristic thinking.
> The more easily people can call a scenario to mind, the more probable they find it.
This is practically a restatement of the "availability bias" from that book. It came to mind immediately when I saw the article's title "How can Medical Professionals Avoid Making Assumptions That Lead to Mistakes?"
The answer is probably that they can't, because they're human. One can put good processes in place, and do things like checklisting that dissuade people from making fast heuristic decisions (which we know are systematically, and predictably wrong). But people really hate stuff like that, doctors especially, and so it's an ongoing cultural battle.
Doctors in this regard are no different than software engineers, or plumbers, or any other human at work, they just get more attention when they screw up because people die.
Well of course it brings Kahneman to mind. A good quarter of the article is a digression into Amos Tversky and Daniel Kahneman's research, including a mention of availability bias by name ("“Consequently,” Amos and Danny wrote, “the use of the availability heuristic leads to systematic biases.”")
There's both more risks but also there's a substantial time pressure on doctors which engineers generally do not face when designing something (ask an engineer to design a critical part of a bridge in an hour and they'll rightly tell you to fuck off, but a doctor often has less time to make critical decisions). The other problem, which is fixable, is the general overworking of medical professionals. The hours they work are often ridiculous, and this also worsens the time pressure and means there's less scope for serious review.
Are only 'priming studies' in doubt? Or are most of the studies in social psychology in doubt today? The experiments and conclusions used to fascinate me, but once you lose trust it becomes hard to believe again.
I used to think all these experiments are conducted on people vastly different from me or the people I interact with, so those findings are not applicable to me. But now it seems that those are not applicable even to people who are a lot like the subjects of the experiments.
I'm probably having the bias where one under the influence of a single significant factor ignores all the rest :).
Another thing to note is that some of the attempts to show cognitive bias at work are more easily explained by deliberately misleading or confusing wording of questions (i.e., framing a question in such a way that the person being asked thinks the question is "what is the conditional probability of Y given X" when the questioners then turn around and say "gotcha! We were really asking for the base rate of Y in the general population!").
It's a bit different because a doctor's mistake can lead to an irreversible outcome.
That's true of some engineers (those who design bridges or the software that goes in a pacemaker or car ECU), but not others (the engineer that designs alarm clocks .. or the ones that design half the shit Big Clive buys from China).
Sure mistakes in other fields can lead to loss of work or infrastructure changes/mistakes that lead to millions being lost in revenue, but rarely something as irreversible as death.
You're thinking small. Imagine the impact a bug in a FEM software package could cause if everything was then designed to be half the strength it should. Or a low quality chainsaw chain pin that would randomly break and release a sharpened chain at high speed. A propane water heater that isn't vented correctly, suffocating everyone in the house when the wind changes direction. Or even furniture that has screws that are too long, so the kid who jumps on the couch gets stabbed.
These kinds of examples are everywhere. Doctors aren't special snowflakes who hold human life in the palm of their hand, everyone from bus drivers to lawyers to electricians can kill people if they screw up.
Instead, I would advocate for a pattern recognition method. Given a database of x million patients, it's likely someone has had the same type of case before, if not very similar. A sample would provide much less variable results than the individual patient,making diagnosis more confident.
Such a system could be used to predict symptoms before they become symptoms, saving time and preventing pain while serving to reduce hospital workload. Figure out a way to standardize it in the intake, and let the system predict what's wrong. It'll solve most of the cases, and identify new trends, leaving human doctors to focus on the edge cases like the one in the article.