Comment from Marginal Revolution by someone who sounds knowledgeable:
"To start with there is a significant problem with the article. Cardiac surgeons don't go to cardiology meetings and don't perform the type of interventions mentioned in the article. Interventional cardiologists are not cardiac surgeons. The recurrent mislabeling of the specialty involved is yet another example of the slipshod treatment and lack of understanding of science and medicine in the lay press which makes for an ill-informed public."
They suggest mortality is lower during meetings because:
"the intensity of care provided during meeting dates is lower and that for high-risk patients with cardiovascular disease, the harms of this care may unexpectedly outweigh the benefits."
Not sure if they accounted for delayed surgeries in the study.
> Not sure if they accounted for delayed surgeries in the study.
That's sort of what I am wondering. Perhaps it just delays the inevitable - the patient is gravely ill is is going to die if they don't perform _potentially_ life-saving surgery. The surgery, is of course risky.
The conference delays the surgery, so the patient's surgery or other high risk procedures are delayed. This gives the patient a few more days of being ill, but doesn't probabilistically change the outcome of actually undergoing the procedure.
> The conference delays the surgery, so the patient’s surgery or other high risk procedures are delayed.
My understanding from listening to the author’s podcast, is that this is the proposed mechanism. There is a percentage of patients who were going to get better on their own anyway. But if they receive urgent care, it may cause harm.
The conclusion seems to be that there is a measurable percentage of patients who got surgery but didn’t need it and thus suffered greater harm than if they had been left alone. Because heart attacks are so critical, medical staff errs on the side of action instead of waiting. This seems reasonable, but may in fact be bad.
They appear to be already accounting for that since they are measuring 30-day mortality for acute conditions. They’re saying it’s possible the reduced mortality is due to the high risk procedures actually being unnecessary.
As an argument to illustrate why 30 day mortality isnt a long enough period, imagine this scenario: you have a cancer that has a 90% chance of killing you in one year. You will be cured if you get the surgery tomorrow, but the surgery has a 30% mortality rate. In one month, 30% or those who got the surgery will die, where all those who didn't get the surgery will still be alive. In one year, 70% of those who got the surgery live, whereas only 10% who didn't get the surgery are alive.
To understand why, i think you have to know 2 data points
1) The first date (and then-current surgery schedule) at the point when the conference dates where announced.
2) The date (and then-current surgery schedule) at the point, when the doctor booked his/her travel plans.
Both lists and dates will help you understand if changes in information also resulted in the changes of mortality (by rescheduling hard cases to a later date, for example).
This is complete and utter nonsense. The "exceptions" are 99% of medicine. Almost all of medicine is applying strategies we know on average improve outcomes as well as we know how and as well as that clinician is able to within the scope of the time given. If you don't know this is likely that you haven't had much need of medicine. I you had you would know better.
This isn't to say outcomes are always good our knowledge is imperfect, people are imperfect, and not every situation has a good answer.
Emphasis—“on average” and yet often applied deep into both tails of unknown distributions.
“Complete and utter nonsense” also ignores many inconvenient truths about medical care today and of course in the not-so-distant past. Medical history should temper the tone.
> I've been trying with the idea that most medicine is actually just straight up actively harming people in complex ways.
This says that most medicine is harmful full stop. This is conspiracy theory thinking. It is not far off from I've been thinking maybe the earth really is flat.
Most medicine is setting broken legs, dispensing antibiotics for infections, prescribing insulin for diabetes. In other words interventions that are straightforwardly positive. It is only when the situation is already dire and outcomes are already poor that intervention is sometimes negative and even then we are often discussing whether an intervention at 72 resulted in the person dying then instead of 74 wherein the person would have died thrice over between 60 and 72 and been crippled between.
Yes I too read about both the era where we thought bad smells caused disease and disdained hand washing AND modern end of life care which is oft pointless this doesn't mean medicine is mostly harmful. Words have meanings and the posters are nonsense as you know.
1. You're pre-supposing that intervention in these cases is both common enough to affect things on a sociological level, and necessary enough to also contribute to the effect.
I suspect given that the rarity of many serious ailments until much later in life simply no intervention would suffice in any reasonable epidemiological sense.
2. Your hypothesis presupposes that serious medical care is commonly necessary enough to significantly improve public health.
I know of young people that have been harmed by medical science, and not many come to mind whom I would consider having been in absolute need of medical intervention.
Given that medicine often harms patients demonstrably, with mistakes and opiates contributing majorly to human fatalities, it occurs to me that I can more commonly produce anecdotes where medication or medicine harmed rather than helped where it would have been absolutely necessary.
The majority of us if we live long enough will need medical help to live or live well. For the overwhelming majority of these interventions there is medial evidence as far as the beneficial nature of these interventions which you cannot simply refute by your badly considered incomplete anecdotal understanding of other people's experience.
Of course more things go wrong as people get older but accident or illness can happen at any age and without intervention in the overwhelming majority of cases in which we intervene the outlook isn't great and many people have 40 or more years left when they need help.
Just as a singular for instance people become diabetic. No intervention means they die soon.
People break their bones. No intervention means people experience weeks to months of screaming agony and are far more likely to experience ongoing pain and permanent decrease.
People get pre-cancerous growths or trivially treatable early cancers. No intervention means they die decades early.
People get a bad chest infection and their lungs start to fill up with fluid. Non-intervention means someone who could have lived to 80 dies at 40.
People break their hip in their 50s with decades of life back. What is the chance of walking by just lying abed and drinking tea. It's negligible because certain kinds of breaks don't actually get fixed without surgery.
Here is some data on hospital admissions and emergency department visits per 1000 by age. You will note that even among the relatively young visits are not particularly uncommon. Young people are less likely to have something go wrong with their body but more likely to have something go wrong with their judgement and have an accident.
These people aren't all morons marching in lockstep to get snake oil they are going to the emergency room because they did something stupid and broke their legs or 1000 different other legitimate interventions.
The truly strange thing is that the word epidemiological is in your vocabulary and not only do you know absolutely nothing about the world around you but you are aggressive in your ignorance. Defending the complete fantasy you have erected with vigor if not ability.
It's like talking with a true believer about the "theory" of evolution
Not sure if that's a useful definition of 'harm'. It's like pointing out that most substances are poisonous. Can't just ignore the dose or context when it comes to medicine.
I mean, fair enough. Just because you're an immunologist doesn't mean you carry spare adrenaline, antihistamines, inhalers, and steroid infusions in your fanny pack at conventions. All they can do is call an ambulance.
It's a bit like expecting a hacker to hack a network without their laptop.
(bit weird if HE didn't have his epipen on him though ...)
> Just because you're an immunologist doesn't mean you carry spare adrenaline, antihistamines, inhalers, and steroid infusions in your fanny pack at conventions.
Maybe they should.
> It's a bit like expecting a hacker to hack a network without their laptop.
A real hacker can break into a network with some bubblegum, a pen, and a corgi.
I saw some sort of collapse at a medical school. Loads of people went to help. At the time we wondered how that went, with half trained students on the loose.
From my experience, it was more "too many cooks" than the ultimate bystander effect.
I saw someone feel unwell at a party, nothing serious, just a drink too much, but half of the room happened to work in healthcare, and half of the room came to help. As expected it went all over the place, until a relative (also a doctor) came in, ousted the crowd and took proper care of the poor guy.
In that situation you need an anesthesiologist, not an allergologist. Even a random anesthesia tech without medical education would do far better than an allergologist. A paramedic too.
Speaking as someone with a health care worker in the family who just went on strike, I think this makes a lot of sense. When hospital workers go on strike, it often forces the hospital to go on diversion, leading to other hospitals taking on all new patients, who are usually in some form of medical crisis and have a higher chance of dying than stabilized patients already under care. Thus, it makes sense that a hospital which has workers that go on strike have a lower death rate on average.
The article mentions controlling for this in numerous ways. It was looking at elective surgeries, as well as county wide mortality rates and not just a single hospital. That said, in the elective surgery cases it could well be a spin on what you're mentioning and people just deferred their surgeries until after the strike. You'd think surely they also controlled for this, though.
As someone dealing with elder care of multiple family members I also believe mental anguish caused by medical environments, including insurance and billing in the US, and the dismissiveness of hospice care (you’re taking too long to die, speed it up or transition to a lower form of care) doesn’t help the matter.
Modern medicine is a miracle but struggles to evolve beyond many immediate hurdles. In an extreme minority of cases it can be better to avoid traditional intake methods.
Hard to say without more details, though it's certainly plausible.
There's other possibilities though. Like if the timing of other interventions is being delayed until the cardiologist is able to see the patient instead of deferring to a less specialized physician.
No, not necessarily. There's no indication of that whatsoever. The point was just that there's insufficient information to conclude much of anything about why this was observed. It could also be that PCI is over applied leading to increased mortality.
Interestingly, there were no differences in the number of procedures performed on meeting and nonmeeting days (it's not the surgeries that are killing people).
The hypothesis that I find most interesting is that the cardiologists who are at the meetings spend less time caring for patients and more time doing research, hence they aren't as good at caring for patients.
I've never been to one of those conferences, so just a second hand anecdote:
A couple of years ago some friends of ours invited us to lunch with a couple of their relatives who were in town for a cardiology conference. They (the relatives) were both stout* people, technicians of some kind rather than doctors, and the husband was super hung over from the previous night.
Anyway, they told us all about how the sessions at these things were pretty dry, but the after party was always a drunken, hours long slurry of alcohol and aorta-clogging food, and it was so ludicrously un-heart-healthy that it was a running gag.
So I'm wondering if the people who opt to go to those things tend to perform differently in their work than the ones who stay home and live quieter lives?
(*I only mention this because a few days after we had lunch, the husband apparently had a heart attack while he was driving, pulled off to the side, and died.)
Could it be that the conferences take place at a time of year where mortality due to cardiac events is higher, e.g. in summer? Maybe I missed it, but I don't think they controlled for time of year.
The author of this study talks about time of year in a later podcast, iirc. They did control for time of year (maybe in a later study) and found no effect.
> In teaching hospitals, mortality was lower among high-risk patients with heart failure or cardiac arrest admitted during meeting dates (P < .001) No mortality differences existed for low-risk patients in teaching hospitals or high- or low-risk patients in nonteaching hospitals [or high-risk patients with AMI in teaching hospitals]
So in the specific case of teaching hospitals with high-risk patients with heart failure or cardiac arrest, the normal treatment is making things worse.
Outside of that special case, the cardiology meetings don't seem to have any effect (positive or negative). This could mean that the normal treatment is useless. Or it could mean that the hospital is doing a good job of planning around the cardiology meeting -- e.g. delaying non-urgent treatment until the next day, while ensuring there are still enough doctors on staff for the urgent cases.
High-risk patients with heart failure and cardiac arrest hospitalized in teaching hospitals had lower 30-day mortality when admitted during dates of national cardiology meetings.
A rare case of meetings proving beneficial? But why?
It would be worth looking into the seniority of the doctors attending the meetings. This is purely anecdotal, but my town hosts some meetings and conventions, including doctors, and I've been hired by those events as a musician.
I'm always struck by how young the attendees are. They look like kids. It may be that meetings are more of an attraction for people trying to build their careers, make connections, and have a free vacation, whereas the senior doctors are happy to stay at home and man the fort, plus they have the usual obligations of older workers, such as families.
This is also the case at my techie day job: Most of the interest in attending meetings is among the junior engineers.
Sometimes when the boss is away the team works better. At least, that is the case with my team. I don't really know why. Because I really think I am not a bad boss. But apparently either I am or they just don't need one and I am in the end a distraction.
Maybe coordination costs are lower when the boss is away? So more time is spent focusing on the task in the short term. And consequences would show up latter? When my boss went on maternity leave , the first 2 months were a breeze then things started getting harder.
This would seem to apply to health outcomes being cited in the thread as well. Yes, if we shut down all hospitals tomorrow, less people would die in the short term. Presumably that affect diminishes and reverses relatively soon.
Even with 30-day mortality this can be the case, heart patients I am sure do survive risky procedures and die two weeks later because of complications due to the procedure fairly regularly. (Not that I have an opinion on the root cause here.)
"To start with there is a significant problem with the article. Cardiac surgeons don't go to cardiology meetings and don't perform the type of interventions mentioned in the article. Interventional cardiologists are not cardiac surgeons. The recurrent mislabeling of the specialty involved is yet another example of the slipshod treatment and lack of understanding of science and medicine in the lay press which makes for an ill-informed public."
https://marginalrevolution.com/marginalrevolution/2023/08/86...