Comments

It's unfortunate that your aunt met with less than acceptable care. It sounds like she may have more than one physician treating her. That could lead to a breakdown in the continuity of her care; all of her medical information is not in one place for all caregivers to access. While that is no excuse for almost grossly over treating her, it may explain the "cluelessness" of many physicians.

Additionally, Medicare and HMOs require doctors to follow a strict care path for specific illnesses and conditions. If they don not follow the "rules", the patient's care will not be paid by the insurer. That may explain the instructions given by each physician - they were "only following orders".

It's a symptom of a system that has made Medicare and HMOs the decision makers for doctors rather than the doctor choosing the best care for his/her patient. The system is broken and the solution seems to be the application of more duct tape. What we really need is an entirely new health care system, designed(not by the government)from the ground up.

Posted by Wayne at December 17, 2009 4:08 PM

In my experience, my Dad aged 84 was seeking answers from the medical profession about his decreasing mobility. He just wanted to walk properly again. All the typical band-aid solutions to treat the symptoms, but no real clear diagnosis as to what the problem was in first place. They thought it might be "this", but then again it could be "that". Eventually he was asked by his doctor "You are in your 80's, how long do you want to live for?" 2 years later my Dad died a shell of his former self.

Posted by Laynie - the marketing msucle at December 17, 2009 4:48 PM

Tom,

Your story reminds me of Kerr's great 'On the Folly of Rewarding A while Hoping for B' (see page 3 of the PDF). Basically it boils down to messed up incentives. (This is the best academic article I've ever read, it is short, interesting, funny & worth every manager's time to read).

Yes, the current healthcare bill barely touches this, but Atul Gawande at the New Yorker thinks that it might start showing us the right path.

Posted by Aaron Windeler at December 17, 2009 7:31 PM

Tom - Doesn't surprise me one jot. Beware the 'expert' in any walk of life - especially healthcare. Always question them. We know our own bodies best ..... And a 94 year old is a super expert.

I am reminded vividly of the fabulous article you sent me a couple of years ago - "On Being Sane In Insane Places" by David L. Rosenhan - Wonderful messages therein and oh so relevant to all healthcare interventions.

"Trust me I'm a Patient" is my motto and the title of one of my workshops.

BTW - Seasons Greetings to all commenters to this Blog and of course all members of TP Team.

Posted by Trevor Gay at December 17, 2009 7:59 PM

It's another example of the person (hourly employee or 94-year old aunt) closest to the issue/problem having good insights about what's appropriate corrective action.

Posted by Paul Thornton at December 17, 2009 8:49 PM

If it wasn't for my personality-flaw defense mechanism, I would be a bit more hesitant to revive the old sage about medical students: "the smart ones go to vet school" because the incompetence that your aunt experienced is nothing to joke about. Sorry. Surgery for a 80+, much less 90+, year old that can stand or speak should be grounds for looking into revocation of a medical license. I am barely able to type I am so mad...

I have posted this suggestion before but there could be no greater service and cost-reduction force provided by any legislative action than having a paid, independent Patient Advocate stationed at every medical facility. The PA should be involved in real-time starting with the consultation phase and ending with the customary wheelchair ride out the door. Reviewing later is borderline useless. What is being debated in Washington is worse than useless.

Posted by Terry Ransbury at December 17, 2009 9:24 PM

Three docs die in a plane crash. Standing at the pearly gates.

"So, what did you do worthy of entrance into Heaven?" Saint Pete asks the first doc.

"I was a plastic surgeon," the doc replied.

"Hmmm..." mumbles Saint Peter. "Working to preserve and augment the beauty of His creation. You can enter."

"And what did you do worthy of entrance?" He asks the second doctor.

"I was a proctologist" the doc replied.

"Oh, my" replied Saint Peter. "Thankless work. You may enter."

"And you, my friend, what did YOU do worthy of entrance into the Kingdom?" Saint Pete asked.

The third doctor replied "I worked my way up and became the director of an H.M.O."

"Very well," said Saint Peter. "You may enter. But you can only stay for 2.7 days."

Posted by Dan Gunter at December 17, 2009 10:20 PM

Tom,

I am not surprised. There is no penalty in the medical profession for not using "best practices". In a recent study (can't put my hands on it right now), physicians used the proper treatment in 55% of cases. Which means they used sub optimal treatments in 45% of the cases. How long do you think they would last in manufacturing?

So physicians end up relying on their years of experience to make decisions regardless of empirical evidence. Or the "entrepreneur physicians" focus on how much reimbursement yield they can get per patient case.

Their are bright lights out there. They need to be identified, nourished and replicated.

Posted by Bruce Fryer at December 18, 2009 12:56 AM

Aaron, many thanks for the Kerr link. A typo on p2 leads to an amusing unintended morality/immortality correlation, but it's a thought-provoking read.

Posted by RobCH at December 18, 2009 2:26 AM

"Doctors in the midst of the scientific arrogance of the 1960s looked down at mothers' milk as something primitive, as if it could be replicatd by their labortories-not realizing that mothers' milk might include useful components that could have eluded their scientific understanding-a simple confusion of absence of evidence of the benefits of mothers' milk with evidence of absence of the benefits (another case of Platonicity as 'it did not make sense' to breast-feed when we could simply use bottles). Many people paid the price for this naive inference: those who were not breast-fed as infants turned out to be at an increased risk of a collection of health problems, including a higher likelihood of developing certain types of cancer-there had to be in mothers' milk some necessary nutrients that still elude us. Furthermore, benefits to mothers who breast-feed were also neglected, such as a reduction in the risk of breast cancer.

"Likewise with tonsils: the removal of tonsils may lead to a higher incidence of throat cancer, but for decades doctors never suspected that this 'useless' tissue might actually have a use that escaped their detection. The same with dietary fiber found in fruits and vegetables: doctors in the 1960s found it useless because they saw no immediate evidence of its necessity, and so they created a malnourished generation. Fiber, it turns out, acts to slow down absorption of sugars in the blood and scrapes teh intestinal tract of pracancerous cells. Indeed medicine has caused plenty of damage throughout history, owing to this simple kind of inferential confusion.

"I am not saying here that doctors should not have beliefs, only that some kinds of definitive, closed beliefs need to be avoided-this is what Mendoctus and his school seemed to be advocating with their brand of skeptical-empirical medicine that avoided theorizing. Medicine has gotten better-but many kinds of knowledge have not."

--Nassim Nicholas Taleb, "The Black Swan."

Posted by Judith Ellis at December 18, 2009 5:57 AM

A 70+ gentleman of my aquaintance was having trouble with his knees. His doctor thought it was advancing age.

What he didn't know, because he hadn't inquired futher, was that this gentleman played hockey two and three times a week, went for several mile brisk walks afterwards and worked out with heavy weights in the gymn on the off days.

...and his knees hurt...

Posted by Lois Gory at December 18, 2009 9:42 AM

"Likewise with tonsils: the removal of tonsils may lead to a higher incidence of throat cancer, but for decades doctors never suspected that this 'useless' tissue might actually have a use that escaped their detection. The same with dietary fiber found in fruits and vegetables: doctors in the 1960s found it useless because they saw no immediate evidence of its necessity, and so they created a malnourished generation. Fiber, it turns out, acts to slow down absorption of sugars in the blood and scrapes teh intestinal tract of pracancerous cells. Indeed medicine has caused plenty of damage throughout history, owing to this simple kind of inferential confusion."

We have absolutely no choice but to make inferences. Sometimes the inferences will be wrong, sometimes they will be right. The inferences we made about smoking and cancer were right. The inferences we made about diet and heart disease were right. Each day, we infer that we won't die driving to work - most of the time we are right.

In the early 1900's, polio increased in the United States, but did not increase in Mexico. The reason for this is interesting. Sanitation increased in the US and the water supply was cleaner. Below is the explanation from cloudnet.com

"Put simply, paralytic polio was an inadvertent by-product of modern sanitary conditions. When people were no longer in contact with the open sewers and privies that had once exposed them to the polio virus in very early infancy when paralysis rarely occurs, the disease changed from an endemic condition so mild that no one knew of its existence to a seemingly new epidemic threat of mysterious origins and terrifyingly unknown scope "

Should we have just done away with sanitation?

Posted by zorro at December 18, 2009 10:33 AM

How does the currently proposed public health care legislation intend to fix these problems without creating new ones. Simply fixing them might pay for the cost of the proposal!

Patients and taxpayers want to know!!

Posted by Randy Bosch at December 18, 2009 11:11 AM

I lost my silver bullet.... Has anyone seen my silver bullet?

Seriously, except in the extreme cases of emergency medicine, EVERYTHING medical should be put back into the normal economy (just like food, housing, car repair, lawn maintenance, room additions, clothing, entertainment, etc.) and let market forces do their thing.

Everybody CANNOT be protected from everything no matter how much oversight is thrown at it (see: Bernie Madoff). Caveat emptor with a good dose of public/private 'stink eye' watching what is going down might be the thing. Call it a "neighborhood watch" on a national scale.

I do technical work for a living (IT support). Doctors do technical work for a living (human support). Many in my business charge too much for too little. Same with some doctors. What is the answer?

Except for the extreme "life or death" aspect, what makes medicine so different than any other part of the economy?

I'm just askin'...

Posted by Randy Spangler at December 18, 2009 7:06 PM

"We have absolutely no choice but to make inferences. Sometimes the inferences will be wrong, sometimes they will be right. The inferences we made about smoking and cancer were right. The inferences we made about diet and heart disease were right. Each day, we infer that we won't die driving to work - most of the time we are right."

Zorro - Who are the "we" here? The doctors make their educated and experiential analysis and we respectfully make our decisions. I will say this with all of the pharmaceutical advertising and the role that big drug companies play in health care we should all be somewhat concerned about the inferences of doctors. I have a family member who runs a successful medical billing practice and she is in and out of doctors’ offices all the time and sees up close the litany of pharmaceutical reps coming in one after the other bearing gifts for the doctor and his staff.

My mother did need to know this not to be the most trusting. She never fully trusted modern medicine. A new study to be released will report that autism is on the rise. 1 out of every 100 child is affected by the disease. If I’m not mistaken, there have been studies that infer that there are links to immunization shots. When we were growing up all kids were required to get shots of all kind. My mother simply refused to allow us to get shots. We were never sick throughout our entire childhood. Today, we remain a rather healthy bunch. Don’t know if there is a direct correlation, but my 15 year old niece has had all of her shots and she has Asperger’s syndrome. The science is not clear on this matter. While doctors’ first oath is "do no harm." Of course, we have had great harm done for years out of ignorance, arrogance, and inference.

The point Nassim makes throughout the book has to do with empirical knowledge gained by direct and social experiences. What appears to be science isn’t always. But many areas of gray are forced upon us as fact when the better decision would have been to simply say that we are not sure. He deals with "rigorously" codified empirical knowledge as we are made to believe in the stock market or medicine. Doctors are practicing and Wall Street is gambling. Being alert or having someone there in your stead if you are unable to be so is very important. I'm sure that the position for many doctors is a difficult one, as they are trained to know what to do in life and death situations, for example. And, we, of course, want the best doctors to make their best decisions in emergency cases. Instead of saying that we don’t have an answer for this or that we are often misdiagnosed or over medicated.

That is a cute reply about sanitation, by the way. But I do think that there will be a design change to ropes on blinds because one baby was killed even though for many years this design had been deemed safe and no child had died from strangulation until now. Should the design be changed? I'm not sure. But I wish many blessings on the family who lost the loved one.

Posted by Judith Ellis at December 18, 2009 7:55 PM

Tom,

I really hope your aunt gets well.

Best!

Posted by Andres Agostini at December 18, 2009 10:12 PM

Just came across this short interview of Nassim interviewing the authors of Dance with Chance Spyros Makridakis, Robin Hogarth and Anil Gaba. They address some of the many points we are discussing here: medical practitioners, medical tests, over-treatment and diagnosis, the market, experts, and sanitation.

"Gains of life expectancy don't come from medical practitioners. They come from sanitations, drop in crime, from a lot of things...The more money you inject into medicine the more you're going to have a Type 2 Error."

--Nassim Nicholas Taleb

(Type 2 Error as defined by businessdictionary.com: "Statistical probability in hypothesis testing that the test sample supports a conclusion that a value is correctly stated when, in fact, the value is misstated.")

Posted by Judith Ellis at December 20, 2009 12:23 PM

"Gains of life expectancy don't come from medical practitioners. They come from sanitation's, drop in crime, from a lot of things...The more money you inject into medicine the more you're going to have a Type 2 Error."

First off, has Talib ever heard of antibiotics?
More generally, the more experiments you undertake (of any kind), the more type II errors you make. Talib is not saying anything.
I believe Talib is using his knowledge to obfuscate.
The more experiments you perform, the more likely you are to have type I and Type II errors. This is because all results for most experiments are determined using probabilities - so nothing is certain. That's just the way it is. Any scientific conclusion based on statistical results (which covers much of modern science) can be wrong.
There is nothing special about medicine.

Type II : fail to reject the null hypothesis when the null hypothesis is false.

In English, this would mean saying someone is cancer free when the person has cancer.

Type I : reject the null hypothesis when the null hypothesis is true

This would be saying someone has cancer when they do not.

Posted by zorro at December 20, 2009 6:11 PM

As far as autism goes, heres a recent article
http://www.nytimes.com/2009/12/19/health/19autism.html?_r=1&hpw

Posted by zorro at December 20, 2009 7:03 PM

Tom
You bring to light a struggle we (Physical Therapists - PT) face everyday. A significant amount of high level evidence exists that shows we are the best first choice for musculo-skeletal care. Studies soon to be published will show that if you go to a PT first for Low Back pain the downstream cost savings is very significant. Yet insurers many times will not pay for services if someone sees a PT without an MD referral even though State laws allow it. Not only that, PT's are seeing their reimbursement rates reduced to levels that are unsustainable ($50 or less per visit). So much for value-based purchasing!!!

The healthcare issue to me is akin to any business. If your cost to produce something is too high why would you increase production before getting your costs in line? Yet our government by adding all the uninsured to our system without addressing the basic cost issues, will do just that- insanity!!!

As usual thanks for bringing the real life example to light.

Posted by Jeff Hathaway, PTr at December 20, 2009 7:26 PM

Zorro - You make it seem as if you have broken down what Nassim has not but you have not.He made a point that you expounded upon. His research is all about probability and randomness. The point above as it semms to me is precisely what you have said, "there is nothing special about medicine" in this regard except, of course, as he points out in the interview medical practioners' propensity to cause death. In many cases where life is spared or lengthened it has to do with basics such as sanitation and crime reduction. Your point about antibiotics is well taken. But clearly many deaths are caused by the lack of sanitation in spite of antibiotics. If I have missed something, please break it down for me so a two two year old would understand. I knew you would jump all over the two types considering your study in statistics.:-) Did you watch the interview? Regarding Nassim's assumed onfuscation, what are you talking about? He has simply made a point. Why did you perceive it to be grand? It is okay to present the obvious. Plus, sometimes it may not be so obvious as you felt the need to expand upon it. What you have outlined with regards to the two types is good. But it does not negate Nassim's point nor does it make his less clear. It is your tone that is objectionable here. You have not said anything that would be beyond obvious to Nassim or many others. He simply made a point that you sought to elaborate on so it seems to me, no?

Posted by Judith Ellis at December 20, 2009 7:38 PM

Thanks for the autisim link, Zorro. You're super for such things.Your thoughtfulness is appreciated. I shall pass it on to my sister and childhood friends Merton and Marva Hanks. They have a daughter who is autistic. His career with the 49ers and current position as an executive with the NFL enable them to raise a lot of money for the cause. This is great! Their very beautiful and striking daughter had her piano debut at Carnegie Hall last year. Her parents were so very proud. There is hope. But their wealth affords them many opportunities that other kids do not have. My niece is also in one the best school districts in Michigan and she has a personal aide in each class. I shutter to think what is happening to other kids in other school districts. Money matters.

Posted by Judith Ellis at December 20, 2009 8:03 PM

Gains of life expectancy don't come from medical practitioners. They come from sanitations, drop in crime, from a lot of things...The more money you inject into medicine the more you're going to have a Type 2 Error."

The problem is simple - he's wrong -
Gains in life expectancy do come from medical practitioners! When was the last time you heard of someone dieing of smallpox? About sanitation - we practice sanitation because medical science discovered germs. Before germs were known to exist, we did not practice sanitation.
He is correct about sanitation and the drop in crime being a factor. But this is not news.(by the way, Malcolm Gladwell has written about how legal abortion might very well have a hand in the drop in crime. Less unwanted children - less crime - so, it is possible medical practitioners had a hand in that) When he is saying 'the more money you inject ...' he is in effect saying the more you experiment, the more mistakes you make - once again, this is not news.
To use one of Talib's favorite words, what he is saying is trivial. This is obfuscation, because I feel he is presenting what he is saying as non-trivial. And his comment about medical practitioners is simply wrong.
Don't get me wrong - I am not saying medical science does not leave a lot to be desired. But Talib is saying unequivocally that medical practitioners have done nothing to increase life expectancy. He is just wrong.

Posted by zorro at December 20, 2009 8:06 PM

http://bit.ly/6ge0yo

Atul Gawande, MD in the New Yorker about the Senate Bill and experimenting to improve the health care system. He compares it to the work in agriculture through much of the 20th century.

There may be no universal fix. Just thousands of experiments (interations) and a fair number of failures to improve care....

Posted by Randy Sailer at December 20, 2009 11:40 PM

Zorro – I see your point and it is quite obvious that Nassim will too. I will ask him directly for a more detailed explanation of this statement. He seems to be most skeptical about "confirmation theory." I assume that he makes a distinction between "empirics" and others. I also assume that the point has to do with some type of ratio. What is for certain is that he is not frivolous neither does he take himself too seriously. He is also not ego-driven. He has no problem in saying, "I don't know." I'll ask for furhter explanation. But I must say that I actually find it quite amusing that you insist on saying what Nassim has written that isn't news, as if we have read anything of yours that is new. You assume that he is 'presenting' something that is not new, but that is your assumption—not his.

Here are some of Nassim’s points more broadly stated:

"All the while institutional science is largely driven by causal certainties, or the illusion of the ability to grasp these certainties; stochastic tinkering does not have easy acceptance. Yet we are increasingly learning to practice it without knowing — thanks to overconfident entrepreneurs, naive investors, greedy investment bankers, and aggressive venture capitalists brought together by the free-market system. I am also optimistic that the academy is losing its power and ability to put knowledge in straightjackets and more out-of-the-box knowledge will be generated Wiki-style. But what I am saying is not totally new. Accepting that technological improvement is an undirected (and unpredictable) stochastic process was the agenda of an almost unknown branch of Hellenic medicine in the second century Mediterranean Near East called the 'empirics.' Its best known practitioners were Menodotus of Nicomedia and my hero of heroes Sextus Empiricus. They advocated theory-free opinion-free trial-and-error, literally stochastic medicine. Their voices were drowned by the theoretically driven Galenic, and later Arab-Aristotelian medicine that prevailed until recently."

-- The Birth of Stochastic Science, NNT

"We can commit a logical mistake in reality but not in the classroom. The asymmetry is best visible in cancer detection. Take doctors examining a patient for sings of cancer; tests are typically done on patients who want to know if they are cured or if there is 'recurrence.' (In fact, recurrence is a misnomer; it simply means that the treatment did not kill all the cancerous cells and that these undetected malignant cells have started to multiply out of control.) It is not feasible, in the present state of technology, to examine every single one of the patient’s cells to see if all of them are nonmalignant, so the doctor takes a sample by scanning the body with as much precision as possible. Then she makes an assumption about what she did not see. I was once taken aback when a doctor told me after a routine cancer checkup, 'Stop worrying, we have evidence of cure.' 'Why?' I asked. 'There is evidence of no cancer' was the reply. 'How do you know?’ I asked. He replied, ‘The scan is negative.' Yet he went around calling himself doctor!"

"An acronym used in the medical literature is NED, which stands for No Evidence of Disease. There is no such thing as END, Evidence of No Disease. Yet, my experience discussing this matter with plenty of doctors, even those who public papers on their results, is that many slip into the round-trip fallacy during conversation."

--The Black Swan, NNT

Posted by Judith Ellis at December 21, 2009 12:11 AM

I got a problem with inflamation in my left arm, It is some sort of "itis". Visited nearly 10 docs througout a four year period. This overuse of hands is a problem of our times. Too much computers, cel phones and others.

Well, my own conclusion is that i should do swimming as the best form of treatment.

Posted by Fausto at December 21, 2009 7:19 AM

"You assume that he is 'presenting' something that is not new, but that is your assumption—not his."

Why did he say it? If he is not pointing something out, what's the point of saying what he said?

He is also absolutely wrong about medical practitioners. And that is a big deal. He is ignoring all sorts of
big medical advances when he said medical practitioners have no effect on life span.

"om. The asymmetry is best visible in cancer detection. Take doctors examining a patient for sings of cancer; tests are typically done on patients who want to know if they are cured or if there is 'recurrence.' (In fact, recurrence is a misnomer;"

Colon cancer is prevented by finding pre-cancerous growths and removing them.
And, its not impossible that it will be possible to detect single instances of cancer cells in the near future with nano-tech.

"An acronym used in the medical literature is NED, which stands for No Evidence of Disease. There is no such thing as END, Evidence of No Disease."

The correct statistical language would be "We cannot reject the null hypothesis", the null hypothesis being that 'there is no cancer".

Its exactly what happens when someone is deemed to be 'not-guilty' of a crime.
Legally, what is shown is there is not enough evidence to say the person is guilty. But no one is saying the person did not actually commit the crime. That is rarely if ever proven.
The no-cancer diagnosis means that 'we have enough evidence to proceed as if the cancer is cured. From now on, we will treat you as if you are cancer free. Except, you need to come in for regular checkups".

I'm positive MD's do not understand the difference between a true cure and 'behaving as if cancer has been cured'.
The Medical Students here are required to take an Epidemiology course - and so are the Stat students - Medical Students have a very difficult time with the concepts of probability in this course - so much so, that it has been 'dumbed down' - but that does not make me feel that med school would be a snap by any means.

Posted by zorro at December 21, 2009 1:56 PM

Good points all, Zorro. Thank you. I have not spoken to Nassim yet. But I will.

Posted by Judith Ellis at December 21, 2009 2:05 PM