The Twilight of Expertise (medical doctors)

Long ago the RAND Corporation ran an experiment that found that additional medical spending provided no additional health benefit (except in a few cases). People who didn’t like the implication that ordinary medical care was at least partly worthless could say that it was only at the margin that the benefits stopped. This was unlikely but possible. Now a non-experimental study has found essentially the same thing:

To that end, Orszag has become intrigued by the work of Mitchell Seltzer, a hospital consultant in central New Jersey. Seltzer has collected large amounts of data from his clients on how various doctors treat patients, and his numbers present a very similar picture to the regional data. Seltzer told me that big-spending doctors typically explain their treatment by insisting they have sicker patients than their colleagues. In response he has made charts breaking down the costs of care into thin diagnostic categories, like “respiratory-system diagnosis with ventilator support, severity: 4,” in order to compare doctors who were treating the same ailment. The charts make the point clearly. Doctors who spent more — on extra tests or high-tech treatments, for instance — didn’t get better results than their more conservative colleagues. In many cases, patients of the aggressive doctors stay sicker longer and die sooner because of the risks that come with invasive care.

Perhaps the doctors who ordered the high-tech treatments, when questioned about their efficacy, would have responded as my surgeon did to a similar question about the surgery she recommended (and would make thousands of dollars from): The studies are easy to find, just use Google. (There were no studies.)

It’s like the RAND study: Defenders of doctors will say that some of them didn’t know what they were doing but the rest did. But that’s the most doctor-friendly interpretation. A more realistic interpretation is that a large fraction of the profession doesn’t care much about evidence. In everyday life, evidence is called feedback. If you are driving and you don’t pay attention to and fix small deviations from the middle of the road, eventually you crash. You don’t need a double-blind clinical trial not to crash your car — a lesson the average doctor, the average medical school professor, and the average Evidence-Based-Medicine advocate haven’t learned.

10 Responses to “The Twilight of Expertise (medical doctors)”

  1. retired urologist Says:

    You asked for my response regarding doctors’ “disinterest in evidence” here. I gave you my response earlier regarding your doctor’s handling of your hernia problem. I said: ““Dr. Consorti should have been more honest with you about her lack of evidence regarding hernia surgery.” You replied, “This is unfair to Dr. Consorti. She honestly believed the evidence existed, I’m sure.” You seem to be having trouble deciding which side you’re on. Must be the olive oil (excuse me, the “evidence-based” olive oil).

    Regarding your question about “more evidence” surrounding the cheap shot Robin Hanson, whom you admire, took at the doctor who supposedly had a nurse fired for reporting him about his lack of handwashing: I did not want “more evidence”; I wanted “some” evidence. I do not consider gossip to be evidence.

    Don’t misinterpret me: there’s no doubt that doctors have been trained incorrectly when compared when other rationalists. There’s no doubt that they waste a lot of public resources. There’s no doubt that the system for training and managing them should change. However, your comment: “People who didn’t like the implication that ordinary medical care was at least partly worthless could say that it was only at the margin that the benefits stopped,” is inappropriate, and incorrect, since that is exactly what the study showed, and it is exactly how Robin Hanson presented it (see here.

    Next you’ll be telling me that psychology is a science, and that a “Rand Experiment” would document the great value of your field.

  2. seth Says:

    Your view that what the fired nurse says is “gossip” while what a hospital administrator says is “evidence” indeed sheds light on these results.

    Experimental psychologists, unlike doctors, don’t try to help people. They do research.

    Thank you for your comment.

  3. retired urologist Says:

    Seth,

    Where did you get the idea that I felt “what a hospital administrator says is ‘evidence’”? I know of no unbiased reason for you to present such as “my view”. Robin Hanson has said that when involved in a disagreement, if the other party has far more experience and expertise in the subject, one should diligently re-examine his own position and yield, unless there is overwhelming support for one’s position in the disagreement. I have such experience and expertise, as described here; you and Hanson do not. The nurse story makes no sense in the real world, but has solid emotional appeal to anyone writing about the shortcomings of the medical profession. Why don’t you take Mark’s advice in his comment, check out the story once and for all, and then write a post about the cognitive dissonance involved, wherever the chips fall? I think that would fall under the heading of “research”, don’t you?

  4. seth Says:

    okay, what do you mean by “evidence” here?

  5. retired urologist Says:

    By “evidence”, I mean that which can reproducibly be used to prove or disprove something. First-hand, or eye-witness, accounts of an event are an example, even though they are not always accurate. In the “nurse story”, you heard it from Hanson, Hanson heard it from his wife, and his wife heard it from the nurse. This is “hearsay” or “gossip”, but certainly not evidence. The story does not report anything that the administrator said; in fact, mention of the administrator is an example of how third-hand misinformation is generated, since the administrator is not mentioned in Hanson’s original telling of the story, which goes: “A colleague of my wife was a nurse at a local hospital, and was assigned to see if doctors were washing their hands enough. She identified and reported the worst offender, whose patients were suffering as a result. That doctor had her fired; he still works there not washing his hands. Presumably other nurses assigned afterward learned their lesson.” Another example of the loss of accuracy in far-removed “evidence” is your description of the doctor as a “surgeon”, while Hanson described him only as a doctor. Calling him a surgeon makes the diminished hand-washing seem more malevolent, and makes your post seem more important to readers.

    Think of this as I would, having been involved in many employer/employee encounters in hospitals, both as Chief of Staff and as an owner. Would the nurse’s boss put his/her own career in jeopardy by terminating an employee without due cause in order to assuage an arrogant doctor? Did this hospital have no policy for dealing with inept employees that involved counseling and second/third chances (all do)? Would the boss tell the nurse directly that she was being fired because of the report? Otherwise, did she just assume it on her own because it made a good story and absolved her of blame? Or did she make it up? If she knew that her story was factual, would she have taken no action against the hospital? Remember, this is not a back-woods facility; it’s in a large metropolitan area. Is there such a nurse at all? What’s her name? Now, look at the teller of the story as you heard it: the class Hanson teaches for part of his income has as its subject the inefficaciousness of the American medical system, and particularly of the doctors who provide the healthcare. Would there be any reason for bias there? Any tendency to want to pass along such a story without checking it out? After all, you did.

    Would it take some effort to find the truth behind this story? Yes, it would. But those who strive for rationality cannot pass along convenient unverified stories simply because it’s too much trouble to find the truth. Pending further evidence, you and your readers should consider this story to be an ad hominem attack on doctors, a valueless and completely unnecessary one, since there is so much verifiable evidence that doctors are not doing a good job. Since you are a researcher in the field, I am confident that you will see the confirmation and intellectual attribution biases involved. Smart people are the best at defending their unconscious biases.

  6. seth Says:

    You want a first-hand account of a firing? The nurse was present when she was fired so her account is first-hand. I am completely puzzled as to what data you are looking for.

    Your definition “that which can be reproducibly be used to prove or disprove something” makes no sense to me. If you can give examples, that might make it clear what you mean.

  7. retired urologist Says:

    Seth,
    I’m signing off. You are not what I thought.

  8. Nathan Myers Says:

    I’m afraid I’m with retired here. Yes, evidence could be found of doctors’ resistance to advisable procedure, and of misplaced administrative support for such resistance. Hanson’s anecdote doesn’t qualify, for the reasons retired generously explained at length. It qualifies, instead, as an illustration, of the sort used to lead off lifestyle magazine articles.

    Maybe it’s true, maybe it’s accurate, maybe it’s not; it doesn’t matter much, so nobody bothered to nail down the details that would be needed if it did matter. We have no idea who it was, or what hospital, or what doctor, and not even any attestation from anybody who does know, in confidence, and offers to vouch for the correctness of the details exposed. The problem is that it’s easy to make stuff like this up, and if it’s credited, there are plenty of people happy to make plenty of other things up.

    What we do have is death rates and infection rates that vary radically from one hospital to another. Death rates are hard to fake. Hanson’s anecdote offers an illustration of how such disparities, and the negligence that creates them, could continue.

    I think you owe him an apology or three.

  9. seth Says:

    Nathan, I’m impressed by the similarities in how two different doctors — Dr. Eileen Consorti, my surgeon, and retired urologist — reacted to simple questions about data.

    Similarity 1. Didn’t answer the question. Consorti never provided the data she claimed existed. retired urologist never clearly explained what he meant by “evidence.”

    Similarity 2. In response to these questions, implied there is something wrong with me for asking. Consorti called my interest in the effects of the proposed surgery “scientific” (that is, unnecessary); retired urologist said “you are not what I thought [in a bad direction]“.

  10. Nathan Myers Says:

    I thought he explained well the difference between anecdote and evidence, and how the one could be converted to the other — if indeed there is any truth in it — with a little investigative work. His disappointment that you couldn’t seem to see the necessity of doing the extra work before citing it as evidence was manifest, not to say heartbreaking.

    Spend some time on snopes.com to see the range of falsehoods supported by anecdotes of exactly this character.

    If you’re after something else, you have utterly failed to make yourself clear.