From purely anecdotal experience, that number is totally believable. Again anecdotally, the medical field seems to only have two kinds of people, the extraordinarily competent and dedicated, and people who don't give a whiff of a shit. The medical bell curve looks more like a bathtub.
It is important to understand that in the American private healthcare system, the doctor is the true “customer” of the hospital, in that, with the exception of services provided by hospital-employed physicians, the things the hospital itself can actually bill for have to be ordered by physicians in private practice who have patients admitted to the hospital.
There is a tremendous power imbalance between physicians and non-physician clinicians and a powerful incentive to cover up bad acts by bad doctors who perform a large number of profitable procedures.
That's the problem with a fragmented health system. A lot of doctors are specialists in a certain procedure and want to repeat their pet procedure on every patient they see. I saw this with my ex who had chronic leg pain. Most of the doctors we met just wanted to repeat what they do every day (and makes them good money). There are only a few doctors who have a wide knowledge of the area and can recommend a treatment that actually fits.
The only missing peace is the a doctor on the care team who chooses which type of surgery is best, becasue once one is referred to a specialist: they are going to get that specific specialized care.
Perhaps such a system incorporates some aspects of private enterprise, but ultimately it should still be seen as a non-private system.
A truly private healthcare system would allow anybody to practice any kind of medicine at any time, without specific requirements and restrictions being imposed by the state.
It would be up to each patient to decide whether or not he or she will deal with a particular practitioner or provider of services. (Of course, this can be complicated in the case of an incapacitated patient, without prior planning.)
As is typical with non-private/socialist/communist systems of any sort, where natural free market balancing forces such as consumer choice, competition, and reputation are limited or absent, we should expect to see the inefficiencies you described, including significant quality variation, bureaucratic games, and misaligned incentives.
Healthcare in America seems very non-private in nature to me. It may not be as overtly non-private as the healthcare systems in Canada or many European nations, but it certainly does not seem to be private, either.
Even today, organized healthcare beyond vaccines and antibiotics has only a marginal impact on lifespan and healthspan. It's way behind sanitation (clean drinking water, sewage systems, waste disposal) and lifestyle issues (substance abuse, obesity, lack of exercise).
My wife for many years has been complaining of bone and joint pain, strange rashes, and other odd symptoms suggestive of an auto-immune condition. I kept telling her to ask her doctor for at minimum an ANA to see if it comes back with anything. Her doctor kept brushing it off as "stress and anxiety" - something I've learned incompetent medical professionals throw around without ever gathering a mental history or referring the patient to a psychologist - and basically refused to do further tests. The GP basically wrote her off as a hypochondriac with zero evidence; no tests, no referrals to a mental health provider, no looking back at her history, nothing. Doesn't "give a whiff of a shit" is spot on.
I finally convinced my wife to see another GP. This one definitely fits the bill of "extraordinarily competent and dedicated" and on that first visit the new GP ordered an auto-immune panel. Well well well, she came back with high ANA and Rheumatoid Factor markers. She's been seeing a rheumatologist since then who has been evaluating her for rheumatoid arthritis and lupus.
EDIT: this is not my only anecdotal experience either. There's so many of them. For myself: over many years I was slowly losing sensation from the neck down along with a myriad of other neurological issues that were strange but had no specific point of origin. Got several MRIs all of which came back inconclusive.
About 3-4 years later the problem suddenly progressed to me running into walls, losing significant sense of sensation, and losing my balance. I visited an orthopedic clinic and got a second set of MRIs (brain and neck), but this time I asked for a CD so I could review the material myself. The radiologist reported no issues, but I used radiopedia and medical journals to study and cross-reference normal/abnormal MRIs with mine. I found an area between C5-C7 on my neck with significant spinal cord compression. The orthopedic doc read off my radiology report and said "your results were normal". I ended up begging her to go through the MRI stack with me just to see it with her own eyes. She reluctantly agreed. We get to the C5-C7 section and she pauses, says "I'll be right back, I need to consult with one of our surgeons" and boom, I was scheduled for surgery for the next month. Unfortunately I didn't make it a month. Over the next week things deteriorated quickly and I ended up having emergency surgery.
That said, there are improvements that can be made. We have very low health literacy in the US and too many providers assume the patients are as literate as them. We need a much stronger teach back style encounter. As above, we need most care done by mid levels. We need to realign incentives among the patients, providers and payers. This is quite broken outside of derm and ortho.
I think the no wiff of shit group can be split in two. Those who never gave a shit, and those who have been beaten down by a system that has normalized profits over patients.
Yes, the treatment runs the gamut, but the overall healthcare system - sans the higher end (naturally) - is more checklist-driver assembly line than patient care. It's not about quality, the system runs on quantity.
Of course things are missed, they were never looked for in the first place. Fwiw, I saw this happen to my father first hand. I dred the day my mother or I have to depend on the healthcare system. It's not all bad. But the odds favor the house.
Now that I've had a little more experience with doctors and hospitals, I'd say they were spot-on.
That's why I said you're what people say you are. Heck, I don't know my own statistics and I don't know where I stand in comparison to my colleagues. Yet I enjoy a very good reputation with colleagues, but patients often are weary of me because I'm socially awkward.
Weary means tired.
Physicians sometimes jokingly refer to surgeons as "technicians" because what they are doing is often more discretely defined, clearer boundary conditions, clearer indicators of performance/success/quality (especially over X number of cases when you know the national averages for outcomes), and ultimately of a mechanical nature. The work physicians do can sometimes be described similarly, but much less frequently and it can be much harder to do.
The physician/surgeon distinction is a critical one in medicine that is under-appreciated in most conversations about "doctors".
I'll let you make some quick inferences using this video https://www.nejm.org/do/10.1056/NEJMdo004274/full/?requestTy... from this paper https://www.nejm.org/doi/full/10.1056/NEJMsa1300625
Crucially, if you can get someone to hide which surgeon is skillful and which one is not and view the video and judge for yourself, you might be surprised at your skill in differentiation. In my experience, my friends have 100% guessed which surgeon is better correctly. So it is possible that this is Sorites-style.
I know a surgeon with a substantial rate of spectacular failure and a very bad reputation. But most of the time, outcomes are excellent. Is that a bad surgeon on average? No idea. And Im in the OR every day.
I assume the general silent belief would be that your guy with the spectacular failure is some kind of "take the tough cases" dude?
By the way, when I was much younger (maybe 10-15 years ago), I recall my dad coming back from an AO Foundation conference where there was a talk about some particular procedure in some Scandinavian country where the range of outcome quality was so high for a particular non-emergency THR/TKR or something like that and so they shut down the procedure in the remote hospitals and centralized it in a few (3?) tertiary healthcare centres. Do you recall something like that? I have this memory in my head but I can't find the original material. The story is so good: EBM driving patient outcomes; but I can't find it so I don't share it and I would like very much to, if it is true.
No, the silent belief is that he's the worst surgeon we have.
> they shut down the procedure in the remote hospitals and centralized it in a few (3?) tertiary healthcare centres. Do you recall something like that?
That's become an extremely common strategy for specialized surgery throughout Europe.
Haha, classic! I love it! I was honestly a little worried of offending you if he was a friend.
> That's become an extremely common strategy for specialized surgery throughout Europe.
There we go. Fine, I'll just go look it up.
There's data flowing all over the place. But perhaps the lawyers and the insurance stand in the way of improvement?
GP: This condition X is much worse than normal, so I'm going to refer you to Dr. A, the best I know in the field.
Aggregate enough of this and Dr. A has worse outcomes on paper for condition X than everybody else, since s/he gets the patients with the hardest to treat coming in.
The human body is complex. Why not look for as much help as possible?
That's not a good enough reason.
Given the social and financial magnitude the excuse is nearly criminal.
We can do somewhat better at measuring quality for larger provider organizations across patient populations. The NCQA HEDIS measures are evidence based and reflect current consensus on best practices.
Suggesting what is available be tracked isn't ignorance, it's innovation and improvement 101. It's a call to prevent waste and unlock societal value. To suggest otherwise is lazy and insanity.
Or perhaps the industry is afraid of something? Fear makes for great excuses.
But.
If they can identify the importance of hand sanitation and implement programs to ensure that, then there is hope. But as it is, it feels like the land of "that's how we've always done things."
Note: this isn't only hospitals but extended care facilities. They're printing money on the backs of the suffering and losses of others.
Do no harm?? Perhaps it once meant something. No much anymore.
That doesn't mean that they make mistakes, some extremely competent workers just do what they're told. But I don't know of any evidence that hospitals have gone through the same engineered hardening process as heavy industry (eg, airlines) so I expect huge gaps between actual practice and what is possible. I've never seen a hospital process that looks to have been given an engineered finish & I don't think they have enough mathematicians floating around to squeeze for efficiencies.
The former will however cover for the latter. Same thing with police unions. That's why it's so hard to prove malpractice.
If we just classified things that are obvious. Wrong medication applied (ie paper says to deliver 10mg of Advil but you got a vitamin C tablet), wrong leg amputated, wrong patient data looked at leading to a bad diagnosis. We would likely find a large number of incidents, however no way on earth will you get the American medical cartel to report on them honestly.
From limiting residency slots, making it nearly impossible to hire foreign doctors and lobbying for safe medications that are sold over the counter in the rest of the world to be sold as prescription only in the US. Just to name a few, the AMA has served it's members well to the detriment of anyone buying healthcare in the United States. That to me is a cartel, they just use a "certificate of need" to enforce it's will rather than a gun.
https://www.ama-assn.org/education/accelerating-change-medic...
They were actively lobbying to reduce residency slots as late as 2012. They only started the program you linked to when became common knowledge that they were attempting to limit the number of doctors.
Rather than copy / paste a comment: https://news.ycombinator.com/item?id=30108269
Edit: Funny enough I was replying to you back then too. Small world.
summarized by the meme
it takes two wipes to know you need three, but three to know you needed two
It's also completely inefficient. Humans make judgement calls based on available resources. If everyone over 45 received "optimal" care, they would all effectively live in hospitals.
there's a 4X difference between good surgeons and bad surgeons in terms of bad outcomes or complications. And the same study shows that surgeons are actually accurate in terms of assessing who is good and bad but there's really no way for patients to find out before surgery
That's because they're hard to standardize. What qualifies as a medical error? It's easy to go back after the fact and analyze a case where someone has a poor outcome and say 'we should have done this another way'. That doesn't mean there was any indication at the time that the other way would have been better or that the poor outcome could have been foreseen.
I do believe there are a lot of medical mistakes made. I'm a little skeptical that there are legitimately 250k that result in unnecessary death each year. I assume many of those 250k were being treated for serious illnesses that may have taken their lives anyways (not all medical interventions are 100% effective). It would be nice to have a standardized definition, but I'm not sure how that's possible unless we are only talking about treatment received was different than treatment ordered.