My anecdotal data (which is primarily second-hand from friends who work closely with doctors in a hospital setting) agrees with your anecdotal data, for whatever that is worth. There are some spectacularly bad doctors out there which the medical system provides cover for, mainly, as far as I can tell, because they generate revenue.

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.

I believe this is a big part of it. Anecdotal as well, but my grandmother had a new leadless pacemaker installed for dubious reasons by a doctor that specialized in this particular type of leadless pacemaker. The pacemaker migrated at one point and it resulted in her chest filling with fluid, the removal procedure was very tough on her (leading to other complications on an already frail body) and marked the beginning of the end for her.

"installed for dubious reasons by a doctor that specialized in this particular type of leadless pacemaker"

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.

It's a double-edged sword. For surgeons, specialization improves outcomes as practice makes perfect. Since this is HN, I'll liken it to using the same programming language daily, versus being asked to fix a bug in a language you last used years ago, within a fixed time window.

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.

That doctor on the care team is usually missing. Actually I would guess that most people don’t have a “care team”. They are referred to a surgeon or other specialist that then does their pet procedure.

I don't think that any profession or system with extensive state-imposed restrictions and regulations (education requirements, medical boards, licensing, exams, continuing education requirements, and so on) should be considered "private".

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.

With private healthcare as you describe, poor people are left with subpar care, and you've got a revolution on your hands. At least I would be very prone to violent action in such a system.

I support affordable universal access to basic healthcare regardless of ability to pay, but you're overestimating the impact of the healthcare system. Up until a few generations ago there was no real "system" at all, and treatments frequently caused more harm than benefit. This wasn't a significant cause of violent revolutions.

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).

Sure, but not long ago medical care was essentially useless even for rich people. If now, poor people see rich people get cured while they die or suffer major consequences from common illnesses, I don't think that's gonna go well.

Yeah I can confirm that as well.

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.

It isn't quite as bad as you paint but there is truth in what you say. This is simply Goodhart's Law in action. We've made fee for service the model which means the only way to make money is to see more patients. Pumping patients through as fast as possible isn't conducive to care and you don't have time to give a shit. We need to fix this by moving care to the mid and low levels as much as possible so that we can still pay people and have better care.

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.

Also, anecdotal, but worth adding...

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.

My parents always warned me, based on their own experience, that you need a healthy family member watching doctors and nurses like a hawk at all times, looking into the drugs and dosages they're prescribing, and even doing work on diagnoses, to make sure they don't kill you, and that it was extremely risky not to have a competent, dedicated advocate of this sort around. I was always a little skeptical of this.

Now that I've had a little more experience with doctors and hospitals, I'd say they were spot-on.

I gather you are not a healthcare professional, hence the artificial dichotomy stemming from your perception as an outsider. Medical competency is very difficult to assess objectively. You're good/bad because people say so. There isn't any form of performance feedback.

Anecdote here, but my friend who is an anesthesiologist (MD) says:(1) anesthesiologists know exactly who the good and bad surgeons are (they see the outcomes and also must manage fluid loss), and (2) bedside manner by surgeons has no correlation to good surgical technique so patients have no idea.

Am also MD and anesthesiologist. This is partly true. The true part is because anesthesiologists are more able to appreciate medical abilities than the layman is. The false part is that people, including colleagues, tend to judge on what they see and hear. Oftentimes, you won't work every day with the same surgeon, so you actually have no idea regarding success/failure statistics.

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.

I believe "wary" is the work you're looking for. This means the are guarded and maybe suspicious.

Weary means tired.

Yes thanks, autocorrect :-)

*"ought-to-correct""

Judging surgeon competency is much easier than judging physician competency, and physicians make up a much larger share of "medical doctors" than surgeons.

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 work at a medical device company and I also had reps warn me of certain surgeons when I looked for one for a friend.

There are lots of reasons why it is not easy to determine surgeon performance but it's not impossible.

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.

From everyday work experience, I strongly believe people to be totally unable to fairly assess a surgeon in an everyday clinical context. Looks, manners and personal sympathies are the main drivers for that kind of judgment.

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.

FWIW, in this respect, I'm just relaying from my parents: dad's an ortho trauma surgeon who now runs a trauma department, and mum's an ophthal surgeon. As much as I'd like to claim I'm casually reading the NEJM every day, I've only ever read papers they share with me, which they do at an annoying frequency considering I'm in trading.

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.

> I assume the general silent belief would be that your guy with the spectacular failure is some kind of "take the tough cases" dude?

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.

> No, the silent belief is that he's the worst surgeon we have.

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.

How can that be? A patient gets diagnosed. There's treatment. There's an outcome. That can't be measured? And assessed?

There's data flowing all over the place. But perhaps the lawyers and the insurance stand in the way of improvement?

One example of how it can go wrong:

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.

It's not a legal or insurance issue, it's a data gathering and classification issue. There is no such thing as a standard patient. Especially when it comes to surgical procedures, everyone is unique. We generally don't have ways to accurately assess the impact of factors like patient age, fitness level, body composition, and co-morbid conditions. So instituting a quality measurement system like you describe would have the perverse effect of causing physicians to keep their numbers up by refusing to take the riskiest patients on at all.

Insurance, precisely. Insurance companies are pushing for performance assessment to put pressure on prices. All well and good until you understand that you can't force hospitals/practitioners to all get a random sample of patients. So measurements are biased, and therefore people game the system. In practice, it means all healthcare providers will concentrate on easy cases to lower risk and maximize revenue. So as you see, free market thought doesn't really work in healthcare.

There are too many variables. You could have two people with the same diagnosis but one has a complication. Even if you do everything 'right' the success isn't 100% because there are slight variations in people and diseases.

Agreed. All the more reason to look for patterns of what works or what might not.

The human body is complex. Why not look for as much help as possible?

Collecting the data to explore is massively different than using it to evaluate individual performance.

We don't even know what all the factors are, and we don't have a practical or affordable way to gather and record all that data in a high-quality, consistent manner.

So we don't even start to try?

That's not a good enough reason.

Given the social and financial magnitude the excuse is nearly criminal.

It's always disappointing to see comments like this on HN by arrogant, ignorant technologists who haven't done their homework and fail to understand the complexities of healthcare delivery. Biology is a lot harder than software or engineering. There are many researchers working in this area but outside of a few limited areas they haven't succeeded in creating models that are useful for assessing the quality of individual practitioners. And that generally wouldn't even be useful since healthcare is a team activity where systems matter more than individuals.

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.

https://www.ncqa.org/hedis/

To clarify: We're talking about an industry that only (relatively) recently realized ubiquitous hand santizers was a good idea. And then took additional time to motivated / train staff to use them. Let's keep this in mind.

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.

We do try. But what we've got is not nearly good enough. You underestimate the messiness and overestimate the information retrieval capabilities of healthcare systems.

Oh. I understand the healthcare system's systems are a shitshow. I've seen it first hand. FFS the staff isn't even aware of the importance of sleep (i.e., lights left on, TV left blasting).

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.

> and people who don't give a whiff of a shit

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.

That sounds like too broad a generalization. In their bid to maximize profits and "increase efficiencies" Medical institutions themselves have a huge impact on outcomes. I wish the medical industry was closer to airlines/FAA, which is more effective and investigating accidents and suggesting systemic fixes, instead of the current culture that suggests "That's a bad-apple/negligent doctor. No need to dig deeper into their load or processes. Case closed"

> 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 former will however cover for the latter. Same thing with police unions. That's why it's so hard to prove malpractice.

Also the later group usually gets paid much more because you can do a lot more billable actions or get better performance statistics, if you only pretend to do medicine.