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.