Comments on: My take: Incentives, hospitalists, probabilities http://www.kevinmd.com/blog/2008/02/my-take-incentives-hospitalists.html medical blog Mon, 23 Nov 2009 01:35:28 -0500 http://wordpress.org/?v=2.8.4 hourly 1 By: Anonymous http://www.kevinmd.com/blog/2008/02/my-take-incentives-hospitalists.html/comment-page-1#comment-84180 Anonymous Thu, 13 Mar 2008 03:49:00 +0000 http://clients.emmense.com/kevinmd/2008/02/my-take-incentives-hospitalists-probabilities.html#comment-84180 I am a senior resident in a surgical specialty, I like what I do, but honestly if I could go back in time there is no way I would go into medicine knowing what I know now. <br/><br/>The lawyers are more an indicator of a problem rather than the problem itself. The way I see it, the problem is that the patients don't seem to appreciate our work, they rarely show any gratitude, and the smallest misstep on the physician's part will be used against him without fail. <br/><br/>In the end such experiences and the surgical training produce excellent surgeon-technicians, but cynical and noncaring human beings. It is a struggle trying to stay engaged and caring. This is a situation that makes me very uncomfortable, makes me want to leave the US and go work somewhere in a 3rd world country. I am a senior resident in a surgical specialty, I like what I do, but honestly if I could go back in time there is no way I would go into medicine knowing what I know now.

The lawyers are more an indicator of a problem rather than the problem itself. The way I see it, the problem is that the patients don’t seem to appreciate our work, they rarely show any gratitude, and the smallest misstep on the physician’s part will be used against him without fail.

In the end such experiences and the surgical training produce excellent surgeon-technicians, but cynical and noncaring human beings. It is a struggle trying to stay engaged and caring. This is a situation that makes me very uncomfortable, makes me want to leave the US and go work somewhere in a 3rd world country.

]]> By: Anonymous http://www.kevinmd.com/blog/2008/02/my-take-incentives-hospitalists.html/comment-page-1#comment-83782 Anonymous Wed, 20 Feb 2008 19:23:00 +0000 http://clients.emmense.com/kevinmd/2008/02/my-take-incentives-hospitalists-probabilities.html#comment-83782 If you can't scan everyone, you can probably check a patient with sudden onset tearing pain in the middle of the body and dramatically elevated blood pressure, for asymmetric blood pressure.<br/><br/>Find that, and it's a scanning.... and that's a cheap and side-effect free way of boosting the chances of catching a dissection.<br/><br/>The doomed patient had her vitals taken once on intake, by a tech. There were never taken by the physician, addressed in any way, nor ordered to be taken again, and no opposite arm reading was ever taken. If you can’t scan everyone, you can probably check a patient with sudden onset tearing pain in the middle of the body and dramatically elevated blood pressure, for asymmetric blood pressure.

Find that, and it’s a scanning…. and that’s a cheap and side-effect free way of boosting the chances of catching a dissection.

The doomed patient had her vitals taken once on intake, by a tech. There were never taken by the physician, addressed in any way, nor ordered to be taken again, and no opposite arm reading was ever taken.

]]> By: Yep, there's at least a little more http://www.kevinmd.com/blog/2008/02/my-take-incentives-hospitalists.html/comment-page-1#comment-83763 Yep, there's at least a little more Wed, 20 Feb 2008 08:43:00 +0000 http://clients.emmense.com/kevinmd/2008/02/my-take-incentives-hospitalists-probabilities.html#comment-83763 A couple of points about the dissection case - <br/><br/>you wrote "A patient presented to the emergency room with back pain, and died of a missed aortic dissection. The likelihood of such an occurrence would be about two in 10 million. "<br/><br/> Even the unnamed son-in-law noted that the severe back pain raised the liklihood from the general "females of a certain age" statistic he threw out (with little to support it)<br/><br/>And at least one other risk factor was present - the deceased in question had a blood pressure of 208/89. <br/><br/>A few more details are available which would not color the case in the doctor's favor. <br/><br/>But that <i>statistic</i> does not really apply at all to the (deceased) patient in question. A couple of points about the dissection case –

you wrote “A patient presented to the emergency room with back pain, and died of a missed aortic dissection. The likelihood of such an occurrence would be about two in 10 million. “

Even the unnamed son-in-law noted that the severe back pain raised the liklihood from the general “females of a certain age” statistic he threw out (with little to support it)

And at least one other risk factor was present – the deceased in question had a blood pressure of 208/89.

A few more details are available which would not color the case in the doctor’s favor.

But that statistic does not really apply at all to the (deceased) patient in question.

]]> By: Anonymous http://www.kevinmd.com/blog/2008/02/my-take-incentives-hospitalists.html/comment-page-1#comment-83750 Anonymous Wed, 20 Feb 2008 02:07:00 +0000 http://clients.emmense.com/kevinmd/2008/02/my-take-incentives-hospitalists-probabilities.html#comment-83750 Jocelyn, pick a better anecdote to make that argument. No way is there enough info to make a judgement call on that case, and there *are* circumstances possible which would make sending that pt home without even recommending and x-ray, inexcusable, even in a female under 45 Jocelyn, pick a better anecdote to make that argument. No way is there enough info to make a judgement call on that case, and there *are* circumstances possible which would make sending that pt home without even recommending and x-ray, inexcusable, even in a female under 45

]]> By: Anonymous http://www.kevinmd.com/blog/2008/02/my-take-incentives-hospitalists.html/comment-page-1#comment-83741 Anonymous Tue, 19 Feb 2008 22:57:00 +0000 http://clients.emmense.com/kevinmd/2008/02/my-take-incentives-hospitalists-probabilities.html#comment-83741 "There must be a higher burden of proof for cases like this, where it's precisely the doc's judgement that they are paid for..."<br/><br/>Cases like what? You know literally nothing about this case but one person who wasn't involved's take. This is how you make policy? “There must be a higher burden of proof for cases like this, where it’s precisely the doc’s judgement that they are paid for…”

Cases like what? You know literally nothing about this case but one person who wasn’t involved’s take. This is how you make policy?

]]> By: Donna http://www.kevinmd.com/blog/2008/02/my-take-incentives-hospitalists.html/comment-page-1#comment-83737 Donna Tue, 19 Feb 2008 20:27:00 +0000 http://clients.emmense.com/kevinmd/2008/02/my-take-incentives-hospitalists-probabilities.html#comment-83737 It would be nice if people would stop using the ER as a Dr's office for every ache and pain. No your headache..menstrual cramps, runnynose is not an Emergency!!<br/>Donna G RDH It would be nice if people would stop using the ER as a Dr’s office for every ache and pain. No your headache..menstrual cramps, runnynose is not an Emergency!!
Donna G RDH

]]> By: Suicide Malpractice http://www.kevinmd.com/blog/2008/02/my-take-incentives-hospitalists.html/comment-page-1#comment-83729 Suicide Malpractice Tue, 19 Feb 2008 13:39:00 +0000 http://clients.emmense.com/kevinmd/2008/02/my-take-incentives-hospitalists-probabilities.html#comment-83729 Outcome bias is the tendency, even in experts, to seek to find blame as an outcome is horrible. <br/><br/>http://en.wikipedia.org/wiki/Outcome_bias<br/><br/>The Supreme Court has held that civil defendants have procedural due process rights. One of them is a right to a fair hearing. The outcome bias of scapegoating plaintiffs and plaintiff experts violates such a right.<br/><br/>The second holding of the Court is that clinical decisions require deference and a presumption of correctness. <br/><br/>The aortic dissection case should be appealed as a violation of Supreme Court holdings. Outcome bias is the tendency, even in experts, to seek to find blame as an outcome is horrible.

http://en.wikipedia.org/wiki/Outcome_bias

The Supreme Court has held that civil defendants have procedural due process rights. One of them is a right to a fair hearing. The outcome bias of scapegoating plaintiffs and plaintiff experts violates such a right.

The second holding of the Court is that clinical decisions require deference and a presumption of correctness.

The aortic dissection case should be appealed as a violation of Supreme Court holdings.

]]> By: jocelyn http://www.kevinmd.com/blog/2008/02/my-take-incentives-hospitalists.html/comment-page-1#comment-83727 jocelyn Tue, 19 Feb 2008 09:33:00 +0000 http://clients.emmense.com/kevinmd/2008/02/my-take-incentives-hospitalists-probabilities.html#comment-83727 Just as there will always be mistakes, and doctors play probabilities, there will always be lawyers waiting around to make their money off of that uncertainty - I don't think it's the medical system gone wrong, I think it's the legal system. There must be a higher burden of proof for cases like this, where it's precisely the doc's judgement that they are paid for... isn't it hypocritical to train, hire and retain docs specifically for their judgement and then sue them when they use it? Just as there will always be mistakes, and doctors play probabilities, there will always be lawyers waiting around to make their money off of that uncertainty – I don’t think it’s the medical system gone wrong, I think it’s the legal system. There must be a higher burden of proof for cases like this, where it’s precisely the doc’s judgement that they are paid for… isn’t it hypocritical to train, hire and retain docs specifically for their judgement and then sue them when they use it?

]]> By: Health Punk http://www.kevinmd.com/blog/2008/02/my-take-incentives-hospitalists.html/comment-page-1#comment-83722 Health Punk Tue, 19 Feb 2008 02:46:00 +0000 http://clients.emmense.com/kevinmd/2008/02/my-take-incentives-hospitalists-probabilities.html#comment-83722 1. The part everyone seems to forget with incentives is that you will get exactly what you design to an extreme...often to the detriment of things not incentivized. The key question when designing incentives is to ask "What are we not incentivizing, and are we comfortable with the consequences of ignoring those things?" The other thing to do (something we've done) is to ask people what they'd do to "game the system" (anonymously) when presented with a particular model.<br/><br/>Actually, in process/quality improvement, this is one of the reasons why E. Deming opposed "management by objective" approaches.<br/><br/>2. Hospitalists rock. We need to share incentives (share risk?) in some fashion to motivate the behaviors that fat doctor refers to (preventing unnecessary hospitalizations). <br/><br/>3. Liability caps are needed. 1. The part everyone seems to forget with incentives is that you will get exactly what you design to an extreme…often to the detriment of things not incentivized. The key question when designing incentives is to ask “What are we not incentivizing, and are we comfortable with the consequences of ignoring those things?” The other thing to do (something we’ve done) is to ask people what they’d do to “game the system” (anonymously) when presented with a particular model.

Actually, in process/quality improvement, this is one of the reasons why E. Deming opposed “management by objective” approaches.

2. Hospitalists rock. We need to share incentives (share risk?) in some fashion to motivate the behaviors that fat doctor refers to (preventing unnecessary hospitalizations).

3. Liability caps are needed.

]]> By: DDx:dx http://www.kevinmd.com/blog/2008/02/my-take-incentives-hospitalists.html/comment-page-1#comment-83719 DDx:dx Mon, 18 Feb 2008 22:03:00 +0000 http://clients.emmense.com/kevinmd/2008/02/my-take-incentives-hospitalists-probabilities.html#comment-83719 #1. I appreciate the new Kevin format of reflection and position statement. While I don't always agree, you are concise and readable. And I have noted an evolution in your thinking which is, what I believe we all(Patient, physician, policy maker) need.<br/>#2 Hospitalist. I believe in continuity. The hospitalist is another chink in that grand plan. And, the point that the new graduate is not "Office Skilled" is well taken. It can take years to become good at office practice. But the two should not be considered separate specialties. The hospitalization of a patient well known to the physician should be under the care of "the expert" in the patient.<br/>3. Malpractice fear is the community physician's displaced fear of authority, like the medical student's fear of the chief resident and the resident's fear of the attending. I always believed these fear based teaching situations were to help us learn who "WE", the physician was, not to inculcate a persistent fear of authority...But alas... #1. I appreciate the new Kevin format of reflection and position statement. While I don’t always agree, you are concise and readable. And I have noted an evolution in your thinking which is, what I believe we all(Patient, physician, policy maker) need.
#2 Hospitalist. I believe in continuity. The hospitalist is another chink in that grand plan. And, the point that the new graduate is not “Office Skilled” is well taken. It can take years to become good at office practice. But the two should not be considered separate specialties. The hospitalization of a patient well known to the physician should be under the care of “the expert” in the patient.
3. Malpractice fear is the community physician’s displaced fear of authority, like the medical student’s fear of the chief resident and the resident’s fear of the attending. I always believed these fear based teaching situations were to help us learn who “WE”, the physician was, not to inculcate a persistent fear of authority…But alas…

]]>