Why Doctors Hate Science

[Mouthfire]

All I know is that the doctors here in Boulder are obviously woefully undertrained in incentivived.

When I went in for my allergies the doctor suggest I waterboard myself, I mean buy a cheap nasal irrigation thingy at Walgreens, rather than take drugs that he could prescribe.

When I was in the hospital recently the doctor mentioned a bunch of tests he could do, but then advised me not to do them because other symptoms would rear their head in plenty of time if I had anything those tests would find.

When wunky was in the hospital yesterday the doctor spent a lot of time in examination eliminating tests that he could perform, and then advised her that an over the counter medicine would actually be better than anything he could prescribe her.

Who trained these people????

I hope you're being sarcastic..... I would LOVE a doctor like that....

 

[Ivor the Engineer]

Sources for my previous post:

http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

The focus of the present study is to examine whether supplier-induced demand exists for primary care physician services in Norway. We compare how two groups of physicians, with and without incentives to induce, respond to increased competition. Contract physicians receive their income from fee-for-item payments. They have an incentive to compensate for a lack of patients by inducing demand for services. Salaried physicians receive a salary which is independent of output. Even though increased competition for patients reduces the availability of patients, they have no financial incentive to induce. Neither of the two groups of physicians increased their output as a response to an increase in physician density. This result could be expected for salaried physicians, while it provides evidence against the inducement hypothesis for contract physicians.

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

The ultimatum game is an experimental economics game in which two players interact to decide how to divide a sum of money that is given to them. The first player proposes how to divide the sum between themselves, and the second player can either accept or reject this proposal. If the second player rejects, neither player receives anything. If the second player accepts, the money is split according to the proposal. The game is played only once, and anonymously, so that reciprocation is not an issue.

...

Experimental results

In many cultures, people offer "fair" (i.e., 50:50) splits, and offers of less than 20% are often rejected.[2] Research on monozygotic and dizygotic twins has shown that individual variation in reactions to unfair offers is partly genetic.[3]

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

The dictator game is a very simple game in experimental economics, similar to the ultimatum game. Experimental results in the dictator game have often been cited as a conclusive rebuttal of the rationally self-interested individual (homo economicus) model of economic behavior,[1] although this conclusion is controversial.[2]

In the dictator game, the first player, "the proposer", determines an allocation (split) of some endowment (such as a cash prize). The second player, "the responder", simply receives the remainder of the endowment not allocated by the proposer to himself. The responder's role is entirely passive (he has no strategic input into the outcome of the game). As a result, the dictator game is not formally a game at all (as the term is used in game theory). To be a game, every player's outcome must depend on the actions of at least some others. Since the proposer's outcome depends only on his own actions, this situation is one of decision theory and not game theory. Despite this formal point, the dictator game is used in the game theory literature as a degenerate game.

This game has been used to test the homo economicus model of individual behavior: if individuals were only concerned with their own economic well being, proposers (acting as dictators) would allocate the entire good to themselves and give nothing to the responder. Experimental results have indicated that individuals often allocate money to the responders, reducing the amount of money they receive.[3] These results appear robust: for example, Henrich, et al. discovered in a wide cross cultural study that proposers do allocate a non-zero share of the endowment to the responder.[1]

If these experiments appropriately reflect individuals' preferences outside of the laboratory, these results appear to demonstrate that either:

1. Proposers fail to maximize their own expected utility, or
2. Proposer's utility functions include benefits received by others.

Additional experiments have shown that subjects maintain a high degree of consistency across multiple versions of the dictator game in which the cost of giving varies.[4] This suggests that dictator game behavior is, in fact, altruism instead of the failure of optimizing behavior. Other experiments have shown a relationship between political participation and dictator game giving, suggesting that it may be an externally valid indicator of concern for the well-being of others.[5][6]

Results for the trust game:

http://www.pnas.org/content/105/10/3721.figures-only

 

[luchog]

I think there is a genuine problem, but also a resistance born more of machismo from some older doctors. If they went through that hell in order to get where they are, then so should younger doctors. Like some sort of bizarre initiation rite.

I know that that "it was good enough for me, and it's good enough for them" attitude is far too common; but it's not the only reason for long hours. There's also the "stress test" aspect to it. Medicine can be very stressful at times; particularly if one is working in certain fields. The long hours and grueling work can be a way of weeding out those who are less dedicated, and less able to handle the stresses of, say, an emergency room at peak capacity.

Obviously there needs to be a balance between the stress test, and working someone so hard that fatigue and overload results in otherwise easily avoidable, and potentially fatal, errors.

And, of course, there's the training issue mentioned earlier. 48 hours per week results in a lot less training and experience than 70 or 80 hours a week; which means extending the training period by a year or more; or accepting less experienced doctors into a field where "learning on the job" is not a desirable modus.

 

[luchog]

I thought geeks were those side-show performers who pounded nails into their nasal cavities?

Linda

No, that's a "Blockhead". "Geek" was the industry term for what was typically billed as a "Wild Man"; and was the one who bit heads off of animals or ate large insects; and later came to include performers of actions which the viewers would find repugnant or horrific, but still entertaining.

 

[dudalb]

I do find it amusing that UK docs are complaining about a 48hour work week. When I started residency, I regular went through a 100 work week and the surgeons regularly went higher. The 80hour max work week rule came to my hospital half way through my residency and it was such a major change.

48hours a week is not enough for certain specialties and I see signs that a 80hour work week may well not be enough. I think it is barely enough for pediatricians, ER docs and General Internists, but for a Surgeon, even with 5-6years of residency, I'm seeing some of new grads lack certain skills that was once expected from the older generation.

One of my Doctors Joined the Marine Corps before going to College, and he described being an Intern as the Medschool answer to Parris Island.

 

[T.A.M.]

One of my Doctors Joined the Marine Corps before going to College, and he described being an Intern as the Medschool answer to Parris Island.

an intern is the worst.

All the responsibilities of a full fledged Staffman (for the most part), with little of the experience, and none of the respect from the others (nurses, techs, Janitors...lol) you work with. Hurrendous hours, can't complain or it gets worse...oh those were the days...lol

TAM

 

[Dancing David]

Do you think there's an under supply of physicians?

If so, what do you think are the causes and how may they be mitigated?

(I'm listening)

Wow, in th US there are a number of issues.

First off dioctors are not seen as making as big an income as lawyers, financial officers and other professions. So there are not as many people who want to be doctors.
Second many qualified individuals choose to go into a specialty, so they are not GPs doing internal medicine. They are seeing a select group of pateints often for a higher salary and better hours.
Third, a lot of people don't want to be on call or have the work hours, or the caseload of a GP.
Fourth, there is not as much pretige in being a doctor in recent times.
Fifth, renumeration from thrid party payors. Mainly the government, Medicare and Medicaid, the burden of paper work is huge, the fees are capitated, and they are often 50% to 25% of what private insurance pays. Consequence, limited access for people on government insurance.
Sixth group practices are easier for doctors, they have less call time and smaller case loads. But they also are the most likely to refuse the government insured patients.
Seventh, the lack of general health insurance. creates a heavy burden on doctors who do see uninsured and underinsured patients.

Those are just some of the reasons why there are not enough doctors or there are not doctors who are willing to see government insured or no insurance patients.

 

[Ivor the Engineer]

Could someone please explain what an 80 hour week means for a physician in a hospital? How many of those hours are spent resting?

Compare the hours doctors are expected to work with airline pilots:

http://ecfr.gpoaccess.gov/cgi/t/tex...e=14:2.0.1.3.10&idno=14#14:2.0.1.3.10.11.8.32

§ 91.1059 Flight time limitations and rest requirements: One or two pilot crews.

(a) No program manager may assign any flight crewmember, and no flight crewmember may accept an assignment, for flight time as a member of a one- or two-pilot crew if that crewmember's total flight time in all commercial flying will exceed—

(1) 500 hours in any calendar quarter;

(2) 800 hours in any two consecutive calendar quarters;

(3) 1,400 hours in any calendar year.

(b) Except as provided in paragraph (c) of this section, during any 24 consecutive hours the total flight time of the assigned flight, when added to any commercial flying by that flight crewmember, may not exceed—

(1) 8 hours for a flight crew consisting of one pilot; or

(2) 10 hours for a flight crew consisting of two pilots qualified under this subpart for the operation being conducted.

(c) No program manager may assign any flight crewmember, and no flight crewmember may accept an assignment, if that crewmember's flight time or duty period will exceed, or rest time will be less than—

|Normal duty|Extension of flight time
(1) Minimum Rest Immediately Before Duty|10 Hours|10 Hours.
(2) Duty Period Up to|14 Hours|Up to 14 Hours.
(3) Flight Time For 1 Pilot|Up to 8 Hours|Exceeding 8 Hours up to 9 Hours.
(4) Flight Time For 2 Pilots Up to|10 Hours|Exceeding 10 Hours up to 12 Hours.
(5) Minimum After Duty Rest|10 Hours|12 Hours.
(6) Minimum After Duty Rest Period for Multi-Time Zone Flights|14 Hours|18 Hours.

And here's a study indicating how physicians working long hours significantly affects their performance:

http://content.nejm.org/cgi/content/abstract/351/18/1838

Background Although sleep deprivation has been shown to impair neurobehavioral performance, few studies have measured its effects on medical errors.

Methods We conducted a prospective, randomized study comparing the rates of serious medical errors made by interns while they were working according to a traditional schedule with extended (24 hours or more) work shifts every other shift (an "every third night" call schedule) and while they were working according to an intervention schedule that eliminated extended work shifts and reduced the number of hours worked per week. Incidents were identified by means of a multidisciplinary, four-pronged approach that included direct, continuous observation. Two physicians who were unaware of the interns' schedule assignments independently rated each incident.

Results During a total of 2203 patient-days involving 634 admissions, interns made 35.9 percent more serious medical errors during the traditional schedule than during the intervention schedule (136.0 vs. 100.1 per 1000 patient-days, P<0.001), including 56.6 percent more nonintercepted serious errors (P<0.001). The total rate of serious errors on the critical care units was 22.0 percent higher during the traditional schedule than during the intervention schedule (193.2 vs. 158.4 per 1000 patient-days, P<0.001). Interns made 20.8 percent more serious medication errors during the traditional schedule than during the intervention schedule (99.7 vs. 82.5 per 1000 patient-days, P=0.03). Interns also made 5.6 times as many serious diagnostic errors during the traditional schedule as during the intervention schedule (18.6 vs. 3.3 per 1000 patient-days, P<0.001).

Conclusions Interns made substantially more serious medical errors when they worked frequent shifts of 24 hours or more than when they worked shorter shifts. Eliminating extended work shifts and reducing the number of hours interns work per week can reduce serious medical errors in the intensive care unit.

How many extra physicians would be required to bring their working week down to 48 hours?

 

[T.A.M.]

an 80h work week varies from physician to physician.

Surgeon:

Mon to Fri

Morning Rounds from 6-730AM
Surgery prep from 730-800AM (case review, etc..)
Surgery from 800AM-600PM
Evening Rounds from 600-700PM

13h day, x 5 days = 65h

Saturday - Morning Rounds 800-900AM
Saturday - Afternoon Paper Work 12PM-3PM
Sunday - off

= 4h

A total of 69h.

You add in a MINIMUM of "on call" once a week, and you easily have your other 11 hours

Now that is a busy surgeon, likely without residents or interns as support staff (a rural surgeon for instance).

city GP:

Mon-Fri

8AM-4PM = Clinic
4-5PM = Paperwork

9x5 = 45h

On Call 1 in 4, that is an additional 12h every 4 days, or 24h every 8 days.

so roughly 69-70h per week (though not all of that is straight work, but some bad nights on call it can be).

Rural GP:

Mon to Fri

7-8AM = Hospital Rounds
8AM-4PM = Clinic/Out Patients
4-5PM = Paper Work

10h/day x 5 days = 50h

1 in 3 on call = 24h every 6 days of extra call. On average you are awake and working half of this, so call it 12h work, 12h waiting to work.

Giving an average of 62-74h per week depending on how you look at it.

See how hard it is to quantify. I am sure there are things in the Surgeon (as I am not one) category I may be leaving out.

TAM

 

[Skeptic Ginger]

....

My main dog in this race is my abhorrence with the art of coercing doctors to do what vested-interest laced guidelines demand. I think good doctors should be truly free to follow their clinical judgment. It should not cut into their paycheck if they see that a certain patient needs a treatment approach that deviates from the usual guidelines.

I think you misunderstand what guidelines are all about. You wouldn't follow them if they didn't fit the patient's needs. That's silly. You follow guidelines because it keeps your practice up to date with the best/latest research.

 

[Skeptic Ginger]

That's another good example.

I said: People with knowledge and experience have provided useful and interesting information.

You heard: People should be sub-ordinate to authority figures....

And then there is the matter of some patients wanting that paternalistic provider. I often have patients defer decisions back to me when I try to give them the information to make their own informed choice.

 

[BillyJoe]

Originally Posted by kellyb
My main dog in this race is my abhorrence with the art of coercing doctors to do what vested-interest laced guidelines demand. I think good doctors should be truly free to follow their clinical judgment. It should not cut into their paycheck if they see that a certain patient needs a treatment approach that deviates from the usual guidelines.

I think you misunderstand what guidelines are all about. You wouldn't follow them if they didn't fit the patient's needs. That's silly. You follow guidelines because it keeps your practice up to date with the best/latest research.

I already tried that response.
But it ran smack up against Ivor's favourite ploy, which is to post more links..
The other point is how does the clinical judgement of one doctor trump the guidelines produced by many doctors (before seeing whether or not applies to the particular patient belonging to the one)

BJ

 

[Ivor the Engineer]

And then there is the matter of some patients wanting that paternalistic provider. I often have patients defer decisions back to me when I try to give them the information to make their own informed choice.

To all the medical practitioners in the thread:

What fraction of your patients would you estimate want a paternalistic provider?

 

[paximperium]

To all the medical practitioners in the thread:

What fraction of your patients would you estimate want a paternalistic provider?

Don't know. Perhaps you'd like to do a study on that?

I've always founds it amusing to treat patients taking twenty meds, had ten surgeries done to them and they have no clue what medical problems they have or what the surgeries were for.

 

[BillyJoe]

If my father was and my mother is anything to go by, it is 100%
My son, however, knows everything there is to know about his thyroglossal cyst.

 

[Ivor the Engineer]

Thanks TAM for the breakdown of doctors' working hours.

I've been reading several opinion pieces, reports and presentations about how the European Working Time Directive (EWTD) is going to affect the training of physicians and continuity of patient care in the NHS. There appears to be three main types of response:

1) It will result in poorly trained, incompetent doctors and no continuity of care for patients. - Mainly in newspapers, though not uncommon among doctors, particularly those still in the early stages of their careers.

2) Work smarter not harder. - Seems to be a minority at the moment, but those hospitals that have started to implement new systems have found it is possible to organise both doctors' training and patient care in 48 hours. It is a BIG change from how things have been done in the past. E.g., doctors have to actually talk with each other and previously wasted training opportunities have to be utilised, as well as removing training which was of little value (i.e. not every consultant should be considered a useful teacher).

3) **** the EU.

In the long run I think it will result in both happier medical professionals and better patient care, though dragging the medical profession into the 21st century is going to be a struggle.

 

[Ivor the Engineer]

Don't know. Perhaps you'd like to do a study on that?

<snip>

That's why I was asking you.

 

[T.A.M.]

To all the medical practitioners in the thread:

What fraction of your patients would you estimate want a paternalistic provider?

Given I am relatively young (in practice for 8 years), my population base is very young. I find the younger the patient, the LESS likely they want a paternalistic MD, and the more likely they want a PARTNER in their medical care.

I would say about 30% of my practice wants a father figure physician.

TAM

 

[paximperium]

That's why I was asking you.

I'm ER doc so the variation is too wide to draw a firm conclusion.
Older, lower educated and poorer patients tend to want you to tell them what to do more than younger, educated and more affluent patients who wants to be more involved.

 

[Dancing David]

No, that's a "Blockhead". "Geek" was the industry term for what was typically billed as a "Wild Man"; and was the one who bit heads off of animals or ate large insects; and later came to include performers of actions which the viewers would find repugnant or horrific, but still entertaining.

Like Celine Dion or Rush Limbaugh?