*Do No Harm*

I loved this book, which is written by a neurosurgeon with a knowledge of behavioral economics (he even has designed a talk  “All My Worst Mistakes,” based on Daniel Kahneman’s work).  The subtitle is Stories of Life, Death, and Brain Surgery and the author is Henry Marsh.  Here is one bit:

…as the brain has the consistency of jelly a sucker is the brain surgeon’s principal tool.

Here is another:

All that really matters is that I am as sure as I can be that the decision to operate is correct and that no other surgeon can do the operation any better than I can.  This is not as much of a problem for me now that I have been operating on brain tumours for many years, but it can be a moral dilemma for a younger surgeon.  If they do not take on difficult cases, how will they ever get any better?  But what if they have a colleague who is more experienced?

And another:

Few anaesthetists believe what surgeons tell them.

How about this one?:

‘There are operations where one really doesn’t know what’s going to happen,’ I muttered to Mike.

Highly recommended, it is already out in the UK, in the U.S. coming out in May 2015.  It has made many best of the year lists in the UK.  Here are some related videos.

Comments

Time to post a link to this article again?

http://homepage.psy.utexas.edu/HomePage/Faculty/Swann/docu/brooks-swann.pdf

Von Hippel, W. & Trivers, R. (2011). The Evolution and Psychology of Self-deception. Behavioral and Brain Sciences, 34(1), 1-56

Surgeons probably could not operate if they were not irrationally confident. They need to think they are doing the right thing because they, personally, are the best. The question is whether they should be allowed to. The first half dozen times a team tries a heart transplant, for instance, the patient dies. It takes them a while to get up to speed. Doctors could control that - by insisting that new teams train under old teams, but medicine is run for the benefit of the doctors, not the patients, so they don't do that. You want to give it a try, there is little to stop you.

But it is nice to see their colleagues have a more rational view of their skills:

Few anaesthetists believe what surgeons tell them.

I think the nurses might have something to say too.

The first half dozen times a team tries a heart transplant, for instance, the patient dies. It takes them a while to get up to speed.

Two of the first three heart transplant patients survived the operation satisfactorily. What killed them was not the surgery, but tissue rejection.

"Doctors could control that – by insisting that new teams train under old teams, but medicine is run for the benefit of the doctors, not the patients, so they don’t do that."

Training under more experienced teams is not very helpful beyond the first few years of training. Ultimately there is one lead surgeon on a case and getting good necessarily implies you are the one doing the procedure without supervision in many cases. That is why being on - call as a resident is by far the most educational time one has in medical training. Also, your statement on docs running the system implies a lack of knowledge of how medical training works in the US (i.e., the years of training explicitly subsidize massive inefficient bureaucracies like academic medical centers by using under-paid residents; in comparison the UK and France have extremely different systems with similar levels of training in which hospitals are not the economic beneficiaries)

"I think the nurses might have something to say too"

Anesthetists are physicians who understand cardiac and respiratory physiology much better than surgeons do (it is in fact what they are trained for). Nurses (amongst more routine tasks) administer drugs to a patient at a doctor's order and call the doctor if an issue arises (little thinking involved). In general, a little knowledge is an extremely dangerous tool in the hands of those who do not actually understand human physiology and disease and luckily for us as patients, nurses in general have to follow physician's orders. Arguably, the much greater knowledge that physicians have is still ridiculously insufficient and it is pretty ludicrous that one would advocate lowering the bar given the number of existing medical errors in the system **

**Note: that is not to say that one could not lower labor costs by altering payment systems, importing fully qualified physician labor, capping salaries as in many national health care systems, etc. All of these approaches may have benefits but implying you could use an untrained resource who does a different job (nursing) as a knowledge source on medicine is just naive

"a little knowledge is an extremely dangerous tool in the hands of those who do not actually understand human physiology and disease and luckily for us as patients, nurses in general have to follow physician’s orders"

You do not understand healthcare. Diagnosis relies more upon pattern recognition and then implementation of algorithms memorized from the research literature then it does remember what one read in his Robbins' pathology textbook as a 2nd year medical student. A smart nurse with 20 years of experience is better at diagnosis in a medicine clinic than a physician with a few years experience. The Cochrane Review makes it pretty clear that PAs and Nurse Practitioners are more or less equivalent to general family practice, pediatricians, and outpatient internists.

"A smart nurse with 20 years of experience is better at diagnosis in a medicine clinic than a physician with a few years experience"

Your statement caveats so much that a casual reader will not notice how dangerously disingenuous it is. For example:

"smart nurse"--> allows you to discount the vast majority of nurses who either do not have the training or intelligence to do even basic diagnosis or treatment

"20 years of experience" --> in a very different field from medicine where complex diagnosis and treatment (without the aid of protocols) is mandatory. Google the failure rate for experienced NPs who take the easiest part of the medical licensing exam (a minimum but definitely not sufficient part of training). In other words, this experience is almost valueless and the Cochrane Review's look at cherry picked studies of patients with minor colds isn't exactly compelling data

"better at diagnosis in a medicine clinic" --> No idea what this means as a "medicine clinic" is not a specific term. If you mean, can a nurse notice a cough and cold in a family practice clinic as well as anyone else (family member, stranger on the street) then absolutely yes. If you mean, notice the 1 out of a 100 cases that are actually meaningfully different as a physician's job is (e.g., incipient pneumonia in a 80 year post MVA), then you must be joking (or never employed / worked with nurses). Usually posters like val dela wriggle out of this by saying "oh they will refer the complex cases," but never mention that that casts doubt on the entire purpose of clinic visits (i.e., why not just let ppl self-diagnose and treat minor ailments as they do in many other countries)

Overall, val dela suffers from a ignorance of what he/she doesn't even know. You mention Robbins and pathology but not that that enormous text book is nothing more than background material for 1 class in 2nd year of med school. You should know the principles of that textbook (and if you don't, you shouldn't be anywhere near a patient in a life or death situation) but no one at any time has argued that that is sufficient.

Buy this short book below and this will give you a flavor of what even idiot physicians (and there are many) should be able to handle in a clinical setting (when they won't have the luxury of reading about it in a book):

http://www.amazon.com/Master-Boards-USMLE-Step-3/dp/161865375X/ref=sr_1_1?ie=UTF8&qid=1418414539&sr=8-1&keywords=step+3+usmle

V December 12, 2014 at 9:39 am

Training under more experienced teams is not very helpful beyond the first few years of training.

Sorry but that is incredibly untrue. As seen in the case of the first heart transplant where Christaan Barnard spent several years training with the best surgeons in the US before going home and trying it himself.

"Also, your statement on docs running the system implies a lack of knowledge of how medical training works in the US (i.e., the years of training explicitly subsidize massive inefficient bureaucracies like academic medical centers by using under-paid residents; in comparison the UK and France have extremely different systems with similar levels of training in which hospitals are not the economic beneficiaries)"

Britain also has the same system - where young doctors who don't know a damn thing spend insanely long hours dealing with emergency cases. While older doctors, with decades of experience, are GPs and deal with flu shots. This is entirely to the benefit of the medical system as a whole and to older doctors in particular. It does not serve the public. Who, when they have a real emergency, get some pimply child who has probably been working the past 48 hours without any real sleep. A medical system run for the benefit of the patients would give the flu shots to the child and the emergencies to the competent, qualified, well rested professional.

"In general, a little knowledge is an extremely dangerous tool in the hands of those who do not actually understand human physiology and disease and luckily for us as patients, nurses in general have to follow physician’s orders."

Needless to say you missed my point. You must be a surgeon. Just as no man is a hero to his vallet, I suspect that few doctors are as heroic as they think they are to the people who have to work with them.

"Arguably, the much greater knowledge that physicians have is still ridiculously insufficient and it is pretty ludicrous that one would advocate lowering the bar given the number of existing medical errors in the system **"

Who is advocating lower the bar? I am suggesting that we do not let students treat emergencies and that older doctors should put aside their egos and accept further training - real training. Not what passes for it these days. But it is not going to happen because the system is run by and for those older doctors.

"As seen in the case of the first heart transplant where Christaan Barnard spent several years training with the best surgeons in the US before going home and trying it himself."

No one is saying training is not helpful. The point is that data shows one peaks as a physician relatively young (i.e., soon after residency ends in your early 30s). See this Slate article (or the primary literature) for details:

http://www.slate.com/articles/health_and_science/explainer/2012/12/are_younger_doctors_better_should_old_doctors_be_tested_for_lack_of_competence.html

Anecdotal stories of Christian Barnard are not helpful for showing your point at all

"Britain also has the same system – where young doctors who don’t know a damn thing spend insanely long hours dealing with emergency cases."

I am disputing the pay scales involved and who the economic benefit flows to not the principle of on-call hours (a universal). See links below that show how hospital physicians with similar experience levels to the US make much higher relative salaries while in the equivalent of our residency:

http://bma.org.uk/practical-support-at-work/pay-fees-allowances/pay-scales/sas-england
http://www.telegraph.co.uk/health/nhs/10595090/GPs-pay-Number-of-doctors-earning-100000-has-quadrupled-report-shows.html

"A medical system run for the benefit of the patients would give the flu shots to the child and the emergencies to the competent, qualified, well rested professional"

Agree. The entire system is ridiculous in terms of how it allocates talent but this is to the benefit of hospitals not necessarily physicians (see the point above). Also, one would hesitate to call someone in their 11th year of training, their 30s in age and the top part of the intelligence scale a "child" in general though I see where you are coming from.

"You must be a surgeon. Just as no man is a hero to his vallet, I suspect that few doctors are as heroic as they think they are to the people who have to work with them"

Agree with your point about heroism. That said, your point does not mean that the people who have to work with them actually know what they are talking about. After all, a pilot is not necessarily a hero to the stewardess on the plane but that does not mean she knows much about flying even with 20 years of experience

"I suspect that few doctors are as heroic as they think they are to the people who have to work with them."

I'm a lay person who's worked closely with doctors for a quarter century, and I am more in awe of them today than ever. I've witnessed bad judgement, personality flaws, etc. But nothing can diminish my admiration for their hard work, intellect, and their general commitment to the ethical practice of medicine. Even the bastards make personal sacrifices to do the right thing, while the run-of-the-mill look for opportunities to do the kind of good that is not available to those of us who are not doctors. The OR nurses who work as part of a regular surgical team know their guys' negative character traits intimately, but you find a lot of hero worship -- even among among the old timers. In short, my long and daily experience with doctors leaves me with the impression that they are the most conscientious profession, the hardest working, and most self-sacrificing. Quality doctors are not a given in society. Nobody is forced to undergo years of training for the privilege of treating your anal fissures. It is kind of a miracle that we have these people.

with decades of experience, are GPs and deal with flu shots.

I cannot recall ever receiving a shot of any description from someone who did not have the initials "RN" or "RNNP" after her name. My primary care physicians have always given interviews, poked around with their instruments and arranged referrals. Nowadays, they hardly take their eyes off the electronic medical record.

And move to Upstate New York, where there is a class of older physicians who work the emergency room.

Few anaesthetists believe what surgeons tell them.

Coincidentally, a friend is an anaesthetist and he said there are many jokes going on about the surgeons. And that he was quite surprised to figure out that it is for a reason when he attended some anaesthetist conference where a surgeons conference was taking place in the same building at the same time. Somehow he was totally unimpressed by the level of their lectures...
Just a different point of view...

'the brain surgeon’s principal tool'

Here I was, thinking the principal tools required involved getting the skull out of the way, so that the brain surgeon could actually get to the brain. Like this - http://en.wikipedia.org/wiki/Craniotome_(tool)

I suspect that getting the skull out of the way is a lot like taxiing an airplane on the runway: a necessary first step, but not where the real skill is needed.

Being nearly old myself, I'm not going to disagree with the lesson that experience matters. Of course, it's the opposite of today's popular lesson, that youth aren't burdened by the mistakes of the experienced and are willing to take risks the experienced would avoid. How many different ways can the Book of Proverbs be re-written?

Today's column by David Brooks was written with Cowen in mind: "Behavioral economics policies are beautiful because they are small and concrete but powerful. They remind us that when policies are rooted in actual human behavior and specific day-to-day circumstances, even governments can produce small miracles."

@rayward- I've never read much by David Brooks, but isn't he just a mealy mouthed toad stating the obvious, a kind of unlearned Francis Fukuyama?

"The obvious" is not obvious to those not well versed in a subject. Sometimes what is obvious to the expert in a field is not so much obvious as it is the product of culture/indoctrination.

Sometimes what is obvious to the expert in a field is not so much obvious as it is the product of culture/indoctrination - See more at: http://marginalrevolution.com/marginalrevolution/2014/12/do-no-harm.html#comment-158421722

Until the British brain surgery book comes out, here is a great book on behavioral econ covering healthcare written by an economist business school Prof at Johns Hopkins: Hough, "Irrationality in Health Care: What Behavioral Economics Reveals About What We Do and Why" (Stanford University Press). Really good analysis and excellent summary of literature.

"it can be a moral dilemma for a younger surgeon. If they do not take on difficult cases, how will they ever get any better? But what if they have a colleague who is more experienced?"

This dilemma arises in every field. In my business, we are fond of the saying "Well, we're not surgeons. No one died." I suppose this doesn't work so well for them.

If they do not take on difficult cases, how will they ever get any better !!!

Even worse, at times when high risk & highly complicated patients/procedures need to be done you realize NO ONE has significant experience in doing it. You maybe as good as anyone else & you have little to no experience in the specific case in question. In that instance you only proceed if you believe you have sufficient experience in cases approaching the complexity of the current case & it is impractical to try to "ship" the case elsewhere(too emergent, or no else has real experience either). And yes anesthesiologists take what some/many surgeons tell them with a grain(or shaker full) of salt- it is best to do high risk cases with a surgeon you have built a good relationship with- in an emergency it is best if everyone knows what "I am having a little trouble/some blood loss..." etc really means.

Along the lines of "first, do no harm," I guess this is as good a place to put this as any: Medical decisions are influenced by industry money. This mostly takes the form of prescribing decisions influenced by gifts from drug industry reps. They can be free lunches, textbooks, payments for nominal "advisory" roles, etc. The evidence that these gifts influence clinical decision making--and for the worse--is very clear. But there is also evidence that physicians think they are not influenced by gifts, though they believe their colleagues are influenced by such inducements. Cognitive dissonance. It's harming health care, driving up spending and there isn't much good reason for it. Industry can disseminate info about therapies without bribing doctors to listen.

Anyway, a revised Hippocratic Oath should include "First, do no pharm."

Hell of a setup, but A+ punch line

It ain't the pens, books or lunches that are the problem- they only get the rep in the door- it is the paid gigs mainly to academics/"experts" that are more of a problem- read about norian scandal. The idea that docs sell their soul for pens or a lunch is baloney. We all know terrible reps with a great product & very good reps stuck pushing a turkey.

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