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Just Numbers

March 4, 2015

Medicine is obsessed with numbers.  Or rather, journalists and medical administrators are.  Here are two related examples of how large a grain of salt one must put on numbers.

Cardiac surgical procedures, like everything else in medicine, have quality indicators.  One of these is what we doctors call “30-day mortality”.  What this term means is that surgeons are evaluated in part on how many of the patients they operated on died within a month of having surgery.  Presumably a surgeon whose patients rarely die within 30 days is a better surgeon than one whose patients die all the time.  The American Academy of Hospice and Palliative Medicine, whose members deal frequently with the elderly, thinks this number, 30, harms old people.  The problem, according to Paula Span of the New York Times, is that surgeons refuse to operate on people who are more likely to die within 30 days, and that they keep patients alive in ICUs until day 31 to keep their numbers up.  Bad doctors!

The problem with the number 30 is not that it’s to short or too long, it is that it is a terrible metric for quality.  Patients die despite everyone’s best efforts, especially patients who are at higher risk for dying to begin with.  We need to find a metric that actually reflects quality of care.  Of course doctors are going to be leery of operating on really sick people, if their jobs are at stake!  I know people would like for doctors to be saints who take care of everyone all the time with nary a pecuniary thought, but I’m sorry, doctors are not saints.  Neither are patients.

Speaking of risk, here’s number two reason numbers are evil.  A recent article in the Journal of the American Medical Association reviewed the current literature on how accurate patients assessments of risks and benefits are.  The authors found that 65% of the time patients overestimate the benefits and 67% of the time they underestimate the risks.  The problem, according to Austin Frakt and Aaron Carroll of the New York Times, is that doctors don’t give patients adequate information about risks and benefits.  Bad Doctors!

The problem is not that doctors don’t give people the numbers.  The problem is that the numbers don’t influence patient’s decisions.  Reams of research as well as best-selling books by people like Nobel prize winner Daniel Kahneman tell us that risk assessment has little to do with statistics.  Humans estimate risk based on things like what is most prominent in the news, how they feel about the risk in question, and how closely they compare to others who have undergone the event in question.  For example, women who have had bilateral mastectomies after a breast cancer diagnosis were asked how much the surgery had decreased their risk of recurrence.  The average response was women felt their risk had gone from 76% to 11%.  The actual risk before surgery is actually only 17%, so the surgery reduces the risk of recurrent breast cancer six percentage points. (This is for women who don’t have the BRCA gene).  I’m sure women are told what the risk of recurrence is and how much the surgery decreases the risk.  I’m sure they are.  But the numbers are being told to  women who are scared out of their minds about breast cancer and just want it to go away.  They don’t hear nor care what the statistics are.  That’s called being human.  Pick a subject.  Vaccinations – gross overestimation of risk because the guy down the street has an autistic kid.  Dying in a plane crash – driving in your car is way more dangerous but the newspaper just had a big story about a horrific plane crash.  Ebola – one case in the US but everyone is afraid they will get infected because it’s a really bad disease.

Please.  No more numbers.




From → Healthcare

  1. Measurement of performance and quality is a necessity in every profession or trade. Apparently the author is indifferent for the public’s need to know about the performance of physicians, hospitals, and other health care givers – because it is “inconvenient”.

    While I agree that measurements of performance need to be meaningful, and not subject to manipulation by those being measured, the author just wants to do away with ALL quality metrics and offers no substitute.

    That is irrational and unacceptable.

    There is an unreasonable aversion to quantitative thinking in many in the Medical and biologically related fields. That is unfortunate. They forget that Medicine is about the PATIENT, not the physician or others in health care.

    I would suggest these people, like the author, re-read the Hippocratic Oath and then develop what they feel are usable, meaningful metrics that can be applied and utilized to optimize the results of patient care. Whining about “Please. No more numbers.” just manifests an attitude of indifference to the patient and arrogance on the part of the physician.

    • Thanks for reading. On the contrary, it is numbers that distance doctors from patients. I am certainly not averse to measurements of performance and quality. I just think that 30-day mortality is a bad way to measure these things. A patient can get high-quality health care and still die. Sometimes the measure of good doctoring is how good we are at helping people die in the most humane way possible. I would love to have good metrics, but the qualities that define good healthcare cannot always be quantified with a number.

  2. D. Lane permalink

    Part of the problem with these discussions is that they focus only on risk of death comparisons.
    While the risk of dying in plane crash is less than dying in car accident, dying in plane crash may seem scarier; for example, there may be a greater perceived lack of control, there may be a longer period of time between one’s awareness of the threat of a crash and the actual crash, there may be a greater risk of being burned to death, etc., etc.

    Similar issues arise when discussing the overemphasis on breast cancer relative to heart disease in women’s health. Many women are less-concerned about dying from heart disease (though it is more likely) because the manner of death seems less horrific, Succumbing to metastatic breast cancer (potentially taking root in the liver, bones, lungs, and – most ominous – the brain) after undergoing disfiguring surgery, radiation, and multiple rounds of chemotherapy is a daunting prospect to say the least.

    My point is that these “irrational” risk assessment scenarios are not necessarily evidence of irrationality. Some of the explanation, at least, may be based on entirely rational beliefs about quality of life relative to length of life.

    D. Lane

  3. jane permalink

    Having watched a loved one undergo a malpractice cascade in which the long-term risks of the unnecessary intervention he was coerced into were – as I later learned from extensive reading – never honestly disclosed, I will never assume that doctors tell patients all the relevant numbers and the poor stoopid patients just ignore them. I have heard too many stories from people whose doctors represented an NNT of 50 (or 200) for a drug to prevent a nonfatal event with language along the lines of “You have to take this or you’ll diiiieee!” If you always make sure your patients hear the absolute likelihood of the major benefits and harms of each intervention you propose, that’s commendable – but some of your colleagues simply cannot be relied upon to do that. Hopefully they can be persuaded to follow your good example.

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