Two Anecdotes

In December 2008, two seemingly unrelated events occurred. The first was the release of Stephen Greenspan’s book, Annals of Gullibility: Why We Get Duped and How to Avoid It. Greenspan, a professor of psychology, … discussed gullibility in fields including finance, academia, and the law. … The second was the exposure of the greatest Ponzi scheme in history, run by Bernard Madoff, which cost its unsuspecting investors in excess of $60 billion. … The irony is that Greenspan, who is bright and well regarded, lost 30 percent of his retirement savings in Madoff’s Ponzi scheme.
At conference dealing with spine surgery, a surgeon presented the case of a female patient with a herniated disc in her neck and pain that was caused by a pinched nerve. She had already failed typical conservative treatments such as physical therapy, medication, and waiting it out.
The surgeon asked the [doc] audience to vote on a couple of choices for surgery. The first was the newer anterior approach, where the surgeon removes the entire disc, replaces it with a bone plug, aim fuses the discs. The vast majority of the hands shot up. The second choice was the older posterior approach, where the surgeon removes only the portion of the disc that is compressing the nerve. No fusion is required because the procedure leaves most of the disc intact. Only a few audience members raised their hands.
The speaker then asked the audience, which was almost entirely male, “What if this patient is your wife?” The show of hands was reversed for the same two choices. The main reason is that the amount surgeons are paid for the newer and more complicated procedure is typically several times what they’d receive for the older procedure.

On the impotence of book learning:

In December 2008, two seemingly unrelated events occurred. The first was the release of Stephen Greenspan’s book, Annals of Gullibility: Why We Get Duped and How to Avoid It. Greenspan, a professor of psychology, … discussed gullibility in fields including finance, academia, and the law. … The second was the exposure of the greatest Ponzi scheme in history, run by Bernard Madoff, which cost its unsuspecting investors in excess of $60 billion. … The irony is that Greenspan, who is bright and well regarded, lost 30 percent of his retirement savings in Madoff’s Ponzi scheme.

On distorted doc incentives:

At conference dealing with spine surgery, a surgeon presented the case of a female patient with a herniated disc in her neck and pain that was caused by a pinched nerve. She had already failed typical conservative treatments such as physical therapy, medication, and waiting it out.

The surgeon asked the [doc] audience to vote on a couple of choices for surgery. The first was the newer anterior approach, where the surgeon removes the entire disc, replaces it with a bone plug, aim fuses the discs. The vast majority of the hands shot up. The second choice was the older posterior approach, where the surgeon removes only the portion of the disc that is compressing the nerve. …

The speaker then asked the audience, which was almost entirely male, “What if this patient is your wife?” The show of hands was reversed for the same two choices. The main reason is that the amount surgeons are paid for the newer and more complicated procedure is typically several times what they’d receive for the older procedure.

More here.  I’m actually surprised by this doc story; I’ve heard that docs over-consume med like everyone else.
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  • http://metanomics.net Robert Bloomfield

    Have you heard that doctors overconsume overly expensive medical care, or (as I suspect in this case) overly risky care?

  • Jimmy

    It’s not about overconsuming, it’s about caring about the person.

    I had the same problem in my lower back, and the first doctor suggested the first treatment, so I went elsewhere.

    I ended up going with the minimal surgery and it worked well. I walked out of the hospital within minutes of waking up, and within a week was in better condition than presurgery. The other procedure is a *huge* deal that takes a lot to recover from.

  • http://georgiacontrarian.blogspot.com/ Bob Swerlick

    The story about the spine surgeons has no citation. It sounds like an urban myth.

  • Jake

    The reason for the preference reversal may or may not be due to the financial incentives involved, but certainly the information that you gave doesn’t make this clear. In what other ways do these procedures differ?

  • diogenese

    I don’t know about the veracity of the story, although I’m a pretty big sceptic on spine in general. However, I would say doctors do over consume as much as the next guy, PSA screening for prostate ca being a typical case (also where outcomes are more straight forward).

    Anyway, financial incentives messing up medical decision making isn’t new — and the current re-reimbursement system rewards AGGRESSIVE care.

  • Bill

    Where is the source for doctors overconsuming medical care.

    My daughter is a pathologist and her husband is in internal medicine.

    Doctors, based on my daughter’s statements, run away from surgery if at all possible and are minimalists. If they have it, they search out other doctors who perform the specific surgery the most often and whose team has the best results. One of my neighbors, a prof at the med school, is watchfully waiting on his prostate. Not yet.

  • Andy McKenzie

    One alternative explanation besides incentive structure:

    Docs are in general willing to experiment with new techniques because they know that they will push the boundaries of the field and possibly eventually lead to better techniques. So, if they are performing surgery on the average patient they prefer to experiment on the technique that might eventually be better.

    On the other hand, if they are performing surgery on their own wife they will be much more risk averse and will opt for the tried and true method.

    Gawande talks about exactly this dilemma wrt training new docs in his book Complications.

    • quanticle

      Its not just doctors. Its true of many fields. For example, I wouldn’t mind working on a AJAX/Ruby on Rails banking system. But, would I want my bank using such a system? Of course not! Given that it’d be one of the first rollouts of such a system there’d be a higher risk of security flaws that could lead to compromised financial data.

      Its a “belling the cat” problem. The benefits of the advancement, whether its a new medical procedure, or a new online banking UI go to everyone. The risk, however, is concentrated on a single individual or a small group. Unless there’s a way to compensate the individuals at risk for the increased risk they’re taking (e.g. charge the others for the free benefit) there’s little incentive for anyone to try the latest method.

      For some things, (e.g. computers, cars, etc.) having the latest and greatest is higher status. This increase in status serves as compensation for the risk that the new technology doesn’t work out. However, for medical procedures, there is no such reward – not many people would consider bragging about the technique used to fix their back.

      • http://hanson.gmu.edu Robin Hanson

        No doubt this is also why car dealers try to sell you expensive cars, because they want the world to have more car innovation.

  • Flashman

    Of course, there is another possible explanation to the doctors’ reluctance to engage in costly experimental services involving their wives. It is a well known fact, that doctors a stingy. It is also possible that many HATE THEIR WIVES. Put these two things together et voila.

    Perhaps a better question might have been: What if it were your daughter – the one with braces and a pony?

    Anyway, thanks for the great blog….

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  • http://williambswift.blogspot.com/ billswift

    “Intelligence briefings are only useful to the intelligent.”

    Likewise, “book learning” is only valuable to those alert and intelligent enough to apply it. Admittedly, that is only a tiny minority of the population.

  • Jim S

    I disagree with your comment about doctors being over consumers of medicine, based on my 21 year marriage to a family practice doc. Based on her advice I didn’t get a “check-up” at all in my 20’s or early 30’s.

    Based on her anecdotes, I happen to believe that most over consumption is consumer driven. She is constantly trying to talk people out of things like PSA tests, mammograms for young women, etc.

    I’d love to see a study which compared the consumption rate for medical services between avid TV watchers and non-TV watchers. People are bombarded with messages about all the things they should do for their health, and all the tests they should get, as well as unrealistic cures on medical drama’s, when it mostly boils down to eat decently and get some exercise.

  • Bryan
    • Noumenon

      Seems to boil down to “I did it because I’m gullible. Here are some factors that make people gullible.” I would have hoped he had a real excuse like “I checked X, Y, and Z and they were all OK, so…” He does say he was lulled by the promise of moderate rather than spectacular returns, which seems valid to me.

  • richard

    andy mackenzie is absolutely correct. the real reason is not because of a financial incentive, it is probably because any surgeon would be more risk averse when dealing with his own wife. the conclusion of the author that the surgeons are motivated by avarice is most likely the product of his own bias against physicians.