What doctors do

I know I’m not a doctor but after talking to many, working for a health-focused start-up for a year and a half and teaching statistics to many, there are things about medical practice and health that are better understood from the eyes of a statistician.

Watching House, M.D. with doctors is fun, if you have that kind of humour. First Hugh Laurie is an incredible actor, but more importantly, actual doctors participate: they try to figure out what is wrong. Except, unlike a common mystery series, they are trained for it, and have embedded good practice in testing, up to a point that it is a moral code for them — and they are genuinely offended when the wrong test is tried. And they argue, a lot. Generally, the show appears to neglect common ailment, and test done to sort them out. 

When discussing with them, that seems to be the problem, but it’s not how doctors express it: they talk a lot about the order of things. “They should [test that] FIRST!” However, they usually have a hard time explaining why in layman’s term: this test goes first. They were taught that way. Diverging from this path is wrong. This order is present in medical thesaurus. It corresponds to the dangerosity of a potential diagnositic (suspicion of brain clots go very first, no matter what) but mostly what is actually a statistical notion, that most non-statistician only have a loose grasp: prevalence. Literrally, the likelihood, given the set of observed issues of each diagnostic. House, M.D. is written mainly by writers who are not practicing doctors, and who get their medical knowledge by opening thesaurus and looking down the list, and rare ailments. They write without prevalence in mind, and this drive practicing doctors mad:

The cynical part is that both diagnostic and treatment costs time and money and puts patients’ health in danger; that’s usually low, but when it is not (total XXX and surgery with its potential infections are classic threats that are recommended with parsimony).

What is poorly understood by patients —and rarely explained— is the difference between treatment and diagnostic. Doctors actually don’t do much, or rarely. They check a lot more than they make a difference: most people are healthy, and most desease actually cure themselves. In the sliver of cases when doctor prescribe more than rest, pain-killers and avoiding more harm, they generally nudge the body towards a faster recovery. Anti-biotics are a common re-inforcement for the natural immune functions; they have almost eradicated the common bacteria, they do not work on viruses — so, whenever you were last prescribed some, it’s highly likely you needed none of it, and were better off sleeping and drinking water.

What remains are rare cases where doctors know what is happening, and can do something about it. That’s far less likely than say case where they are not sure, and would rather not do much. However, because they live for those, and would hate themselves for not trying, they focus all their energy on finding those rare moments, and intervening — and they should. Medical shows, and common folklore on medecine does too: waiting in bed for things to patch up is a less appealing story. Even more shocking: having an unnoticeable, active day while your kidney is flushing leftovers from an infection that white cells have fended off before you could notice is the most boring story one can imagine. It still makes the bulk of your health.

Statistics is not about numbers, but framing the problem, and what should strike statisticians about current understanding of medical practice is the focus on salience —exceptional prevalence—rather than the consideration for the whole set. It is done in medical science, and the cost of including healthy sample to compare results is expensive, can come off as unnatural, but is necessary.

More importantly, expecting doctors to do something is wrong—it would be like expecting a driver to swerve every time they look at the road. Good driving has surprisingly few turns. Doctors correct courses on complex machine that heal themselves. Recognising their expertise in not doing much, the parcimony of their work is necessary. Just like recognizing the value of parcimony of many expert and complex decision makers: managers, educators. Silence, patience, approval can be golden.

This long rant not to dive on negative work, but to recommend a metric.

Most coders and dev-ops spend a majority of their time not coding, but correcting bugs. It’s tedious, and can get at their psyche. Re-focusing their work on positive outcomes is necessary. One way to do that is by lines of code written; a good idea, but great code should often be sparse.  Another way, that makes more sense to me, is by number of interaction processed without a hitch. There is an eery threat in a “Velociraptor free environment for [•] days” poster, but it does make more sense than counting failures. The proper metric is probably to be adapted to the office dynamic.

Similarly, doctors have patients die on them, and a never ending stream of people suffering coming in. That’s not good, or uplifting except in the rare case of their intervention has a visible impact — which is, as I pointed out, more rare to them than it could seem from a patients’ point of view. What doctors could use are different metric than How many died on you today? How many patients are smiling today among all those that came in a week ago, maybe? New treatments are a good guess too, even if also quite rare or often niche. How much of a difference a reassuring voice made, even if viruses are generally just pissed away? Miners should not be paid for the diamonds they find, that would be unfair and counter-productive. Doctors should not be motivated by miracles either.

About Bertil

I'm a PhD student in Digital Economics, and I love viennoiserie. Je suis un doctorant en économie (numérique) et j'aime la viennoiserie.
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