최고의 의사 찾는 비법과 병원 성과 평가 요약

Until I get a bit more time, I'm making these impromptu videos predominantly inspired by conversations I've had here at work.

 Welcome back to the hospital at night.

 It's just past 5:00 a.

m.

 in the morning.

 And I've noticed that you sadistic people seem to like it the more tired I look.

 So, if I look as tired as I feel, then consider this fan service.

 I have two friends.

 That's not a standalone statement.

 I'm far more popular than that.

 My total number of friends is closer to uh three.

 And to be honest, these two probably wouldn't describe me as a friend.

 But the point is I know two people and they are both orthopedic surgeons.

 And if that wasn't bad enough, they are married to each other.

 Can you think of anything more boring than two surgeons married to one another like a patient in the modern NHS? Or as the kids say, I'll wait.

 Now, if you're like me, two thoughts occur to you when you meet this couple whom I will refer to as Mr.

 and Mrs.

 Kohley.

 If you're not aware, surgeons in the UK are not referred to as doctor.

 It's a long story.

 Don't ask.

 Uh, but I think it's a bit archaic and needs updating.

 The first thing I think of is when a couple's day job consists of screwing, nailing, hammering, and of course, bones is what is their pillow talk like? I'm only joking.

 Surgeons don't have time to do that.

 And number two, which one of them is the better surgeon? Well, luckily we can interrogate each surgeon's stats and there's a clear winner.

 Mrs.

 Kohley has a mortality rate of 10%, meaning one in 10 of her patients die within 30 days of their operation.

 Occasionally, they die on the table, but most commonly they die afterwards, either a direct complication like bleeding or a wound infection or secondary like a hospitalacquired pneumonia or heart attack suffer caused by the the stress of recovery.

 Whereas Mr.

 Koli has an impressive mortality of just 1%.

 Only 1 in 100 patients die related to their operation.

 So case closed, he's clearly a better surgeon.

 I mean, is that really surprising? I mean, you know what they say about female surgeons, right? That they're probably very good because they've had to work extremely hard to make it in a heavily male-dominated field.

 And this is the point I wish to convey today.

 Stats can mislead.

 What if I told you that Mrs.

 Kohley works at a major trauma center in a public state hospital doing the most complex cases, major road traffic accidents, stabbing victims, or often frail elderly patients with multiple medical problems who've fallen and broken their osteoporotic hip.

 Or what if I told you that Mrs.

 Kohley is so good at what she does that her colleagues send her the most difficult cases? Then what if I told you that Mr.

 Koli who is the main bread winner for the family and works in a fancy private hospital doing only the lowest risk cases such as elective knee replacements in fit and healthy patients under the age of about 65 or 70.

 Now how do you interpret those results? Dozens of people are involved in a patient's care, all of whom can affect the outcome.

 Why should mortality be solely attributed to the surgeon? Okay, you might retort that we're not comparing like for like.

 What about surgeons doing the same job in the same unit? Well, even then, a key missing statistic is the rejection rate.

 If a surgeon with a fantastic mortality rate only achieves that by turning down cases that their colleagues would have accepted, they might be denying some patients an effective treatment.

 Indeed, they may be saying no to the more unwell patients who would stand to benefit the most.

 So, where do you draw the line? Well, these are the two conversations that I had this weekend that made me want to record this.

 The first was when consenting a patient for a very risky procedure.

 I was going to do this via a keyhole approach, but another option was open chest surgery.

 Both of them carried a very high risk and I spent time trying to quantify this to the patient.

 But of course, there is a third option which is to not operate at all.

 And patients can sometimes not even consider this.

 So, it's my job to present all options and offer as much explanation as I can on the pros and cons of each.

 Then, I have to explore what is most important to the patient.

 Even though the open chest surgery would probably give a better long-term result in this case, his priority was getting home to a disabled loved one that he cares for as soon as possible.

 And as I could offer the keyhole procedure in the next few days, but the open chest option would take several weeks before he could go home, he went for the quicker option.

 But I had to be sure that he understood that it was perhaps a medically less effective option.

 The second conversation was with another patient, but along the same lines.

 This time I had to tell the patient that we didn't feel any operation was possible.

 We discussed their case extensively at our departmental meeting and unfortunately we didn't feel that any operative intervention carried a meaningful chance of being successful.

 So the patient asked me a question which I've been asked before so I've I've given it some thought but it's a very reasonable and understandable question.

 They said doc even if there's a 1% chance why can't we go for it? So we do sometimes do this in extremists.

 If the alternative is certain imminent death such as in an acute emergency, we try whatever we can in the knowledge that there is little to lose.

 This is a big part of my job.

 But in this scenario, the patient was stable.

 They were able to go back home from hospital.

 They could still do gentle basic daily activities and spend time with their family.

 their quality of life was certainly impaired by their condition, but it wasn't absent.

 If a doctor feels that the risks of an operation outweigh the benefits, then they are subjecting a patient to an invasive procedure in the knowledge that it's more likely to harm than help.

 The moment I prescribe a medication or I make an incision, I am doing the patient harm.

 I think we can forget this.

 So why am I not arrested for assault? Because of course we accept the side effects of a tablet or a painful surgical wound because there is a benefit that outweighs the harm.

 But this is not the case for every medical intervention and certainly not in every clinical situation.

 This idea is why the original hypocratic oath is not even said in most medical schools these days because it contains the line I will not cut for stone meaning I won't operate on gallstones or kidney stones which of course we do all the time now.

 But when Hypocrates was alive, cutting for stone caused far more harm than good.

 So even if every now and again a patient might survive, the odds were overwhelmingly against a surgeon trying to cut for Hypocrates's time.

 Hence, he said, "Don't do it because you will harm far more than you heal.

" Remember, this is a point I made in a video about CPR and resuscitation that nothing in medicine is binary.

 The outcome of resuscitation or an operation is not just complete recovery or instant death or even a return to the pre-operative status quo.

 But there are limitless inbetweens like having a stroke and spending 3 months in a rehab unit unable to go home.

 Dying slowly on a ventilator in intensive care, never waking up to say goodbye to your family, going home but being unable to do the things that you want to do, being unable to play with your grandchildren, keep your job.

 So not achieving the better quality of life that you wanted.

 We do anything in medicine for two reasons.

 To improve quality of life or to prolong life.

 But if the latter comes at the expense of the former, then we are not thinking holistically.

 Commission bias is the tendency humans have to want to do something.

 This applies to all kinds of scenarios.

 If you want to learn more about it, especially with Trump back in the White House these days, I made a video about the care he received when he had CO which demonstrated this beautifully.

 Don't worry, it's not a political video.

 It's about how VIPs often actually end up getting worse medical care.

 So, when doctors are presented with a patient who is suffering, everything in our training tells us to do something.

 We exist to try to fix people's problems, but we also need to know when we cannot.

 Surgeons are not being selfish when they think about their statistics.

 Although I will say it is an entirely human characteristic to not wish to be a contributing factor to a patient's death and ethically and indeed medical legally allowing natural death versus doing an intervention and potentially accelerating death with an operation are very different things.

 So surgeons are not necessarily um being selfish when they decline an operation.

 But publishing these um statistics publicly without the nuance that we've just been talking about unfortunately also represents an example of the law of unintended consequences.

 Um or maybe uh Goodart's law.

 Uh I can't remember who Goodart was now um was is maybe I think he's still alive.

 Maybe an economist um or a psychologist or maybe he's even a real scientist.

 But his law states something like anytime a metric i.

e.

 a way to measure something becomes the goal, it ceases to be a good metric.

 And I'm sure you can think of examples from your field, but medicine is a wash with them.

 I actually like a non-medical example.

 This is very famous.

 I think it has its own uh name of the cobra effect, but it's basically the the the goodart's law.

 If you've not heard of it, it dates back to British occupied India when a local British administrator wanted to do something about the prevalence of cobras which are obviously dangerous venomous snakes.

 So offered a financial incentive to people to kill them.

 So what was the metric used to measure success? Well, number of dead cobras villagers could collect one rupee or whatever for each dead snake they produced.

 You can see where this is going.

 Enterprising people started farming snakes and killing them.

 And when the British realized their mistake and the scheme was abandoned, the villagers no longer needed their cobra farms and just released the snakes into the wild.

 And it was estimated the number of cobras um in the wild had increased four-fold instead of the intended uh reduction in numbers.

 Now, the UK government uh some years ago said a goal for good medical care is that all patients in the emergency department should be seen and treated within 4 hours.

 Hospitals who didn't achieve 98% compliance with the 4-hour target were penalized.

 So what happened? Patients were turfed out of the emergency department either home or to a ward before they had been properly sorted out.

 The intention was good medical care.

 But even though hospitals often had almost 100% compliance with this statistic, they may not actually be the hospitals offering the best care.

 Think about this next time you hear about a hospital in special measures or one performing excellently.

 A hospital I work at went from being an excellent rating to needs improvement overnight simply because the scoring system was changed.

 I used to work in another department where a particular consultant prided himself on discharging more patients than anyone else.

 The hospital managers loved him of course because he generated empty beds.

 improved flow through the hospital, but no one thought as highly of him as he did.

 Now, this might give you um a little insight into why I've not always been the most popular with managers and bosses in in places I've worked, but I decided to audit this particularly arrogant consultant's readmission rate compared to other consultants.

 And sure enough, the patients he sent home ended up coming back to the hospital more often than anybody else.

 Now, I don't say this to imply that he caused more harm than good.

 Sometimes you do need senior doctors who are willing to take some risk on board and discharge patients otherwise the whole hospital will grind to a halt.

 But again this demonstrates the importance of getting the full story.

 The publishing of individual surgeons mortality rate created the same phenomenon.

 Surgeons became wary to take on high-risisk cases.

 They opted for simpler safer surgeries lest they be criticized for having a higher mortality rate than others like Mrs.

 Kohley who I hope you can now see is the exact kind of surgeon you want looking after you or as your colleague because she won't shy away from hard cases.

 But having said that sometimes high mortality is indicative of a bad surgeon.

 So always remember there is a limited amount you can in infer from a single data point.

 If you want to get into the weeds about this, there have been iterative changes over the years to the system, like attempting to risk correct the stats and reporting departmental statistics, but I would still strongly counsel against inferring much from these numbers.

 I think what they're good at is establishing outliers, people or departments that are well outside the normal distribution.

 Um, attention can be focused there.

 Good reasons may be found, but within a single standard deviation, there is way too much noise to conclude anything.

 There's an old famous adage in medicine which has been adapted to all sorts of professions.

 I think it's been around well over a hundred years and it says, "A good surgeon knows how to operate.

 A better surgeon knows when to operate, but the best surgeons know when not to operate.

" That's why, in my opinion, it's a bit of a red flag anytime you see on social media those stupid inflight magazines, America's top dermatologist or top 10 plastic surgeons.

 It's just a meaningless phrase.

 In fact, I most often see terms like this these days in newspaper articles about some contrarian doctor who's contradicting scientific consensus referred to as America's foremost vaccine expert or the UK's leading cardiologist, which is obviously not true because the article wasn't about me.

 When not only do such things not exist, they cannot exist.

 You can't rank doctors like this.

 I even see some of the social media influencer types blow up these top doctor magazines and put them on their wall, which by the way, you just pay to be in these things.

 We've all been offered I' I could pay $5,000 and I could be one of New York's top plastic surgeons.

 There is no lee table of doctors that would make any sense.

 Well, there could be if the hospital had listened to my suggestion of a mixed medical martial arts league.

 Think about it.

 We know all the vulnerable points of the body.

 We have an abnormally high pain threshold secondary to the pain of our existence.

 And we can order our own head scans when we get traumatic brain injury.

 All right, everybody.

 That's all for this mini med life.

 I've only had two calls tonight.

 Actually, it hasn't been that bad, but it's kind of that time when there's no point going to sleep.

 I quite like talking about numbers in medicine, often in reference to the extremely dishonest way that both podcasters or influencers use them, but also pharmaceutical companies as well.

 But today we focused on some different kinds of numbers.

 And I hope it was interesting.

 I guess the moral of the story is um don't marry a surgeon.

 All right.

 A few of you said after their somewhat Spartan, no frrills recent videos like this, deficient in production values and premeditation that you like them.

 Uh, which was surprising, but actually very nice to hear.

 Thank you.

 So, hopefully I can keep them ticking along like this uh until I make the the better, longer videos.

 If you've watched this far, please uh hit the subscribe button.

 I haven't asked that since 2019.

 I very rarely post videos, so you won't be flooded with suggestions.

 And I'll be honest with you, seeing my subscriber count static for 18 months after posting even a couple of videos has been a little bit demoralizing.

 So, help a brother out.

 Uh, donate your love so that I don't have to pivot to and becoming an AI slop channel and give me a little hit of that sweet sweet dopamine because if you don't, I'll just uh go over to the drug cabinet and get it.

 It's it's right there.

 I'll mainline it into my eyeballs again.

 I'm in a blissful offline phase these days, so I can't even harvest those likes elsewhere.

 I'm just finding all social media insufferable these days, but every now and again I get that little pang of a very particular narcissistic content creator malaise.

 And I worry if uh you people will forget about me, Britain's number one cardiologist.