If you have ever taught students basic biostatistics, run a journal club, or participated in an EBM course, you know the quizzical looks folks have when you discuss elements beyond the 2×2 table. Well, along comes Nate Silver.
I am a longtime fan and read his first blog before it migrated to the NYT (FiveThirtyEight). His reach is beyond national, and his daily output—shall we say prodigious—is mind blowing, and that speaks nothing of his sophistication and technical skill. You see, he plays with numbers, any kind of numbers. He cut his teeth first with major league baseball (ever hear of PECOTA?), and then migrated to election forecasting and politics. However, nothing is beyond his reach and if you can analyze it and smack it down, he will be the first and best to do it. Seriously, his reputation is pristine.
Now that I’ve dispensed with the preamble, I can advance us into the crux of the post. Simply, it’s Silver’s take on Bayes theorem. The explanation is in his new book (and the plug is incidental, as I have no affiliation with him or the publisher). However, the analogy he uses to impart the Bayes lesson is too delicious to pass up. Hope you like it as much as me.
Do not be afraid to utilize the tutorial tomorrow–as I have already put it through its paces. The lesson works:
This week’s JAMA has an outstanding commentary on the state of trainee teaching on the wards. The piece expresses what others and I have sensed for years, mainly, given technology use, changes in resident work hours, and the ascension of inpatient teachers, attending rounds of yesteryear are dead gone.
We are not experts on energy, defense, or the environment. Most of us at least, I think.
However, what we do know is healthcare. We are quick to recognize misrepresentations in the press, especially on hospital related subjects. Because we know distortions occur, for the very reason our erudition is lacking on the subjects above, we cannot judge matters on which we are not expert. Our passivity sometimes creates a submissive state, and often we succumb to motivated reasoning to reach conclusions on non-HM matters.
Read the following contrasting set of paired statements:
Our thinking is different, and as a result, the company is making a change—and we need to introduce someone in your position who synergizes with corporate goals.
I am unhappy with your performance and I am not renewing your contract when it expires.
This relationship is not working out. I just don’t know what it is—you are so great and all. This is all me, you are too good, and I do not deserve you.
I am unhappy in this relationship and I cannot continue dating you.
You can call the above passive or active communication, but at its essence is the reticence of an individual to deliver difficult news. The top statements are ambiguous and deflect their piercing intent. Conversely, those below them bare the soul of the speaker—directly and with clarity. There is a sting just reading them, and the propensity to avoid the conflict that ensues when we use such directness compels us to obscure our thoughts. Those sentiments entered my mind when I read the following:
[…] A fairly common thing I hear doctors say in the first meeting with the family is, “She is really sick, but we have her on the ventilator and we are doing everything we can, and we’ll see how things go.”
[…] ”Although she is on a ventilator and doing OK right now, I’m concerned because there is a real chance that she won’t survive this. I am hopeful that we will get her through this, but I wanted to share with you the possibility that this may not go well.”
We all must speak these words at some point, and if you are like most physicians, your utterance resembles the first and not the latter statement. Why?
I raise this point because docs and the lay community conger that the confrontation of burdensome and futile care and all its ills are paramount to moving our health system forward. Yet, we are not solving the problem. The fault line is blurry, and reasons for this veer towards physicians and their reluctance to engage in “tough” conversation (lack of time, remuneration, enlightenment or training), and patients who speak as if they want the truth, but have not prepared for the reality of that truth and its implications.
The stakes are greater in life and death as compared to business dealings and relationships, but the parallel is opaque communication—making statements that have multiple meanings. The individual’s DNA code will govern the interpretation.
However, the businessperson and the spouse know what their words signify, but cannot convey the message properly. Conversely, physicians speak the right words, but they do not comprehend, knowingly at least, why their message lacks clarity.
Let me explain. Estimating the chances of a critically ill individual’s recovery is often difficult and unknowable, and physicians’ ability to prognosticate these cases will vary. Moreover, the actions a physician takes, and the message they convey to families will differ based on similar approximations.
I might estimate a patient’s chance of survival at 10%, but because of my, a) uncertainty with that figure, and b) discomfort with delivering anything but fully proscribed care at the “10%” level, will behave in a manner unlike my colleague. Conversely, my colleague may have greater confidence in their calculation, 10% in this case, and will practice differently due to their inherent tolerance for risk.
Beyond the tail ends of the survival curve, our current tools lack precision at foretelling outcomes in acutely ill folks. When interobserver agreement varies by more than 5%, and I am certain that is a reasonable guess in this case, achieving uniform practice is impossible.
Therefore, when a doctor communicates to a family, “we are doing everything we can, and we’ll see how things go,” do not assume the subtext of the communique is, “I don’t want to have a sophisticated, complex conversation because it’s too time consuming, complex, or poorly reimbursed.” Rather, the reasoning may resemble this:
–If your loved one had a 5% chance of survival, I would recommend x.
–If you loved one had a 10% chance of survival, I would recommend y.
–If you loved one had a 20% chance of survival, I would recommend z.
–However, I do not know the right figure, so z is the correct path.
Currently, payers may assume physicians have cracked this code. We have not, and regions within the U.S. that have achieved success in this domain have done so because they comprehend this imprecision and have distributed these silos of uncertainty equally, amongst all parties.
However, this is not the norm and physicians will continue to use opaque language, like that above. We will bristle at prognosticating with direct, clear data. And the system will continue to subsume us with expectations far greater than we can fare. Thus, our internal conflict will persist, with or without self-awareness, and the path to greater clarity will remain blocked.
I also posit, if “having the conversation” was intuitive or close to decipherable, it would have made the ASCO first cut. It did not, and will not for the near term, for the reasons stated. Its absence at this juncture of reform speaks volumes and conveys the difficulties ahead.
Without government, hospital administration, or payers explicitly stating, “if a, then b,” we will continue to navigate these waters mostly alone, not because we want to, but because we are stuck. We cannot quantify what we can only qualify.
Until we break this logjam of estimation and communication, the right words, and possibly intent, will elude us.
I particularly enjoyed this article from the WSJ last weekend. It is a piece you finish and satisfactorily conclude your time was not wasted. You have gained a new perspective in reexamining a deed, in this case lying, that we all engage in periodically—that we rationalize, trivialize, or justify—for unwelcome reasons we sidestep to achieve our selfish ends. This opening paragraph got me hooked:
There is a lot of talk these days of personal responsibility. Obesity, lifestyle choices and any untoward consequence of either are usually attributed to the individual, and the cost—both financial and in quality of life—are duly theirs.
I always enjoy attending speaking engagements when notable authors, historians, and luminaries hit the trail and plug their wares. Not so much because they are plugging their wares of course, but the spontaneous banter and repartee that results from live interactions. Engaging in debate–sometimes, and the in the flesh hither and thither is refreshing and allows curious minds (and fans) to enter in a mode of conversation they normally would not experience. It is nice to see our countries best thinkers in this kind of forum.
How often do we hear declarative statements rooted in dogma, propagated over decades? Countless times, physicians providing continuity care for chronically ill patients “assume” that by the very nature of that continuity, they outperform doctors not in that station, especially as it relates to intimate tasks. “Hospitalists are ill equipped to obtain advanced directives; they don’t know the patient like I do,” or something to that effect.
If you read me regularly, you know I love TED talks. This one is fantastic. What makes it particularly great is despite the subject matter, medicine, you would not know whether the speaker–a physician himself, is speaking to a lay audience or peers. There is some skill in that, as you will see.
I did not know what to make of his introductory remarks, but his talk gets real, real fast; and he sure has guts. It is a polished, hard-hitting account of committing a a major medical mistake, not once, but twice. Brutally honest, and true to a fault, as those who have lived through this will account.
It shows the cross border universality of our practice environment as well (he is Canadian), but that only enhances the value. The problem he expresses is sweeping; the emotions the same.
This is someone that needs to speak at all our next grand rounds. Pass this one on to your colleagues.