Archive
On Dunning-Kruger, Surgical Self Assessment, and some Surgical Buzzwords too Watch out For
It’s been well documented that people are generally poor judges of their own skills. Dunning and Kruger studied and published on this topic, creating the term Dunning-Kruger effect, which summed up, states that “poor performers are not in a position to recognize the shortcomings in their own performance”. Ehrlinger et all followed Dunning-Kruger in their paper “Why the Unskilled are Unaware: Further Explorations of (Absent) Self-insight Among the Incompetent,” further coming to the conclusion that the relatively unskilled are unaware that they lack those skills. Other papers have shown that if you objectively split performers into quartiles, and then ask those quartiles where they believe there relative skills are, it comes out like this:
Top quartile of performers -> believes they are in the 2nd quartile
2nd quartile of performers -> believes they are 2nd or 3rd quartile
3rd quartile of performers -> believes they are in 1st or 2nd quartile
4th quartile of performers -> believes they are in the 1st or 2nd quartile
Effectively, the best performers think they are ok but could be better, while the worst performers believe they are at or near the top of performance. Effectively, they do not realize what they do not know.
Read more…Remembering Paul Underwood
Last week marked the passing of one of my early teachers and mentors, Dr Paul Underwood.
Dr Underwood was a professor emeritus at Medical University of South Carolina, where I attended a residency from 2001 to 2005.
I was fortunate to get to train in a residency that was full of extraordinary people. Little did I know that not every department was like that. MUSC was an incredibly caring environment that looked after each resident like a member of family. Paul Underwood was a big part of that.
I can also say that without Dr Underwood, I would not be an endometriosis surgeon today. There is no question that he is the one that got me started on this path.
One day in my third year of residency Dr Underwood and I were doing an abdominal hysterectomy. We unexpectedly found stage IV endometriosis. While most attending would have been concerned about the complexity of the case, Dr Underwood was utterly unfazed, being a very experienced gynecologic oncologist. At the same time, he never took the case away from me. He always encouraged me to keep operating even when the case was just outside of my normal comfort zone, giving me a few pointers here and there. He was also one of those surgeons who might let a resident go a little too far and get into trouble, knowing he could fix it.
Read more…Why American Healthcare is So Expensive Part 3 – The Insurance System
Today the GOP is deep in its discussions about how to take apart The Affordable Care Act and to replace it with some other kind of system to pay for healthcare. So far, everybody in the healthcare delivery system hates it, and it may go nowhere. But I will continue to argue this – whatever they are trying to do, it won’t work.
Why won’t it work?
Not because the system that are creating is the wrong system. Sure maybe it is wrong. But that’s not the real problem.
As we said before, THE PROBLEM ISN’T HOW WE PAY FOR HEALTHCARE. THE PROBLEM IS HOW MUCH HEALTHCARE COSTS IN THIS COUNTRY.
So why is healthcare so expensive in this country? Last time we talked about how there are incredible incentives to create and use expensive healthcare equipment, even when such equipment does nothing for patients. Today we’re going to talk about something else: The Insurance System.
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I think a lot of people don’t fully understand why we have health insurance. Let’s start with why we have insurance for anything at all.
Insurance is needed when there is a potential future expense that you may not be able to pay for, but that may never happen. Ie its very expensive to repair your car if you smash it, and there is also heavy liability involved in potential damage to another vehicle or people within it, so you insure that potential expense. The vast majority of people who buy auto insurance do not have to make a claim, so insurance is relatively inexpensive relative to the potential size of the claims. You do not insure buying groceries because a) it isn’t that expensive to buy groceries and 2) everybody needs to buy groceries so there is no grocery-buying risk to spread out between different insured entities.
So based on this idea, and the current costs of serious healthcare interventions, it makes sense to insure healthcare.
Why Healthcare in America is So Expensive Part 2 – Surgical Equipment
With this essay we embark on a journey through the world of medical cost. In my last essay, I argued that while our government struggles to create a system that pays for the healthcare system we have, the true problem is the outrageou
s cost of that system, not how we pay for it.
Today, we will examine the surgical equipment industry, and how expensive i
nnovation and technology is valued over actual contribution to patient outcomes, and how every incentive exists to make medical equipment as expensive as possible.
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A few years ago, I was involved in a project with a number of students from Georgia Tech’s biomedical engineering department. I had an idea to solve a basic problem in laparoscopic surgery, and these students were charged with c
reating a prototype solution to the idea. We came up with an elegant solution to an issue that occurred in every laparoscopic surgery in this country, and eventually the students presented this idea as their senior project for their degrees.
Subsequently, I approached my University’s Technology Transfer department (the group that helps faculty to commercialize their ideas.) We went through a process of idea disclosure with the hope that the University would help me to bring this idea to market. In the end, though, it fizzled. They said they weren’t interested in developing the idea. So I approached several industry groups. Again, no interest. Over time I talked with three different groups that develops ideas, and no one was interested.
The kicker of all of this is that the lack if industry interest had nothing to do with the utility of my invention. In fact, all parties agreed that the idea was great and the solution was elegant. They also agreed that they could imagine the device in practice. The problem wasn’t that the device wasn’t a good one, it was that the device was too simple, and too inexpensive to manufacture. I had imagined a device that would probably cost about 5 dollars in every surgical pack. In the end, the development market had little interest in such a device, given what it costs to develop bring a device to market and the likely payout at the end. This thing actually saved money in time and in replacement of more expensive equipment already in use in the OR. But what I found out was that there wasn’t much interest in devices that causes industry to make less money.
Healthcare Reform Has It Wrong: Why American Health Care is So Expensive Part 1
Having been a physician now for 16 years, I have had a first hand view at the variety of healthcare reforms and regulation put into place over that time. Most recently, the Affordable Care Act has been at the center of our attention, but it is by no means the only thing the government has done over that time.
Today, President Trump and the Republicans are working to repeal the Affordable Care Act, and possibly replace it with something else (Something Great if you listen to Trump.) I have mixed feelings about this. I think that the ACA did some good things, but also got some things wrong. At its fundamental core, by forcing all people to buy healthcare through a private insurer (albeit through a government funded network), it was trying to create universal coverage. Unfortunately, the ACA struggled to get healthy people who would pay more than they consumed to enter the system, thus creating a system where there were often more claims than premiums.
A Holiday Message from Nicholas Fogelson and Academic OB/GYN
Merry Christmas and Happy Holidays from Nicholas Fogelson and Academic OB/GYN! Dr. Fogelson is available for clinical consultation at the Pearl Women’s Center in Portland, OR at 503-771-1883. He is a better gynecologic surgeon than he is a rapper. And he’s not completely terrible at rap so there’s that.
Three Problems, One Solution: A New Way to Pay for Medical Education
Case 1:
A middle aged man named called Joe decided in mid life that he would become a doctor. A former boxing instructor, Joe felt compelled to learn medicine to help his fellow man. Already in his 30s, he worked hard to develop the prerequisite education to enter medical school, which he did in the late 1990s.
I met Joe in my first year of medical school. He was a very bright guy and had a great sense of humor. He was a bit different than most of us, and not just in age. I remember him asking me once “why would we use anti-hypertensives to treat hypertension. I mean, if a person’s blood pressure is that high, maybe that’s what their body needs it to be at!”. I remember thinking it was a strange way to think, given that allopathic medicine pretty much presumes that letting the body do whatever it will may not actually be the best course for long term health.
Joe did reasonably well through the first two years of medical school. In his third year he had moderate success, and sometimes struggled with having a different outlook on what medicine should be that the attending physicians that were instructing him. Over time, this became a bigger problem, and Joe eventually made the decision that being an allopathic physician wasn’t what he wanted to do for the rest of his life.
The History of Academic OB/GYN
A few months ago we hit the seven year anniversary of Academic OB/GYN. And today, I found out that we have been nominated in the AAGL Oscars for “Most Innovated Social Media Platform”. This nomination was a pleasant surprise – I completely agree that we should compete for that title, but in truth it always a bit of a shock to find out that people in my field actually have seen what I have been doing here and appreciate it. Most people are afraid of social media, and seven years ago when I started this most people in medicine thought far more of the risks than any kind of benefits. Since that time, things have changed, and many doctors have created robust social media presence. Since I started, the big players have come on the bandwagon. Now we have podcasts from all the major journals, and several website podcasts as well such as medscape and so forth. But I am proud to have been one of the first ,and almost certainly the first to have significant presence in the field of OB/GYN. With that, I thought it would be fun to recall how it started, and how the journey has been for me, and for the brand of Academic OB/GYN.
I started Academic OB/GYN the summer of 2007 at the University of Hawai’i. The impetus to do so actually came from my fandom of a podcast called Diggnation, hosted by Kevin Rose and Alex Albrecht. This was a podcast done by two nerds talking about nerd topics for an hour or so, and also doing a fair bit of drinking. It came to me – wouldn’t it be great to do Diggnation for OB/GYNs? So the next week I lined up some guests, fired up Garage Band, and published the first episode of the podcast. It absolutely took off, and in its heyday we were getting over 500 downloads in the first 48 hours of a new podcast being published, and in some cases topping 5,000 downloads in the first month. In the early years the audio quality was atrocious. Some of the episodes were almost not worth listening to it was so bad. But people liked the content, and they seemed to listen anyway. The audio got better, though never really to a professional level. But the content kept coming, and listeners kept growing. I got lots of mail of appreciation and comments. In 2010 at the University of South Carolina I added Dr Paul Browne as a co-host, and it made the podcast even better. Listenership grew even further. This year we total over 102,000 downloads, over 50% of which listened to the entire podcast. Our most popular episode was an early one with Dr Roger Newman, with over 8,000 downloads, still rising today. Amazingly, new fans still download our old content, and while we haven’t published an episode in three years we still get 20-30 new downloads a day. While total numbers are very little compared to downloads of wider appeal products, for a product that really only appeals to a very narrow slice of the world, the popularity has been staggering.
How Carrying a Gun Can End Your Life
“You should carry a gun Nick”, my friend told me as I started work in his abortion clinic. “We all do, and you never know when you might need it.”
It was sort of shocking advice to get so early in my medical career, that I should be arming myself in case some cuckoo bird activist chose to try to assassinate me for my choice to help women realize their reproductive freedom. I didn’t take that advice, as I didn’t grow up with firearms. Overall, they scare me, and I don’t like handling them. Perhaps this is why I was a little freaked out every time I got in the car with my friend and he unholstered his Glock and unceremoniously dropped it into the side door pocket of his truck. I worked in abortion clinics for years and never chose to carry, though. It would have been easy to get a carry license, given that I was a potential target of legitimate violence (as if that is required). But in the end it seemed really unlikely that a gun could be useful to me, even if somebody tried to kill me. And I could think of a tremendous number of ways it could be to my disadvantage to have it. So I didn’t carry.
But my friend thought differently. He imagined some kind of situation where a bad guy might come up on him and he would be John Wayne, outdrawing the perp and somehow taking him down. It always seemed a little ridiculous that this could possibly happen. The problem would be that you would have no idea who that dangerous person might be. By the time you realized who the bad guy is, you would be dead or injured at least. I can sort of imagine a firearm being useful in some kind of mass shooting situation, but for an abortion provider it wouldn’t be a mass shooting – it would be a directed assassination attempt. And that would be an entirely different situation. But my friend still thought it made sense to carry, and he did.
And wouldn’t you know it, one day he actually had a reason to use that gun, and he did. And this is what happened.
Mitochondrial DNA is Evolving, and That’s Amazing!
This week in the news there have been a number of articles about a new technology that has allowed the creation of an embryo from three parents, and boy it is creating controversy.
Three parents you say?
Yes. Of a sort.
The case in point regards a woman who unfortunately had a child with a deadly mitochondrial disease. Mitochondria are organelles (“small organs”) inside each of our cells where ATP, our primary energy source, is made. Mitochondria are special in that unlike other organelles, they carry their own DNA. In the case of this woman’s tragically afflicted baby, defective DNA that could not support much life.
Geneticists have developed technology to create an healthy embryo without the defective mitochondria by placing a nuclei from the woman’s mitochondrially defective egg into a donor egg, after removing that egg’s nuclei. They then fertilized the new proto-egg with the husband’s sperm to create a new embryo. In essence, the egg had three parents – two in the nuclei, and a third one in the mitochondria.
And the world shuddered.
From all corners were cries of “we’re playing GOD!!!”. “We are altering the human race!!” “We’re no better than Mengele!!”
Most of this comes from a bright line we have put around genetics research that says we will not genetically engineer human beings. Legitimate bioethicists have felt that this is something we should not do, because of a ‘slippery slope’ towards eugenics. Religious radicals are just uncomfortable with advancement in science in any kind. They say it is because it is against God, but I think it is because a true understanding of how the universe works deprecates the validity of their religion, and thus sparks a crisis of faith.
But either way, most people think that manipulating human DNA is unethical.
I, for some reason, don’t see it this way. In fact, I couldn’t be happier that we have made this leap, and hope we keep leaping. We are coming to understand how we are put together, and in such we are coming to understand how to manipulate that process. That is exciting, not concerning.
We are not “Playing God”. For us to be “Playing God”, a “God” would have to have been the reason we came to be on this earth. And unequivocally, it is not. The evidence for evolution is so unbreakably strong that to claim that we are here because of “God” is purely ignorant. Humans are on this earth because our genes were selected for over millions of years, not because somebody put us here. If you believe in God, fine. But please don’t hold humanity back from our future by claiming that we are breaking your religious rules.
Even worse is the claim that to genetically engineer a human is akin to Nazi experiments. True, Hitler wanted to manipulate the future of humanity. But he didn’t want to do it by changing the genetic information of the future. He did it by murdering the people who were already here. To claim these are the same thing is an affront to geneticists, and is too good for Hitler.
In truth, I am absolutely head over heels excited to hear that we were able to eliminate a deadly genetic disease from a family through genetic means. What this means to me is that we are actually CURING disease, not just treating the symptoms that it produces.
Evolution is something that is terribly misunderstood. Its detractors really don’t get how it works. People who don’t understand it think it is about the selection of individuals over others, and thus don’t believe it could ever have ended up in us, but that is not really how it works. It is the selection of GENES that drives evolution, not the selection of individuals.
The problem in this case is that mitochondrial genes do not reproduce sexually, but are rather copied directly from their parent mitochondira, and as such they do not evolve. As such, problems in the mitochondria are passed on forever, never changing except by random mutation.
But now, for the first time, mitochondrial DNA is evolving. Perhaps not by natural selection, but it is evolving nonetheless. And that is exciting.
Don’t take this to believe that I am ignorant of the potential problems. But they are technical, not ethical. Obviously we can not open the doors to unlimited human experimentation, but this is a first step, and it is a good one.
Academic OB/GYN 