You are less likely to die if your doctor is female

Hess, Dr. Donald dhess at SUSQUEHANNAHEALTH.ORG
Thu Dec 22 13:05:03 UTC 2016


Hi Tom:

I am very familiar with the Ioannidis paper that you cited below, and the article under discussion is a perfect example. Rather than depend on sound bites & pre-digested news items, I decided to download the article and read it for myself. Oh my goodness!  This paper demonstrated why observational studies rank at the bottom of the credence scale. With regard to how cases were assigned to gender: It was according to a percentage of the physician’s Part B billing. How can an individual’s clinician’s billing data possibly be related to the outcomes of care provided by an entire team of clinicians? This is reductionistic thinking gone far astray. It only reinforces the delusion that outcomes rest on one individual rather than a clinical team and its local context.

Dr. Prida (in a previous post) made another excellent point: Doing multiple statistical comparisons is bound to reveal some significant correlations no matter how faulty the data. The more comparisons you make, the more likely you’ll find something significant.

In light of all this, it seems to me that the authors didn’t make much effort in their discussion to disprove their findings. This makes me question their equipoise. Were the investigators truly unbiased?

The most unfortunate thing is that the findings of this study have gone viral…which points to a bias that both physicians and the public share: Just because somebody publishes a paper in a peer-reviewed journal does not mean that their conclusions are valid. Reading the last few lines of an abstract is insufficient. Where’s the critical thinking in all of this?

Regards, Don

Dr. Donald Hess

From: Tom Benzoni [mailto:benzonit at GMAIL.COM]
Sent: Wednesday, December 21, 2016 3:47 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] You are less likely to die if your doctor is female

You asked why include Ioannidis?

I'm sure you're familiar with his seminal paper
"Why most published research findings are false"
http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0020124

Likely a measure of prevailing bias.
If the opposite had been found, would it have been published?
"Men are better than women?"
Try it.

Likely seeing an anchoring bias in the conversation:
1. Research published which supports bias.
2. Search around for reasons why it must be so.

Croskerry would say
Search for reasons it is not so (cognitive debiasing.)

tom

On Wed, Dec 21, 2016 at 7:28 AM, Tom Benzoni <benzonit at gmail.com<mailto:benzonit at gmail.com>> wrote:
Consider adding John Ioannidis' work to consideration.
tom

On Tue, Dec 20, 2016 at 5:52 PM, HM Epstein <hmepstein at gmail.com<mailto:hmepstein at gmail.com>> wrote:
So, Dr. Jena, where do you think gender plays a role in diagnostic accuracy? Patience in listening to patients?  I don't want to display gender bias but there are many studies that demonstrate that while our brains are very similar, stereotypical female brains process data differently than stereotypical male brains do. [See cartoon below ;-) ]

[Inline image 1]

Or perhaps we can identify it within Buster Benson's Cognitive Bias Cheat Sheet <https://betterhumans.coach.me/cognitive-bias-cheat-sheet-55a472476b18#.lmlyvgxp3> under Problem #3: Need to Act Fast such as "Illusory Superiority" or "Egocentric Bias"?

 "In order to act, we need to be confident in our ability to make an impact and to feel like what we do is important. In reality, most of this confidence can be classified as overconfidence, but without it we might not act at all."
See: Overconfidence effect, Egocentric bias, Optimism bias, Social desirability bias, Third-person effect, Forer effect, Barnum effect, Illusion of control, False consensus effect, Dunning-Kruger effect, Hard-easy effect, Illusory superiority, Lake Wobegone effect, Self-serving bias, Actor-observer bias, Fundamental attribution error, Defensive attribution hypothesis, Trait ascription bias, Effort justification, Risk compensation, Peltzman effect

​Regards,
Helene​


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Diagnostic Errors on Facebook<https://www.facebook.com/DiagnosticErrors/>

On Tue, Dec 20, 2016 at 9:39 AM, Jena, Anupam Bapu <Jena at hcp.med.harvard.edu<mailto:Jena at hcp.med.harvard.edu>> wrote:
Hi Mark, wonderful to hear from you! I’ll share my thoughts and Ashish should chime in.

First off, terrific question, but hard to say.  The first issue we have/had to address is whether our findings are driven by something unmeasured about the patients male and female docs see. We don’t think that’s likely b/c we focus on hospitalist physicians who within the same hospital are plausibly ‘quasi-randomized’ to patients, i.e., patients don’t choose M vs F docs in that setting. We also observe that the characteristics of patients are similar, which is consistent with the randomization hope.

That begs the question, why? It’s not about spending intensity, LOS, or where patients are discharged. We look at those. So, we are left w/ two things, are there slightly more misdiagnosis, incorrect treatments, or a hybrid problem of prognosis (i.e., may not matching the best treatment to a given patient).  If I had to guess, misdiagnosis would have to be an element b/c we are looking at mortality here. I think it’s more likely that a misdiagnosis may be made than the correct diagnosis made but the incorrect treatment offered. I say that b/c I think (w/o data) that doctors would be better at identifying the correct trx if they have the right diagnosis, but the right diagnosis may be elusive.

There are reasons to think that misdiagnosis may play a role. There may be differences in the ability to ‘extract’ important information, due to time spent, patient comfort w/ the doctor, etc. All this is plausible but hard to know if it could actually improve mortality. I would lay my money on differences in clinical decisionmaking, e.g., anchoring, premature closure of diagnosis; these are features of decisionmaking that are different on average between M and F in other settings (e.g., finance is where this has been shown I believe).

Those are my 2 cents!

Hope all is well, Bapu



Anupam B. Jena, MD, PhD
Ruth L. Newhouse Associate Professor
Harvard Medical School

From: Mark Graber [mailto:graber.mark at gmail.com<mailto:graber.mark at gmail.com>]
Sent: Monday, December 19, 2016 12:51 PM
To: Listserv ImproveDx
Cc: Jha, Ashish; Jena, Anupam Bapu
Subject: You are less likely to die if your doctor is female

Patients of female hospitalists had lower 30 day mortality rates and readmissions - see article attached, or here: http://www.msn.com/en-us/health/medical/you%e2%80%99re-less-likely-to-die-if-your-doctor-is-female-according-to-a-new-study/ar-AAlKb6o?li=BBnb4R7<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.msn.com_en-2Dus_health_medical_you-25E2-2580-2599re-2Dless-2Dlikely-2Dto-2Ddie-2Dif-2Dyour-2Ddoctor-2Dis-2Dfemale-2Daccording-2Dto-2Da-2Dnew-2Dstudy_ar-2DAAlKb6o-3Fli-3DBBnb4R7&d=CwMFaQ&c=WO-RGvefibhHBZq3fL85hQ&r=Xq_etsANojVYFKQHAR8Zagjs9xmtdmxIs8TLN5U_xd4&m=68ElPU8pnAeaPazp_CS1XwQeoWWNNIpaw_i31Ex8pxE&s=SCe-wzgscmnZ7YLiXXpjUJt-xIMF2epKSMCbrRL7sEY&e=>

Two of the authors were on the IOM panel that drafted “Improving Diagnosis in Health Care”, copied on this message.  Congratulations guys, and maybe you can help us:  Does this difference relate to doing a better job with diagnosis, treatment, or both?

     Mark

Mark L Graber MD FACP
Senior Fellow, RTI International
Professor Emeritus, SUNY Stony Brook
President Society to Improve Diagnosis in Medicine (SIDM)


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