Elderly patients 23% more likely to die if surgery is on the surgeon’s birthday

https://www.psychnewsdaily.com/elderly-emergency-surgery-patients-23-more-likely-to-die-if-operation-takes-place-on-surgeons-birthday/

by whx23 • 6 years ago

371 208 6 years ago

psychnewsdaily.com

ekianjo• 6 years ago

So they went to fish for correlations and found this? EDA at its best...

voxl• 6 years ago

I feel like we need an opposite saying for sentiments like this to the age old "correlation does not equal causation", something like "correlation does not mean automatically dismiss"

Quekid5• 6 years ago

Indeed, and this finding could at the very least be said to have some plausible underlying (perhaps indirect) causation.

graderjs• 6 years ago

Correlation doesn't imply causation but it could co-occur with it

Too long

Correlative causation is more correlated with causation than non-correlative causation

Too tongue twisting

Correlation is closer to causation than no correlation

I like that

Ignoring possible causation is correlated with stupidity

Too cruel

Correlation does not equal causation but they are correlated

Not bad

Anyone else?

kkoncevicius4• 6 years ago

The comment you replied to has nothing to do with "correlation does not equal causation". The point was that fishing for results, by trying everything, is guaranteed to find something.

So if, in a study like this, they looked at differences in morality rate between: 1) men and women, 2) younger and older people, 3) younger and older surgeons, 4) surgeries in summer vs winter 4) surgeries in morning vs evening 5) etc etc.... And it came down all the way to n) surgeries on birthday - to find an effect. Then it would be almost guaranteed that such a finding is spurious.

yellowcake0• 6 years ago

The website is currently unavailable so I can't read the article. However p-hacking, to which I believe the parent comment was referring, is a separate issue.

I agree that the incessant belaboring of the difference between correlation and causation in these types of threads is tiresome, but I don't think it applies in this case.

randomsearch4• 6 years ago

How about "if you find a correlation and want to report this as if you think it's significant, then you should formulate a specific hypothesis and perform independent experiments to test it, rather than publishing junk."

wruza3• 6 years ago

Do we? Wait for an hour and there will be a bunch of plausible..apparent descriptions that “invalidate” that “they’re just negligent on their birthday”.

martin_a• 6 years ago

Relevant xkcd: https://xkcd.com/882/

marcosdumay• 6 years ago

Well, that's how you discover things. You go fish for correlations, and publish any interesting findings, so another group can get independent data and check them.

On the meanwhile, a news reporter gets your (probably spurious) correlations and announce them for the entire world as "the TRUTH! science says so, and you don't doubt science, do you?"

That's basically how science gets done on any complex field where we can't test things directly.

sebmellen• 6 years ago

The researchers emphasized that this study focused on common procedures, and on older Medicare patients. This means that the findings may not apply to other types of patients, or to other surgical procedures.

Is there any reason Medicare would play a role in the surgeon's performance?

johncolanduoni• 6 years ago

Medicare patients are all either 65 or older or suffering from a specific covered chronic disease.

thaumasiotes• 6 years ago

Well, it doesn't pay well.

echelon• 6 years ago

Many practices refuse to take Medicare patients.

It's less pay, more paperwork.

Sucks if you're on Medicare. You're stuck with the doctors that do accept it, which probably weeds out some of the better practices.

Healthcare and getting old suck in the US. Think about how this might affect, say, your parents. And eventually you.

cmeacham98• 6 years ago

Medicare (as in the method of payment) obviously wouldn't, but by only polling Medicare patients they bias the patients, as Medicare patients are predominately the elderly.

im3w1l2• 6 years ago

Research on judges has yielded similar results. It has found, for example, that external factors as diverse as outdoor temperatures and sports results can influence judges’ decisions.

When I hear of these funky effects I always wonder how they relate to AI. Presumably this is somehow related to some kind of lossy compression of the state of the world, maybe similar to principal components[0]? Where the "I feel grumpy" component is a mix of defendant-is-guilty, temperature-is-low and my-team-lost.

It might also be related to the binding problem[1]?

[0]https://en.wikipedia.org/wiki/Principal_component_analysis

[1]https://en.wikipedia.org/wiki/Binding_problem

sixhobbits• 6 years ago

Also interesting is "Impossibly Hungry Judges". Many of these correlation effects are paradoxically so strong that they they _cannot_ be the true explanation.

[0] http://nautil.us/blog/impossibly-hungry-judges

tokai• 6 years ago

"The phenomenon of favorable decisions peaking after a meal break is likely an artifact of the order of case presentation. It is not evidence that meal breaks affect the boards’ decisions."

https://www.pnas.org/content/108/42/E833.full

mattkrause3• 6 years ago

Yup. Even ignoring the lack of randomization, there’s another issue with the hungry judges paper that should have raised some eyebrows.

They fit a model using both the case order (1st, 2nd, 3rd, etc) and the time elapsed. Either is significantly related to the case’s outcome, but when both are included, the rank explains away the time elapsed. This is obviously not compatible with increasing hunger/decreasing blood sugar, since those should depend on wall-time.

nefoo62• 6 years ago

I don't have a reference handy, but I seem to recall that that study on judges' verdicts being influenced by temperature, how close they were to lunchtime and so on, failed to replicate. I wouldn't be surprised if the OP study fails to replicate as well. They have a relatively high number of data points (to get an idea of order of magnitude: mortality of 145 across 2064 operations on birthdays) but only reach a P-value of 0.03 on their main conclusion.

im3w1l2• 6 years ago

This one? https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3645463

mattkrause3• 6 years ago

The judges-at-lunch thing turned out not to be a good “natural experiment” because the prisoners were systematically ordered.

The parole board considered cases from one prison at a time. Within each prison, prisoners representing themselves went last and they tended to fair worse than those with attorneys. The judges tended to take meal breaks between prisons, and....poof, there’s the result.

chromanoid• 6 years ago

For human beings: How about simple plain distraction as the problem?

If you refer to AI there are many examples where the training data is biased. One funny example was enemy tank recognition that saw enemies whenever there was gloomy weather, because the sample images of enemy tanks all where shot at such weather conditions to make them appear sinister to human eyes.

If you refer to a mental model, I guess it might simply be a resource management problem. Just because we do not experience the distraction actively it does not mean it is not there. How exactly distraction is compensated is irrelevant to this explanation. Explaining this with mathematical terms is probably pretty arbitrary and leads to framing (in a psychological sense). But I also like speculating on AI ;)

cryptica• 6 years ago

Maybe a surgeon is more likely to be assigned to a risky surgery on an elderly patient when it's the surgeon's birthday.

imtringued• 6 years ago

Or they simply decline non risky surgeries because they want to take a day off or leave earlier.

rightbyte2• 6 years ago

Ye even if they just decline overtime on their birthday and prioritize worse off patient during working hours this stat would show up.

KMag• 6 years ago

I suspect a causation along those lines would be that surgeons are less likely to push back surgeries to the day after their birthday if they're worried that the patient may soon become too sick to operate on.

rzz3• 6 years ago

The surgeon has their mind in other places on their birthday perhaps?

kkoncevicius4• 6 years ago

The study, which appears today in the British Medical Journal (BMJ), looked at 980,876 procedures performed in US hospitals by 47,489 surgeons. Of those procedures, 2,064 (0.2%) took place on a surgeon’s birthday.

So, only a fraction of the surgeons performed operation on their birthdays. Would be interesting to compare the outcomes using the same surgeon group: surgeries on birthday vs same-surgeon surgeries on other dates.

lmilcin• 6 years ago

The question is, are surgeons that are likely to work on their birthdays any different from the ones that would take day off.

spiderfarmer• 6 years ago

I never took the day off on my birthday, but a lot of people do. So it might also make sense to ask why these surgeons are operating on their birthdays. Did they take the day off and went back to perform surgery on a critical patient? Are they overworked? Etc.

rightbyte2• 6 years ago

I mean surgeries on Christmas probably are way more fatal too since they are the ones that can't wait.

You would excepct that it is the day after your birthday the surgeon is worse (risk for hangover or less sleep).

englishrookie• 6 years ago

Is that a thing in the US, taking a day off on your birthday? To the best of my knowledge, nobody does that in Europe - certainly not in the Netherlands.

randomsearch4• 6 years ago

No just "interesting" be essential - without it this is junk science.

kkoncevicius4• 6 years ago

Yeah I mostly agree, was trying to be polite.

esquire_9002• 6 years ago

You make a good point, though I'd like to add that one would expect 1/365 = .274% of procedures to be on a random day (like a birthday). .21% is not so far off that it can't be random chance.

eCa• 6 years ago

That, and since most planned surgeries ought to take place Mon-Fri, if anything it’s a higher percentage than I would have expected.

ChrisLomont• 6 years ago

.21% is not so far off that it can't be random chance

How far off exactly would it need to be before it can be random chance?

wjnc2• 6 years ago

They included fixed effects for hospitals and surgeons: "To test whether our findings were affected by including both hospital and surgeon fixed effects in the same regression models." [1]

Perhaps the link could be changed to the paper itself?

[1] https://www.bmj.com/content/371/bmj.m4381

throwawaylolx4• 6 years ago

Perhaps the link could be changed to the paper itself?

Especially since OP's link won't load.

phreeza3• 6 years ago

They controlled for surgeon effects though, so I suspect the result would be similar.

https://www.bmj.com/content/bmj/371/bmj.m4381.full.pdf

tinus_hn• 6 years ago

If they didn’t change the schedule at all, 100/365 percent of all surgeries would be on the surgeons birthday. Which is 0.27%.

Put another way, assuming a flat distribution, on any given day 980876/365 = 2687 surgeries happen. While apparently on their birthday it’s 2064.

Saying ‘only a fraction of the surgeons performed operation on their holidays’ is a strong exaggeration. It’s about 75% of surgeons.

helsinkiandrew2• 6 years ago

They also found that some surgeons did not work on their birthdays

Is this partially that better/more experienced/senior/more affluent doctors are taking their birthday off, hence people getting more junior doctors?

It would be interesting to see how many more people die on a particular surgeons birthday compared with the rest of their year, rather than the birthday of the surgeon a patient gets.

bottled_poe• 6 years ago

Those that are working on their birthday also more likely to do so under emergency situations...

svrtknst• 6 years ago

Are they? Sounds odd that the norm would be for people to take birthdays off.

habosa• 6 years ago

I remember a previous study showing that junior doctors were actually associated with better results since they were more recently trained and had less ingrained habits/biases.

Don't know if it applied to surgery though.

albertgoeswoof• 6 years ago

I suppose what you want is someone with enough experience, but who hasn't been out of medical school for too long. Probably 7-10 years of experience would be the sweet spot.

I wonder if this applies to other domains as well.

ummonk• 6 years ago

Sounds like you're remembering the heart attack during cardiology conferences study? https://media.jamanetwork.com/news-item/patient-outcomes-whe...

ajsnigrutin• 6 years ago

Most critical cases (with higher chance of death) would probably be given to more senior, experienced surgeons, and that skews the statistics.

barry-cotter• 6 years ago

I would be surprised if it did. I believe the reduction in doctors’ overtime was a wash for parent safety as more shift handoffs and less sleep deprivation more or less canceled except in surgery where it increased mistakes.

kleiba• 6 years ago

Those should be removed from the study.

phreeza3• 6 years ago

The study controls for surgeon factors, so this is taken care of.

paulintrognon• 6 years ago

Archive link: https://web.archive.org/web/20201212210709/https://www.psych...

pankajdoharey• 6 years ago

OK and how is this observational fact of any scientific relevance? Well there could be a similar observation like Elderly people are X% more likely to die if the moon is in the fifth phase of jupiter. So by some hocus-pocus astrological deduction this is a Study worth considering?

wjnc2• 6 years ago

Link to the paper itself [1]. There is a list of secondary analysis in the paper that answer some of the concerns raised in other comments.

[1] https://www.bmj.com/content/371/bmj.m4381

billfruit• 6 years ago

In general I wonder there is some QA/QC process involved in surgery, may be have some sort of independent evaluators observe each surgery and ensure the work is being done upto the laid down guidelines.

wruza3• 6 years ago

More than a decade ago we had to digitize some org’s patient cards into a database. After running few “test” queries against that dataset out of curiosity we found out that you’re less likely to be alcoholic-y if you live on 4-5 floor. The explanation I thought was that they hang out outside, but those who live higher have harder time to go home and prefer to not go. Building with 6+ stories usually have an elevator and “the problem” disappears.

fart32• 6 years ago

This might be different elsewhere, but here, the apartments on lower floors are typically rented and they're cheaper than those on higher floors. It's the case at the building I currently live in, although it's because on the lower floors, there are more apartments (smaller ones) than on the higher ones. Roof apartments are all sold out, not rented.

So, I could imagine, that the higher floors are occupied by more wealthy people, who might be less prone to alcoholism. This theory, however, doesn't check out for high rise prefab houses. But it could perhaps cause the deviation?

wruza3• 6 years ago

Perhaps. The answer is it’s unknown. It was the first time I met correlation so clearly irl, and my idle guess was naive and obviously stupid.

There was no info on building types or sqft/m2, but lower and higher floors are historically cheaper here (1st is little loud/non-private and last is little cold and flood-prone).

mhh__2• 6 years ago

https://www.england.nhs.uk/2019/01/surgical-safety-checklist...

Getting surgeons to adopt the kind of "It's obvious but point and speak or you're fired"-style checklists a la operating an aircraft has reduced complications (from the minor to deaths) by several percent in the NHS. It's perhaps worrying given how low-hanging some of these fruit are - i.e. "Do we have the right patient?".

tomxor3• 6 years ago

I'm probably going to sound silly now but I do this when doing any technical work I deem important or critical enough, point and say outloud what it's for or what state it should be in or in the imperative what to do to it... it does work, it somehow catches silly mistakes compared to keeping everything in your mind, and also gives you confidence because it works like a checklist.

Known as pointing and calling in transport AFAIK.

kba• 6 years ago

What you're describing is very similar to Rubber duck debugging. The idea here is that forcing you to explain what you're trying to do makes it easier for you to catch your mistakes.

https://en.wikipedia.org/wiki/Rubber_duck_debugging

mhh__2• 6 years ago

Its absolutely not silly.

It's similar to why formal verification is so important in hardware, because it's effectively forcing you to be specific about semantics and let's the computer walk through things for you.

rzzzt• 6 years ago

I do this when I am the last to leave a building. "This window is closed... these lamps are off". I read about the transport-related part of it in this article: https://www.atlasobscura.com/articles/pointing-and-calling-j...

danpalmer3• 6 years ago

It's perhaps worrying given how low-hanging some of these fruit are - i.e. "Do we have the right patient?"

It turns out that while it's a good idea to check things this "low-hanging", the value is far larger than catching wrong patients, so don't worry too much!

Much of the value comes from essentially disrupting routine with an opportunity to stop, and from creating a culture of speaking up. I think the NHS was the organisation to trial having the nurse run the checklist, which had the effect of empowering the "lowest level" person in the operating theatre. Studies showed that even just having everyone in the room speak once increased the chance of subsequent communication, and ultimately improved patient outcomes.

Atul Gawande was one of the key people in designing and rolling out these checklists and wrote a book about it that I'd recommend – The Checklist Manifesto.

tomxor3• 6 years ago

That's excellent! it never occurred to me it could have such a positive effect in a team situation. Empowering the supporting members is very insightful, they may be supporting but they are just as critical, they need to feel appreciation for the value they provide to stay sharp and motivated - I hope this can be applied to other contexts, thanks for sharing this.

FabHK6• 6 years ago

+1 on Atul Gawande's book The Checklist Manifesto. It's an interesting read if you're into aviation or healthcare or anticipate being in hospital one day.

oblio2• 6 years ago

People are vain. People's vanity is so strong that they are willing to kill and maim others and even do insane things such as declaring wars.

Regarding your checklist, you should read about Semmelweiss: https://en.wikipedia.org/wiki/Ignaz_Semmelweis

It's crazy to think that entire generations of doctors retired and died arguing against washing your hands!

kennywinker• 6 years ago

Might have surprised me before 2020, but the amount of people throwing hissy fits over masks this year has prepared me for the ridiculous stubbornness of humans asked to change.

riffraff• 6 years ago

i.e. "Do we have the right patient?".

sad anecdote: a friend of mine got surgery to remove a problematic mole on his back, and not only the surgeon got the wrong one, but even got upset with him when my friend mentioned something like "I thought it was further up my back".

praptak• 6 years ago

Procedures in hospitals are interesting. I recently visited a hospital and there was a red sign above the table where nurses dose medicines for patients: "No room numbers on trays, no bed numbers on trays". Seems like a low hanging fruit but a very non-obvious one (well at least non-obvious to me).

roenxi• 6 years ago

It's perhaps worrying given how low-hanging some of these fruit are...

You don't realise how "bad" normal operational discipline is until you've seen it done right. The risk isn't so much that people skip a step, but that phantom steps start creeping in because people aren't quite sure of the standard, that saps a surprising amount of resources away which could be used for checking mistakes. And then people get disorganised and potential holes appear.

A big part of excellence isn't doing the right steps, it is trimming out the steps that don't need to be there, to focus attention on the stuff that works.

michaelt• 6 years ago

Reminds me of a scene in House, where the cynical veteran doctor about to receive surgery on his right leg uses a sharpie to write "NOT THIS LEG" on his left leg.

EvanAnderson• 6 years ago

I know people who have been instructed to do this by medical staff prior to surgery. I have personally helped someone mark a mole they couldn't reach on their back.

FabHK6• 6 years ago

Suboptimal. The "NOT" might be covered by something, and then what remains is "THIS LEG". I would have written "NO NO NO" on one leg, and "THIS THIS THIS" on the other.

In aviation, standard phraseology is generally carefully designed such that (mosts) subsets of a phrase are distinct from the opposite phrase. For example, when ATC warns of traffic, you reply either "traffic in sight" or "negative contact". When ATC hears only half of either, they still know what you meant.

poooogles• 6 years ago

If you want to read more on the background of this The Checklist Manifesto is a great book and has lots of applications when it comes to IT operations. Stupid checklists in markdown that you can check off as you go through have certainly improved our performance in ad hoc tasks that we don't automate.

bookofjoe2• 6 years ago

Back when I was still practicing as an anesthesiologist (1977-2015) I had a pack of 3x5 cards I carried in my scrubs pocket on each of which was an exhaustively detailed list I'd made of EVERYTHING I needed at hand to perform specialized procedures such as inserting an arterial line (putting a #20g plastic catheter through the skin on the inside of the wrist into the radial artery for direct beat-to-beat monitoring of arterial blood pressure, a measurement employed for seriously ill or unstable patients). I would assemble a tray with the following items in the OR before going to ICUs or the ER because invariably one or more of the items I would need would not be present and would take time to procure.

For example:

ARTERIAL LINE

• several sterile alcohol skin wipes • 3cc syringe with 25g needle [for skin infiltration of local anesthetic at puncture site] • bottle of 2% lidocaine with epinephrine 1/1000 • 2x2 cotton gauze pads to use for pressure on failed puncture sites • 3 #20 gauge plastic catheters (22 gauge for small children) • 2 surgical towels to drape over hand and lower arm to absorb blood that accompanied successful arterial puncture • size 7.5 sterile surgical gloves for me to wear while performing procedure • specialized 1" waterproof plastic skin tape to secure and protect catheter in situ

I was constantly amazed by how my colleagues would have to stop and wait for something not present in the unit they were called to. Conversely, when I was called because of an inability to insert an A-line, as they were referred to, and wasn't in a place where I could assemble my desired materials, I'd proceed with the materials at hand, all the while thinking "this could have been done a lot better...."

bookofjoe2• 6 years ago

Note added after HN editing hour closed: The reason I created these Procedure Cards is that when I was really tired — for example at 1 a.m. after I'd been on call and working 18 hours since 7 a.m. the previous day, with six more hours to go till I was relieved at 7 a.m. — I invariably forgot something I needed and had to wait or make do because of this fatigue-induced lapse. With my list, I was able to do what I knew how to do without having to try and remember a zillion specific things.

FiatLuxDave• 6 years ago

I wonder if you would be interested in the discussion in this recent HN thread regarding intubation (or it might all be old hat to you):

https://news.ycombinator.com/item?id=25395314

throwaway22453• 6 years ago

There's increasing suggestion that the claimed benefits of using checklists have not been reproducible in RCTs:

e.g. https://www.bmj.com/content/366/bmj.l4700.full

FabHK6• 6 years ago

One of the studied showed that teams that completed the checklist had lower mortality, but argued that the teams completing checklists might be systematically different from the teams that didn't complete the checklists, and thus the difference could not be attributed to the checklist, per se. Not wrong, but doesn't amount to refutation.

Note that in the debate you cited both, proponent and opponent, advocated the (continued) use of checklists.

Side note: I could see how you could do a blinded RCT, but not how you could do a double blind RCT here.

someburner• 6 years ago

I just got surgery in California and noticed I was asked to state my name and birthday anytime I moved rooms or saw a new person. Seems like this is now part of protocol in a lot of places.

ninju• 6 years ago

I believe a lot of that is verifying that you are the right patient

minikites• 6 years ago

I got in a medium-severity bicycle accident in 2010 and while I was being whisked around the hospital for different tests and procedures I had to do that too.

kube-system• 6 years ago

That is standard procedure in the US for every trained medical professional, all the way down to the MA who measures your height and weight at a routine physical.

throwaway22453• 6 years ago

I've moved from a place where the protocol is "what's your name/birthday?" (while looking at a form with my name/birthday on it)

to a place where the protocol is "are you [name]?"

The difference is unnerving.

MeinBlutIstBlau• 6 years ago

As an advocate of checklists for specific tasks, yes that stuff is good. Oftentimes there are a lot of checks that one would go "yeah no duh." But most good checklist exist with a checkbox because that was an issue before.

quickthrower2• 6 years ago

I’m going to guess (article won’t load for me) it is because the title should be “proportion of elderly deaths is 23% higher for surgery done on surgeons birthday” which might be a different thing if working on your birthday confounds with a certain type of surgery E.g. emergency surgery and being on call vs. elective surgery

moosinho• 6 years ago

Good point. That's probably also the case for surgeries on national holidays.

throwawaylolx4• 6 years ago

It is:

The effect size of surgeons’ birthday observed in our analysis (1.3 percentage point increase or a 23% increase in mortality), though substantial, is comparable to the impact of other events, including holidays (eg, Christmas and New Year) and weekends, which have been argued to affect the quality of patient care.

UncleMeat4• 6 years ago

It isn't a good point. This was explicitly controlled for in the study. People are just making wild guesses about methodological limitations that don't exist.

dj_mc_merlin• 6 years ago

That is not correct, the article talks about methodology:

The patients were all Medicare beneficiaries aged 65 to 99. They had all undergone one of 17 common emergency surgical procedures between 2011 and 2014. Examples of those 17 procedures included cardiovascular surgeries, hip and femur fracture, appendectomy, and small bowel resection. The study focused on emergency surgery, so as to minimize the potential selection bias. For example, surgeons might otherwise choose patients based on their illness severity, or patients might choose their surgeon.

samplenoise2• 6 years ago

The effect size of surgeons’ birthday observed in our analysis (1.3 percentage point increase or a 23% increase in mortality), though substantial, is comparable to the impact of other events, including holidays (e.g., Christmas and New Year) and weekends. But the authors say the “natural experiment” in the present study is more revealing than, for example, holiday-related mortality rates. That is because “those events not only affect physicians’ performance but also influence patients’ decision to seek care (i.e., patients seeking care on these special days might be sicker than those seeking care on other days), as well as hospital staffing.” Unless, of course, the patients know their surgeon’s birthday, which is unlikely (though that may change if this study becomes widely known). That doesn't take exclude the possibility that surgeons may be assigned different patients on their birthdays. Some studies on the 'weekend effect' [1] seem to also control for illness severity, not clear if that was done here. [1] https://en.wikipedia.org/wiki/Weekend_effect

samplenoise2• 6 years ago

"The effect size of surgeons’ birthday observed in our analysis (1.3 percentage point increase or a 23% increase in mortality), though substantial, is comparable to the impact of other events, including holidays (e.g., Christmas and New Year) and weekends. (...) But the authors say the “natural experiment” in the present study is more revealing than, for example, holiday-related mortality rates. That is because “those events not only affect physicians’ performance but also influence patients’ decision to seek care (i.e., patients seeking care on these special days might be sicker than those seeking care on other days), as well as hospital staffing.” Unless, of course, the patients know their surgeon’s birthday, which is unlikely (though that may change if this study becomes widely known)."

That doesn't take exclude the possibility that surgeons may be assigned different patients on their birthdays. Some studies on the 'weekend effect' [1] seem to also control for illness severity, not clear if that was done here. [1] https://en.wikipedia.org/wiki/Weekend_effect

Ensorceled3• 6 years ago

Anecdotally, my father-in-law was chief of staff for a small city hospital and they had a rule about not scheduling afternoon surgeries on important days like anniversaries, birthdays, etc. Basically, if the surgery started going long, you didn't want the surgeon worrying about missing their spouses birthday, birthday with their kids or an anniversary.

It actually wasn't that many surgeries delayed, as the surgeon just juggled surgeries and consults/paperwork/insurance to fit.

If this is fairly standard practice, then an afternoon birthday surgery would be an emergency situation and, hence, more deadly. Given the paper said some surgeons take the day off entirely, any surgeon with that habit would be performing an emergency surgery.

colonwqbang• 6 years ago

This is a beautiful conjecture!

The problem is amusingly circular. Even if you reject the conjure in parent comment, you will be tempted to reduce the number of birthday surgeries due to the increased mortality. This will mean that birthday surgeries are only done in even more desperate circumstances which of course will increase the risk.

So mitigation of this problem will lead to the percentage increasing even more! Actually, it turns out that it is possibly better if the percentage is high!

Ensorceled3• 6 years ago

Yes, it does really mean you need to dig into actual causation or the law of unintended consequences will bite you in the ass.

faeyanpiraat• 6 years ago

I do not completely understand your points.

Shouldn't hospitals have multiple surgeons?

If one of them is on vacation, the other one does the work, and vice versa?

newsgourmet• 6 years ago

I think you have it backwards. The risk of the individual surgeries is not increased. Only the risk that a surgeon will be confronted with an above average critical surgery is increased.

It is not even clear that there actually is a problem. It's just a weird way to slice the data to produce an effect.

FabHK6• 6 years ago

You could control for patient characteristics (age, severity of the condition, etc), and that was indeed done here, see the paper. It also specifically addresses this issue:

The major threat to the internal validity of our findings is that surgeons may selectively operate on sicker and more complex patients on their birthday, perhaps because those patients cannot have their procedures delayed. However, this is unlikely to explain our findings because we found that patients who underwent surgery on the surgeon’s birthday were similar in all observable characteristics to patients who underwent surgery on other days. Furthermore, severity of illness as measured by predicted mortality, and the number of procedures performed per surgeon, also did not differ based on whether a surgery occurred on a surgeon’s birthday compared with other days.

It seems to me that the analysis is quite carefully done:

Findings were qualitatively unaffected by: using in-hospital mortality instead of 30 day mortality; additionally adjusting for the timing of the surgery; including both hospital and surgeon fixed effects in the same regression models; excluding potentially outlier surgeons with the highest mortality; using logistic regression models instead of linear probability models: using random effects models instead of fixed effects models; restricting our analysis to surgeons who performed procedures on their birthdays; additionally adjusting for the day of the year; or excluding surgeons who were born on the outlier birthdays (supplementary eTables 5-13). [...] The study findings were qualitatively unaffected when the analysis was restricted to procedures with the highest average mortality or to patients with the highest severity of illness (supplementary eTables 16 and 17).

Galanwe2• 6 years ago

If this is fairly standard practice, then an afternoon birthday surgery would be an emergency situation and, hence, more deadly

This is spot on. The causality can be both ways.

Note that it would be interesting to dig into what is really computed here, because the whole wording seem intentionally sensationalistic.

1) "23% more likely to die" seems _huge_, but it applies to an already very small chance. The mortality rate just goes from 5.6% to 7%. Using this logic, moving from 0.1% mortality rate to 0.3% would mean "you are 3 times more likely to die".

2) Comparing mortality rates only make sense if the distribution of operation complexity are identical for these days. As the parent post suggest, it seems very likely that low complexity operations are postponed after a surgeons birthday.

3) Where are the confidence intervals? I refuse to even consider looking at a statistics if error boundaries and significance metrics are not provided.

That may very well all be provided in the underlying paper, but the article itself does not really discuss these points.

soco2• 6 years ago

Aren't we doing here statistics on a one-surgeon sample size?

FabHK6• 6 years ago

1) "23% more likely to die" seems _huge_, but it applies to an already very small chance. The mortality rate just goes from 5.6% to 7%. Using this logic, moving from 0.1% mortality rate to 0.3% would mean "you are 3 times more likely to die".

But that is indeed precisely what it means. The 737 MAX might have increased the accident rate from 1 in a million to 3 in a million, and that would have been a tripling. That is not sensationalistic.

3) Where are the confidence intervals?

In the paper: "(7.2% v 5.6%; adjusted difference 1.6%, 95% confidence interval 0.4% to 2.8%; P=0.01)"

jlebar• 6 years ago

If this is fairly standard practice, then an afternoon birthday surgery would be an emergency situation and, hence, more deadly.

TFA says they're only counting emergency surgeries, to avoid exactly this bias.

UncleMeat4• 6 years ago

This is the most frustrating pattern in online discussion of science. A post title presents a conclusion, then the top comment proposes some alternative cause of the conclusion or some hypothesized methodological weakness in the research, then readers assume that the research is bad. Often, the exact specific criticism appears directly in the paper because the researchers thought of that too.

ericpauley• 6 years ago

Simpson's paradox: https://en.m.wikipedia.org/wiki/Simpson%27s_paradox

La1n• 6 years ago

I think it'd be more accurate to describe this as suvival bias, where the worse cases "survive" (i.e. they get to be done on that day).

WarOnPrivacy• 6 years ago

If this is fairly standard practice, then an afternoon birthday surgery would be an emergency situation and, hence, more deadly.

As pointed out by jlebar, this is controlled for by comparing similar emergency surgeries.

"The patients were all Medicare beneficiaries aged 65 to 99. They had all undergone one of 17 common emergency surgical procedures between 2011 and 2014."

wittyreference• 6 years ago

There are emergencies, and there are EMERGENCIES. The former can often wait 24 hours; the latter cannot wait at all. Medicare data does not capture that at all - it only captures the categorical, "surgery type."

e.g., someone has a run of the mill cholecystitis that needs to come out. It can go when there's an opening in the surgical schedule, or tomorrow morning. That's an "emergency" - it came in through the ED, wasn't elective.

Then there's the person w/ chole that looks septic and you're afraid they're going to perf or already have. That person is going to the OR now.

Under Medicare coding, both of those are lap choles, CPT 47562. This doesn't control for that at all, except in the broadest of ways.

Also, a 65yo surgical candidate and a 99yo surgical candidate are wildly different. 99yo isn't going under the knife for anything other than immediate threat of death or unendurable pain. In the lap chole example above, I'm going with a trial of abx in the 99yo unless he's absolutely about to perf; 65yo, sure, let's take the gallbladder out - once he's progressed to sx chole, odds are really good it'll have to come out within the next two years. I think most surgeons would rather do it at 65 than 67.

Looking at the 2x2 of 65, 99, emergency, and EMERGENCY, you capture an incredibly large variety of severity and risk.

misiti3780• 6 years ago

Not exactly the same by similar:

My father is a surgeon at a small hospital and my mother just got her hip replaced a few weeks ago (at a different, larger city hospital) and the first thing he insisted on was she was scheduled as the first patient of the day.

giantg22• 6 years ago

My father is a physician. He always recommends that if you are getting a test done, try to schedule it for the middle of the week and not near a holiday. It seems the lab techs make more mistakes on Fridays, weekends, etc. Just his anecdotal experience.

michalu• 6 years ago

So you have 365 days in the year when a surgery can take place but only one day when a surgeon can have birthday. You compare two samples of 364:1 ratio ... it wouldn't be suprising the tiny sample gets some crazy deviations. Yet you find nothing so you're forced to dig in deeper (well this kind of content does well on internet you better find something) and bam there's a deviation for elderly patients, now you've got something to get your work talked about ...

Funny the website that hosts the study* even displays an "altmetric" chart showing how many media talk about it, how many tweets etc. Well done science :)

*https://www.bmj.com/content/371/bmj.m4381

aldo712• 6 years ago

The website appears to be down. [1] is an archived snapshot.

[1] https://web.archive.org/web/20201216100507/https://www.psych...

Someone• 6 years ago

For those wondering about that “elderly”: the researchers only looked at “100% fee-for-service Medicare beneficiaries aged 65 to 99 years who underwent one of 17 common emergency surgical procedures in 2011-14” (https://www.bmj.com/content/371/bmj.m4381), so they didn’t check whether this applies to non-elderly patients.

It also is worth noting that this is published in the BMJ Christmas Issue (https://www.bmj.com/about-bmj/resources-authors/article-type...), so it should be taken with a grain of salt.

seebetter• 6 years ago

I’ve worked with a lot of surgeons and have heard/seen a lot of unbelievable things. Human beings are human. And often poorly educated in principles and ethics.

nvrGiveUp• 6 years ago

Medical is beyond Science unfortunately. The club exists to protect their extraordinarily high wages and protect them from punishments.

There's a reason physicians don't consider themselves scientists. If they make an error they can claim they knew from Tradition/Art/Authority.

It's politically impossible to outspend the US Physician Cartel (AMA), so I doubt we will have a Science based alternative or science based reform.

bluesign• 6 years ago

“ The study, which appears today in the British Medical Journal (BMJ), looked at 980,876 procedures performed in US hospitals by 47,489 surgeons. Of those procedures, 2,064 (0.2%) took place on a surgeon’s birthday”

Actual data: 2064/980876 operation on bday 6.9% die, rate = 142 death

Expected: (if we use non bday death rate)

1/365=0.0027 2687 operation With better 5.6% death rate = 150 death

So deaths are only 6% more, so basically they are doing less and more emergency operations on birthday, so death rate is increasing it seems.

It means they are making 23% less operations on birthday then any normal day.

throwawaylolx4• 6 years ago

The results are a lot less interesting when you read that the risk increase they found is comparable to that present during regular weekends:

The effect size of surgeons’ birthday observed in our analysis (1.3 percentage point increase or a 23% increase in mortality), though substantial, is comparable to the impact of other events, including holidays (eg, Christmas and New Year) and weekends, which have been argued to affect the quality of patient care.

huntermeyer• 6 years ago

Spurious Correlations: http://tylervigen.com/spurious-correlations

andreygrehov• 6 years ago

Similarly, postoperative mortality rises as the day of the week of elective surgery approaches the weekend [1] [2].

[1] https://pubmed.ncbi.nlm.nih.gov/29251716/

[2] https://news.ycombinator.com/item?id=22020160

e_f_rodrigues• 6 years ago

This is part of the BMJ Christmas Edition...

"While we welcome light-hearted fare and satire, we do not publish spoofs, hoaxes, or fabricated studies."

https://www.bmj.com/about-bmj/resources-authors/article-type...

dangus• 6 years ago

A reminder about statistical math:

If something is 23% more likely to happen, you have to look at the original probability to get a handle on whether that increase is serious.

For example, if something has a 5% chance of happening, and it’s now 23% more likely, that means it now has a 6.15% chance of happening.

mrfusion2• 6 years ago

Couldn’t this be that surgeons don’t want to schedule surgeries on their birthdays so they end up only scheduling the sickest and most urgent?

(Sorry if that’s already been suggested)

pps• 6 years ago

The study focused on emergency surgery, so as to minimize the potential selection bias. For example, surgeons might otherwise choose patients based on their illness severity, or patients might choose their surgeon.

MeteorMarc• 6 years ago

How come nobody mentioned the day <em>after</em> the surgeon's birthday?

buzzerbetrayed• 6 years ago

What makes that day more special than 2 days after the surgeon's birthday? Or any other "normal" day of the year.

vincengomes• 6 years ago

If there was a party on Surgeons Birthday, he might be hung-over the next day. Like the day after Christmas. or New Year.

mrfusion2• 6 years ago

Let’s do a study; how many more bugs do programmers produce if they work on their birthday?

(Im most careers, do people even take their birthday off?)

TehShrike• 6 years ago

I couldn't find this anywhere: what was the standard deviation of the mortality rate between non-birthday surgery days?

Raphmedia2• 6 years ago

I recently had a complex facial surgery. Before doing so, I tracked all informations I could about my surgeon.

Everyone had good comments, good healing, very impressive track record, etc.

Everyone but one patient. She complained on how her surgery was rushed, how quick she was out of the operating theater, how she is scarred from it, etc.

At first, I thought she was lying. Why was she such an outlier?

I asked her for more details. It turns out her surgery was in the afternoon of the last friday before the Christmas holidays.

After knowing this, I made sure to schedule in during the middle of the week aways from holidays. My surgery went well.

I am glad to finally have statistics on this gut feeling I had. 23% is a LOT, and the 30% for the holidays is even worst. I had made a mental note to avoid those days, now it's become a rule.

cloverich• 6 years ago

Just a note, this (and many) titles report _releative_ change as the percentage. E.g. 1% -> 1.5% report as "50% increase". It is IMHO very misleading. At one point I developed a gut reaction to any statistic "Relative or absolute".

Raphmedia2• 6 years ago

6.9% vs 5.6%. Still a big increase and that's just the deaths. I would imagine that errors follow a similar curve.

AlwaysRock• 6 years ago

I read something similar based on how long the surgeon had been working that day. I always wondered how plausible it was to show up for surgery day and ask the surgeon how many hours of sleep they got the night before and how long they have been working that day.

ConradKilroy• 6 years ago

Solution, allow doctors and surgeons time off from bday!

parentheses• 6 years ago

What about the day after?

Triv888• 6 years ago

What about non elderly patients? This study appears to be biased

Elderly patients 23% more likely to die if surgery is on the surgeon’s birthday

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