I have been in the informatics space for some time and none of these ML generated sepsis alerts are helpful in the ED.
We can readily tell who has sepsis when confronted with patient appearance, vital signs, and workup.
The issue is trying to find a signal in all of this data where they have an occult condition that we are not yet observing. These folks get sick real bad and real quick and we often do miss this!
Trying to find that signal with our current medical technology is difficult but there are some immune markers that could potentially alert us. These tests are now coming online and should be prevalent within the next few years. Hopefully, more research will show whether they are helpful or not.
Sometimes, even the best tests or calculators or ML generated alerts do not measure up to physician gestalt.
There’s a thread about how emergency physicians are paid. It varies from group to group:
Physicians can be salaried and receive benefits from their group or hospital
Physicians can be 100% productivity based meaning that they will only get paid by the amount of patients they treat but they receive no other benefits from the group or hospital
In between these two groups, there is a wide variety of compensation Packages that are complicated to discuss in this comment.
Nonetheless, the overwriting factor for all emergency physicians is that we triage patients, not only after triage, but internally as well, including those patients at reside within the treatment rooms and those outside in the waiting room.
The question is, can we see less patients and spend more time with them and the answer is yes but to the detriment of the entire department and possibly not seeing a patient who is sick and who hasn’t been seen yet. Do you have to be able to tell who you can spend five minutes with and who needs 30 minutes.
Through put his king, but quality is queen, so there’s always a trade-off between seeing patients fast enough and to see enough patients through your shift, but to also how they were with all to determine which patients will require more time and more due diligence.
Every shift is a pull and push between these two dichotomies and it’s never easy and there are multiple decisions that have to be made.
The ED is specifically attuned to these presentations but the sepsis alerts and algorithms in place are horrendous and will fire off even for this with viral illnesses and syndromes.
Sepsis alerts are meant to find bacteremia in patients who present with a set of vital signs and laboratory findings indicative of it and even those definitions are not readily agreed upon.
The ED is highly accurate with its diagnosis and treatments despite everything that has been said.
Trying to find a zebra in the hoof beats of horses when the number of patients quickly outstrips your department’s capabilities is a fools errand because if the workup require will overwhelm throughout to the point that the delay in care will put other patients at risk.
There is a fine line between doing enough and doing too much that will grind your department to a halt and then have your waiting room backing up.
Unfortunately for this patient, his occult condition didn’t manifest itself within his two ED visits and we don’t have prognostic capabilities to tell who will and won’t decompensate. We all make value judgements and treat the patients in front of us
You can't automate it. You have to look at the data and charts to figure out the specifics you want and then you plug and chug. I haven't looked deeply at this though but whenever researchers use relative risk and it shows a profound effect, I always calculate the absolute risk to make sure that the intervention is effective.
Many researchers go to relative risk because it shows better results!
I don’t like relative risk and relative risk reduction because it tends to overestimate the effectiveness of the intervention.
In this case, the absolute risk when measuring for death in the GIM pre-intervention and GIM post-intervention are 0.0215 (2.15%) and 0.0146 (1.46%) with an absolute risk reduction of 0.0069 (.69%).
While the relative risk is 26% across the pre- and post-intervention, the absolute risk reduction is only 0.69% with a NNT (number needed to treat) of 1/156. Which means that 1 patient in 156 was helped by this intervention.
In addition, they had 2 false alarms for each true alarm and could suggest that interventions were performed in patients who did not require it — more tests, medications and possibly increased risk from said interventions.
This shows that the CHARTwatch ML/AI is not helping at all that much clinically.
Doctors are paid by the patients that they treat. As an emergency physician, I treat 20-25 patients per shift on average and I am paid by approximately half of them due to not having insurance or money to pay for my services. I am paid roughly $120 per patient. Is that excessive in your opinion?
I would say that doctors in other countries are not paid accordingly and are UNDER-paid. See the UK NHS strikes as an example.
You should be complaining about is the excessive charges and reimbursement that hospitals receive for the care that they give. It gives me pause that despite having multiple physicians in your family that you do not understand the difficulty of their practice or work environment.
Most white collars jobs including doctors, engineers, and administrators make multiples of our European counterparts. I would say that Europe underpays its workers.
Again, I am a highly paid worker just like the rest of you. If I don’t work and treat patients then I am not paid anything whatsoever.
I would be further much ahead financially if I had stuck to being an engineer 18 years ago and not have put off earning an income for 7 years and going into massive debt. This was a risk because I come from a blue collar, lower middle class background without a safety net.
Your complaint should be directed towards the hospitals, for-profit insurance companies, and others who profit massively on the backs of patients.
My "industry" is only myself as I am beholden to my patients. I work and am paid by each patient who I treat and receive reimbursement by 50% of them at best.
If you don’t care about my work-life balance and lump me in with the rest of the healthcare system, then there’s nothing much to discuss.
It’s inappropriate to link once dissatisfaction with one’s income.
There are multiple reasons why US doctors are unhappy about their profession. I’m not sure where you get being oppressed as being the titular complaint.
I was an engineer before going to medical school and have an outside perspective as well.
I have complaints with medicine as to how it has changed over the last 10 years and not for the best. I have the right to complain to make things better for my patients and my work-life balance. That doesn’t mean that I am oppressed.
They do to a degree but most of the money comes from the government to subsidize costs. I’m not privy to the amount or percentage but they do cry about it when the residency union (CIR) asks for inflation adjusted salary increases.
Are you seriously asking residents to subsidize their own training working 60-80 hours a week [1] and being paid maybe $20-25/hr for 3-7 years while the hospitals make money from their services?
If that were the case, then the only ones who would put up with such a system would be those who have rich families to back them up.
I came from a blue collar background and my family could not help subsidize my training and I could not afford to live, make rent, or afford food if I had to pay for my training as well.
There are so many other things that you are completely glossing over including annual income between generalists vs specialists, pediatricians vs non-pediatricians, reimbursement inequality from Medicare (has not kept up with inflation and is ~40% below inflation), Medicaid pays at best 10-15% on the dollar, and so on.
American physicians also work almost teice as many hours as their European counterparts which would increase their incomes.
[1] it’s considerably more because if you report it then the program can be in danger and lose its credentialing
Martin Makary’s study and the previous IOM one are based on faulty statistics used. The number is extrapolated from a small population to a larger one.
I haven’t paid it any attention because of this problem. GIGO.
Give me a few minutes and I can pull up any number of medical studies or references to back up my claims.
I don’t have them memorized to the actual URL but I have kept up to date with the latest studies and summaries that pertain to my field and my patients.
We can readily tell who has sepsis when confronted with patient appearance, vital signs, and workup.
The issue is trying to find a signal in all of this data where they have an occult condition that we are not yet observing. These folks get sick real bad and real quick and we often do miss this!
Trying to find that signal with our current medical technology is difficult but there are some immune markers that could potentially alert us. These tests are now coming online and should be prevalent within the next few years. Hopefully, more research will show whether they are helpful or not.
Sometimes, even the best tests or calculators or ML generated alerts do not measure up to physician gestalt.