Collateralized Death Obligations

When my mother died last Friday, the doctors at the hospital where she had been for three weeks didn’t have a diagnosis. When my father died two and a half years back, the hospital where he’d spent three months didn’t have a diagnosis. In both cases, there were several hypotheses, but none of them were even remotely confirmed. In both cases, there have been a large number of relatives who have brought up the topic of medical negligence. In my father’s case, some people wanted me to go to consumer court. This time round, I had signed several agreements with the hospital absolving them of all possible complications, etc.

The relationship between the doctor and the patient is extremely asymmetric. It is to do with the number of counterparties, and with the diversification. If you take a “medical case”, it represents only a small proportion of the doctor’s total responsibility – it is likely that at any given point of time he is seeing about a hundred patients, and each case takes only a small part of his mind space. On the other hand, the same case represents 100% for the patient, and his/her family. So say 1% on one side and 100% on the other, and you know where the problem is.

The medical profession works on averages. They usually give a treatment with “95% confidence”. I don’t know how they come up with such confidence limits, and whether they explicitly state it out, but it is a fact that no disease has a 100% sure shot cure. From the doctor’s point of view, if he is administering a 95% confidence treatment, he will be happy as long as his success rate is over that. The people for whom the treatment was unsuccessful are just “statistics”. After all, given the large number of patients a doctor sees, there is nothing better he can do.

The problem on the patient’s side is that it’s like Schrodinger’s measurement. Once a case has been handled, from the patient’s perspective it collapses to either 1 or 0. There is no concept of probabilistic success in his case. The process has either succeeded or it has failed. If it is the latter, it is simply due to his own bad luck. Of ending up on the wrong side of the doctor’s coin. On the other hand, given the laws of aggregation and large numbers, doctors can come up with a “success rate” (ok now I don’t kn0w why this suddenly reminds me of CDOs (collateralized debt obligations)).

There is a fair bit of randomness in the medical profession. Every visit to the doctor, every process, every course of treatment is like a toin coss. Probabilities vary from one process to another but nothing is risk-free. Some people might define high-confidence procedures as “risk-free” but they are essentially making the same mistakes as the people in investment banks who relied too much on VaR (value at risk). And when things go wrong, the doctor is the easiest to blame.

It is unfortunate that a number of coins have fallen wrong side up when I’ve tossed them. The consequences of this have been huge, and it is chilling to try and understand what a few toin cosses can do to you. The non-linearity of the whole situation is overwhelming, and depressing. But then this random aspect of the medical profession won’t go away too easily, and all you can hope for when someone close to you goes to the doctor is that the coin falls the right way.

21 thoughts on “Collateralized Death Obligations”

  1. Hi Karthik,

    My condolences. I haven’t met you but follow your blogs regularly and my heart goes out to you.
    My prayers are with you.

    Sowmya.

  2. A few things that are grossly wrong with the current system of hospitals and doctors –

    1) Do hospitals, especially private hospitals have a review system that checks on the morbidity rate? For example all schools registered with the state board, if they don’t achieve a particular pass-rate for X std, their recognition is taken away. Something on those lines is necessary for hospitals too. And care must be taken that this doesn’t go the same way as BBMP’s checks on Bangalore restaurants.

    2) Most doctors have this policy of being on rotation with n hospitals, which means that in each hospital, per visit they would be spending less than 10 minutes per patient, and look into a case sheet prepared by someone else. Ten minutes per day is hardly enough time to think deep enough to treat the condition. Instead they will end up treating the symptoms.

    3) Related to point 2), the death of the family doctor system. This way, there would have been at least one doctor who knew the patient inside out.

    4) Over-specialisation of doctors. My dad was admitted last year with acute stomach pains – turned out the cause was two different things, a kidney stone, and the intestine knotting itself in a odd manner that constricted the flow of food. So, two ‘specialists’ were assigned. And in the 5 minutes per day they would spend with my dad, it was horrible to see how they would deliberately avoid stepping on the other’s toes.

    5) Fighterisation of the whole treatment concept. It has now become completely ‘if this, this and that happens, then pump him with chemical A’ types. So doctors will not bother too much to think about anything beyond prescribing the best-fit medicine.

    Of course, if there is a ‘good’ doctor who takes enough interest in the patient and tries to arrive at a right diagnosis, all the weaknesses in the system is still ok. But given they spend lakhs of rupees just to be able to be called a doctor, I guess they have less incentive to be ‘good’ and more to maximise revenue inflow.

  3. Dear Karthik,
    The news of your mother’s death has come as a terrible shock.I did not know her, but, knew your father.The tragedy is ever so poignant coming rapidly as it did after your father’s equally and tragic demise.Please accept my condolences and do get in touch with me for any help you may need(on government or personal matters).Please take care of your health
    L V Nagarajan (Hareesh’s father)
    PS Dr Verma(Neuro surgeon now in his 80’s )said almost the same thing about 1 % and 99% while explaining his first brain surgery which he did in 1957

  4. My heartfelt condolences Karthik. As stoic as I am ( and from what I infer from your blog, you are as well ) I would hate to be in your shoes.

    Hope you are taking it as brave as you sound here.

  5. I’m sorry to hear about your mother. I hope you’re doing okay – I bet it’s a crazy time now, and likely will get worse a month or so from now before getting better.
    Do keep writing/thinking – seems to be your way of dealing with grief – and your posts are as much thought-provoking to read as ever!

  6. Hi Karthik,
    I’ve been a passive follower of ur blog for over two years now, and as it turns out, this is my first comment here. I was shocked on reading the first line. I actually re-read it twice, to make sure I was reading what I thought I was. I lost my aunt last year, under very similar circumstances, where we finally didn’t get to know what consumed her (She was admitted for two weeks in a so-called “hi-tech” hospital in Bangalore). I still haven’t come over her death. And to see you sound so objective even at this point, is remarkable I must say. Heartfelt condolences to you. And please keep writing. Thats the only way, some of us will get to know that you are okay…

  7. Condolences, my man.

    Just a thought, though, from my experience. Are you sure it is forced to a 1 or a 0 from the patient’s side? In a less lethal situation, it could just lead to a halfway situation, say loss of a limb or something.

    That’s just my comment on your logic. It doesn’t take away the fact that medical science is still an art.

  8. I am so sorry man. I wish you all the best of luck from now on, and hope that the law of probability catches up with those coins.

  9. Hi
    I’ve been a regular reader of your blog for some time now. My deepest condolences for your loss. May God be with you.

  10. My deepest and heart felt condolences..I do not have words to share my feelings at this moment . You are one I am silently following and feeling proud on many occasions since about 10-11 years. I pray God to give you strength you need to carry on…

  11. Karthik,

    My heart goes out to you… am really really sorry about your loss. I can pray for strength for you…that you may overcome this. May God bless both your parents..

    It is terribly tragic and shocking to hear this news.. Came to your blog after someone told me..

    Heartfelt wishes,
    Sonali

  12. Hi Karthik,

    My deep condolences for your sweet mother and my affectionate prabha aunti’s demise. May her soul rest in divine peace.

    Let this Bhagavadgeeta sloka strengthen your life:

    Dukkeshu Anudwigna Manah Sukheshu vigata spruhaha |
    Veeta Raga Bhaya Krodaha Stithadheehi muniruchyate ||

    May God bless my dear family friend.

    Yours friendly,
    Gurudatta K G

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