By Lenny Shteyman MAAA, FSA
A doctor and actuary walk into an emergency room…. It sounds like the beginning of a dark joke actuaries would appreciate, except that it became my reality for five days in a row. Here’s my story.
During my recent paternity leave, my newborn baby, my wife, and I ended up in the emergency room of a prominent Manhattan hospital. The dangerous diagnosis was dehydration caused by a stomach virus. It led to the excessive production of “solid” waste, which was mostly liquid, hence the “” marks. The treatment prescribed was IV fluids. After three days of continuous IV, my newborn was visibly in great shape, with all typical symptoms of dehydration gone, except for one quantitative test, which was unique to this hospital, as I later learned. Since the baby really looked good, and I have two other young kids at home, I insisted on being released, but doctors refused to take the baby off the IV until the quantitative diaper test was cleared. The actuary in me smelled something fishy about this “quantitative test” so I started my own investigation by talking to nurses and doctors.
Investigation
Every 12 hours I was getting a new set of nurses and doctors, and they were incrementally sharing new bits and pieces. One 1st year resident, likely a high school debate club champion, argued very passionately with me at 3am that the test is highly scientific, and can’t possibly be wrong. He brought every single debate technique into the conversation. The nurse from the same night shift said the test has been around only for two months, and she doesn’t know how to estimate figures that doctors are asking for. A more seasoned doctor agreed with me that the test can be seen as subjective, but that’s where the art vs. science of medicine come into play and I need to trust them. Once I gathered all the facts, I saved four soiled diapers and argued with multiple doctors that the assumptions in their calculation are inappropriate, because they don’t tie to actual diaper data. I won the argument against doctors on their turf, which doesn’t happen often, and we were released from the hospital shortly after.
The Test
- A nurse records the weight of each soiled diaper, e.g., 100 grams.
- Minus the weight of a clean one, 20 grams, equal 80 grams.
- Applying 30% default ratio of “solid”-to-total waste: 30% x 80 = 24 grams, in other words, solving
for S in S / (L+S) = 30%, where (L+S) is observable. - Estimated total “solid” waste produced per 24-hour period was 2x normal, hence doctors were still worried about residual effect of the virus and taking the baby off the IV.
The Flaw
- 30% default assumption was completely wrong and inappropriate, and likely closer to 10% in our case. The baby was going through a lot of IV fluids every day and could not possibly have had the same solid-to-total waste ratio as a typical healthy newborn. The (L+S) denominator, the “total”, was inflated due to the continuous IV.
- Alternatively, the calculation was too simplistic—it ignored the amount of IV fluids or the food amount my newborn was consuming.
Root Causes
- Nurses admitted that they felt uncomfortable with estimating percentages, so they never challenged the default 30% setting in the system.
- Doctors did not regularly inspect diapers to validate the information they were getting from nurses. They also didn’t know that nurses were not comfortable estimating percentages.
The Solution
- I suggested that nurses should record approximate volume of solid waste,
instead of percentage, since volume could be estimated with a naked eye. Nurses
and doctors loved my idea, and I hope it will be implemented. - I also told them about 2nd line of defense in Insurance and Banking
sectors, whose job it is to challenge assumptions and methodologies. They thought
it was interesting but didn’t feel that it would work well in a hospital
setting. Everyone’s attitude is already pretty conservative and there are
usually multiple layers of review (residents vs. attending physician, day shift
vs. night shift, doctors vs. pharmacists, etc.)
In conclusion, without speaking up and challenging assumptions, I would be in the hospital until my newborn turned 18. My actuarial training and soft skills came in handy in the real world. One of the doctors asked me what I do for living (likely assuming I was lawyer) and I proudly admitted that I am an actuary. The whole family was re-united and, as an added bonus, my wife was very impressed (but not surprised) by my problem solving and influencing skills.
Lenny Shteyman is an actuary in New York with MetLife.