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Can Good Doctors Be Bad for Your Health?

nytimes.com

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Re: Can Good Doctors Be Bad for Your Health?

#51

Post by zaidf »

lordCarbonFiber wrote: post #19
jpmattia wrote: post #7

> Despite often repeating the mantra “First, do no harm,” doctors have difficulty with doing less — even nothing. We find it hard to refrain from trying another drug, blood test, imaging study or surgery. It's disappointing that the conflict-of-interest is not better recognized. Asking a surgeon if you need surgery? Do you really expect a person under a pile of medical-school debt to give you an unbiased answer?

You're completely missing the actual conflict of interest, balance the creed of 'do not harm' with the reality of protecting themselves from the patients. No one wants to be sued for 'not doing enough' and stick of a potential malpractice suite makes the already incentivized extra procedures make a lot more sense. For once the larger problems don't lie with the system (although they certainly aren't helping), but rat…

You nailed it. The thread is full of doctor-blaming, as if doctors really relish in calling for useless scans. In fact, most doctors hate it and only do it to protect themselves against lawsuits.

The other blindspot many people in this thread have is that just as you can have shitty doctors, you have many more patients with shitty knowledge of medicine.

My own view is that once you pick your doctor, stay informed but at the end of the day, you need to trust his judgement. If you don't, find another doctor. Why? Because ultimately, no surgeon can guarantee a successful outcome. So if you don't trust the doctor or have any doubt about him, if the outcome is poor, you will be inclined to blame him irrespective of whether he is at fault(more times than no, he's not at fault.)

This is not very different from being a developer. If I am hired as a developer, I will take my client's input on the big decisions and let him make the decision if he wants to for certain things. But if my client wants to micromanage me and pick the names of the variables I use in my code or question my coding style, well, he'd be better off with another developer. Ideally, he should have never hired me based on my sample code.

Re: Can Good Doctors Be Bad for Your Health?

#52

Post by theworstshill »

theworstshill wrote: post #25

Thats the reason I don't like dentists who are also proprietors and have fewer patients due to the location of their clinics. Too much conflict of interest - there is no point for them to wait and see if a tooth can reinitialize, they'd rather take off healthy tissue to make a buck. I'd rather go to a established chain clinic where dentists are employees and they always have patients anyway because of the location (l…

reiminiralize

Re: Can Good Doctors Be Bad for Your Health?

#53

Post by TheCoelacanth »

wrsh07 wrote: post #47

Is it possible that top doctors are just taking on the most challenging cases? The implicit "explanation" [which seems testable and currently unverified] is that senior cardiologists attempt more interventions [eg angioplasties], and each intervention carries some risk. It could be true, but why report something that wasn't in the paper?

The study compared results at hospitals when senior doctors were away at cardiology conferences with the same hospitals when the senior doctors were present. They also restricted the study to "acute, life-threatening cardiac conditions" so presumably these were cases that could not be delayed until the senior doctors returned. That seems like it would eliminate most of the effect of case selection.

Re: Can Good Doctors Be Bad for Your Health?

#54

Post by imgabe »

Maybe the most famous doctors only get called in on the most difficult cases (i.e. the ones with lowest probability of survival). When they're out of town, patients with these difficult cases get sent to other hospitals where the famous doctors are not out of town.

Re: Can Good Doctors Be Bad for Your Health?

#55

Post by conorh »

dbroockman wrote: post #49
conorh wrote: post #44

I've posted about this before - my wife is a highly specialized surgeon. This article really only scratches the surface of the issues with surgery around the US, as a software developer working in a pretty transparent and open industry I'm always horrified at how surgeons practice in the US. In my opinion the core of the problem is the lack of transparency in the entire system. There are just very few pressures for s…

Full transparency could have negative unintended consequences. For example, if surgeons knew their success rate were public, they would be incentivized to take easier cases. Who would take a difficult case if they knew it would constitute a bad mark on their record almost for sure? Fundamentally, the issue is that it's impossible to observe for any given patient if that patient's outcome would have been better with a…

In places where they have implemented outcome tracking they give patients risk scores and adjust based on those scores - which in itself is tough (bias to give patients worse scores), but you have to start somewhere. I've had this discussion a few times and fundamentally I believe that transparency is better than the zero objective information we have now - currently we don't even know how many operations a surgeon does - let alone the outcomes!

Re: Can Good Doctors Be Bad for Your Health?

#57

Post by thelettere »

The article conflates "good" doctor with experienced doctor. There is no such evidence that experience leads to better outcomes in most divisions of medicine (1), and indeed many have found (just like this one) that less experienced doctors provide better care (2).

The most important variable in your doctor is their personality and your relationship with them, and not their experience (3).

Addendum: The quality of your doctors organization and staff may be even more important than that of your doctor (4).

(1) McAlister, F. A., Youngson, E., Bakal, J. A., Holroyd-Leduc, J., & Kassam, N. (2015). Physician experience and outcomes among patients admitted to general internal medicine teaching wards. Canadian Medical Association Journal, 187(14), 1041-1048.

(2) Southern, W. N., Bellin, E. Y., & Arnsten, J. H. (2011). Longer lengths of stay and higher risk of mortality among inpatients of physicians with more years in practice. The American journal of medicine, 124(9), 868-874.

(3) https://www.researchgate.net/profile/Alan_Swann/publication/... and Wampold, B. E., Imel, Z. E., & Minami, T. (2007). The story of placebo effects in medicine: evidence in context. Journal of clinical psychology, 63(4), 379-390; and http://www.annfammed.org/content/7/3/261.full

(4) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2586978/ and http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3568449/

Re: Can Good Doctors Be Bad for Your Health?

#58

Post by maxxxxx »

stronglikedan wrote: post #34
moistgorilla wrote: post #20

When I was 19 I was diagnosed with something called hydronephrosis. It's effect on my kidney function wasn't significant but my parents took me to see one of the most famous urologists (I think the hospital was in philadelphia) anyway. I don' remember the specifics but the doctor immediately recommended invasive surgery. My father then took me to another urologist he knew from a friend's recommendation. This doctor s…

Had the same thing happen when I broke my hand. The first doctor wanted to fill it with metal. A second opinion with a more conservative doctor caused me to avoid that surgery, and it healed just fine. I encountered the same egregious attitude when cancelling the appointment. It made me realize all the more that it was a attempted money grab, with no real concern for my wellbeing. It was quite the learning experience…

There is way too much money to be made for surgeons. I sometimes interact with surgeons through work and they all deny that money is a factor in making decisions. But they all like their sports cars :-)

Re: Can Good Doctors Be Bad for Your Health?

#59

Post by mamon »

crpatino wrote: post #38
mamon wrote: post #17

Earlier quoted context omitted.

I wouldn't link that to money issue. Rather than that I would say: "When all you have is hammer, everything looks like nail". Surgeons try to solve all the problems, including changing a light-bulb, by surgery, psychiatrists by psychotherapy, traditional Chinese medicine adepts by acupuncture.

Right, which is why the GPs were such an undervalued cornerstone of the old fashioned medical system. They were the ones supposed to hold the big picture in mind, and to cousel their patients when the intervention of an specialist was needed. Today, they have been turned into glorified technitians and the front end of a pipeline that leads to expensive and potentially unneed treatment. There's no wonder everything tu…

About not needed treatment: http://www.usatoday.com/story/news/nation/2013/06/18/unneces...

Re: Can Good Doctors Be Bad for Your Health?

#60

Post by wdewind »

thelettere wrote: post #57

The article conflates "good" doctor with experienced doctor. There is no such evidence that experience leads to better outcomes in most divisions of medicine (1), and indeed many have found (just like this one) that less experienced doctors provide better care (2). The most important variable in your doctor is their personality and your relationship with them, and not their experience (3). Addendum: The quality of yo…

I was surprised to see this study both written up so seriously in the NYTimes and then taken so seriously on HN because when it came out it was kind of used as a textbook example of how poor study design leads to bad conclusions.

Here's the asterisk:

> although adjusted percutaneous coronary intervention (PCI) rates were lower during meetings (20.8% vs 28.2%; P = .02)

IE: there are nearly 30% fewer angioplasties during annual cardiologist meetings.

Unfortunately the study looked at admissions dates rather than treatment dates (which also lines up with there not being angioplasties during those dates). Someone coming in with heart failure is going through the same procedures regardless of who is there to stabilize them, the actual repair is frequently done later, ie: when the senior doctor gets back from the conference. Another, totally reasonable, possibility emerges then: doctors coming back from conferences perform better for a small period of time after the conference.

Let's see this study repeated with treatment dates instead of admission dates and see what happens.

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