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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?

#61

Post by conorh »

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…

Not going to talk about this generally, but this may not be the case for surgeons, and it depends on the procedure etc. This was one study showing that surgical volumes improved outcomes:

http://www.nejm.org/doi/full/10.1056/NEJMsa012337

Re: Can Good Doctors Be Bad for Your Health?

#62

Post by nchammas »

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…

> 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?

Why would it be a "bad mark" if everyone understood the case was difficult? Given a difficult case, wouldn't a surgeon be graded badly only if they did poorer on average than other surgeons tackling similar cases?

As long as a case's "difficulty" is measured in a consistent way, I don't see how surgeons would be incentivized to avoid difficult cases.

Re: Can Good Doctors Be Bad for Your Health?

#63

Post by JamesBarney »

pdonis wrote: post #29
JamesBarney wrote: post #8

Earlier quoted context omitted.

Hmm, I think I disagree. It was pretty obvious to me that when they used the term "good doctor" they meant better by some objective criteria that many people use as a proxy for "doctor whose actions benefit patients". If "good doctor" had meant "doctor whose actions benefit patients" it would be a contradiction that most would-be readers could dismiss.

> It was pretty obvious to me that when they used the term "good doctor" they meant better by some objective criteria that many people use as a proxy for "doctor whose actions benefit patients". But those doctors aren't better by those objective criteria [1]; that's the whole point. Their patients do worse, on average, by objective criteria. So they aren't "good doctors" in the sense that patients care about. They ar…

The objective criteria that the study uses to separate doctors into "good"(as it is used in the title) and bad was "goes to cardiologist conferences". The good doctor the title refers to is one that attends a cardiologist conference.

Re: Can Good Doctors Be Bad for Your Health?

#64

Post by cylinder »

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…

This is why I hate going to the doctor in Manhattan.

The doctors are either: (a) decidedly mediocre / horrible because most good ones are going to be rational and leave to another part of the country where they aren't below middle class and subject to a malpractice lawsuit around every corner, or (b) have money on their minds at all times (like anyone in NYC really) and will always recommend the (profitable) procedure or (c) very good but cash only, serving the wealthy in boutique specialty or concierge practices

It's a major quality of life issue here. Note I'm referring to private practice, I don't have experience with hospitals.

Re: Can Good Doctors Be Bad for Your Health?

#66

Post by riahi »

nchammas wrote: post #62
dbroockman wrote: post #49

Earlier quoted context omitted.

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…

> 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? Why would it be a "bad mark" if everyone understood the case was difficult? Given a difficult case, wouldn't a surgeon be graded badly only if they did poorer on average than other surgeons tackling…

How do you measure difficulty? It's a surprisingly hard problem.

Re: Can Good Doctors Be Bad for Your Health?

#67

Post by mindcrime »

doki_pen wrote: post #32
aggieben wrote: post #22

I really wish people would quit treating doctors as unquestionable authorities on health. Rather, they should be treated as consultants - expertise for hire - who should be able to give good answers to most questions, but should expect to have to defend their recommendations, and can sometimes be wrong.

Doctors act like authorities and get upset with patients when they disagree with treatment.

Some doctors do that. Certainly not all do. Example: I went to see my GP recently, and as part of the conversation I brought up a drug he had me taking. I said I'd read up on it and noticed that it's considered highly addictive and not a very pleasant drug, and asked if there was any other option. He proceeded to rattle off a list of options and the implications of each, and said "what do you want to do?"

I said "let's try X for a few months and see how that works." He agreed that was a fine course of action.

Similar story: at a recent checkup, my cholesterol numbers had mysteriously shot up by a huge margin. He called and said I should double my dose of the statin blocker I'm on. Well, I don't even want to be ON a statin blocker, and I was doubtful about my cholesterol taking that big a jump for no reason. So I suggested it might be a bad test, or some kind of weird outlier, and suggested we wait a month and test it again. We did and my cholesterol was back to perfect. So no change in the statin dosage.

I can also ask him to order specific tests for things I'm interested in (c-reactive protein for example, or the NMR LipoScience lipid test) and he's fine with doing that.

Now maybe my doctor is really weird in this regard, but he really treats me as pretty much a peer when it comes to decisions concerning my health. Not "peer" in the sense that obviously I'm not a doctor, but as in it's my health, and he acknowledges that it's my health and my decisions, which I can make with his consultation.

Re: Can Good Doctors Be Bad for Your Health?

#68

Post by nchammas »

riahi wrote: post #66
nchammas wrote: post #62

Earlier quoted context omitted.

> 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? Why would it be a "bad mark" if everyone understood the case was difficult? Given a difficult case, wouldn't a surgeon be graded badly only if they did poorer on average than other surgeons tackling…

How do you measure difficulty? It's a surprisingly hard problem.

Good question. Perhaps that is one of the root issues here. As a layperson, I wouldn't know how to answer it, but I'm guessing the answer probably involves more rigorously detailing the various aspects of each case so that comparisons can be fairly made across surgeons treating similar cases--apples to apples and all that.

Re: Can Good Doctors Be Bad for Your Health?

#69

Post by thelettere »

conorh wrote: post #61
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…

Not going to talk about this generally, but this may not be the case for surgeons, and it depends on the procedure etc. This was one study showing that surgical volumes improved outcomes: http://www.nejm.org/doi/full/10.1056/NEJMsa012337

That study was on hospitals though - although yes the same applies for surgeons (1), and obstetricians [although the benefits begin to deteriorate at around 50 (2)].

But cardiologists were what the original study was on, and they don't perform surgery. Rather, they are relied on for their "expert judgement", a highly questionable concept (3).

(1) http://www.sciencedirect.com/science/article/pii/S1743919113...

(2) http://www.bmj.com/content/344/bmj.d8041.short

(3) https://www0.gsb.columbia.edu/mygsb/faculty/research/pubfile...

Re: Can Good Doctors Be Bad for Your Health?

#70

Post by conorh »

thelettere wrote: post #69
conorh wrote: post #61

Earlier quoted context omitted.

Not going to talk about this generally, but this may not be the case for surgeons, and it depends on the procedure etc. This was one study showing that surgical volumes improved outcomes: http://www.nejm.org/doi/full/10.1056/NEJMsa012337

That study was on hospitals though - although yes the same applies for surgeons (1), and obstetricians [although the benefits begin to deteriorate at around 50 (2)]. But cardiologists were what the original study was on, and they don't perform surgery. Rather, they are relied on for their "expert judgement", a highly questionable concept (3). (1) http://www.sciencedirect.com/science/article/pii/S1743919113... (2) htt…

Sorry yes, wasn't saying anything about cardiologists, just wanted to point out that surgery might be different.

I'm familiar with the second study you mention there - I'd take it with a large grain of salt! It highlights the issues with so many medical studies and how hard they are to get right with limited data. The study attempts to generalize surgeon performance based on age for only 22 surgeons that did 'enough' operations that year (for one complication, only 15 for the other), while trying to account for all the other factors (patients, difficulty of operation etc.), and not accounting for the wildly varying volumes for each surgeon and the fact that the study had a large cluster of younger doctors, and not many older doctors (look at the plots) It just doesn't have enough data to be a good study in what they attempted.

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