
Can Good Doctors Be Bad for Your Health? - OopsCriticality
http://www.nytimes.com/2015/11/22/opinion/sunday/are-good-doctors-bad-for-your-health.html?ref=opinion
======
moistgorilla
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 said that there was no reason to have
surgery yet. The kidney with the hydronephrosis had something like 4% below
utilization rate that was normal and that we should wait. We decided to follow
the second doctors advice and do regular checkups every year and the problem
actually just went away.

The most amazing thing about this experience was when we called 3 weeks in
advance to cancel the appointment for surgery the nurse got angry with us and
said something along the lines of "You actually dare to waste the doctor's
time?". It was very surreal.

TLDR: Don't get pressured into getting surgery, go get second opinions.

~~~
stronglikedan
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. I will now never not get a second
opinion.

~~~
cylinder
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.

~~~
stronglikedan
I'm lucky to have found (d) a very good doctor with good morals who's on my
insurance. This was years ago, and I've since moved away, but have developed
some RSI issues in my other hand. I drive three cities over to still see him,
because the peace of mind is worth it to me.

------
conorh
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 surgeons to really improve like
they should have to. If, as a surgeon at a academic center, you want to just
cruise along, no problem, you can just publish a few papers each year, be nice
to patients, and you will be considered a leader in your field - even if you
have terrible outcomes. There is little to no data out there to help patients
objectively evaluate a surgeon, and to force surgeons to become better.

Speaking of things that I found strange - my wife was blown away at her
current practice because for every operation they 'pair-surgeon' full time.
This seemed very normal to me, but outside of surgeon training this is
considered bizarre - when she tells other surgeons they ask her if it is
something to do with billing! (it is not, they can't bill for the second
surgeon). She loves it of course, it forces her to up her game and gives her
someone she can bounce her thoughts off of during the surgery. I've asked her
if she could go visit another surgeon in another facility somewhere and work
along side them for a few days to learn, but because of the red-tape and state
licensing, this is extremely difficult. The cross seeding of surgical
expertise becomes glacially slow after your initial training in residency, you
pretty much hope you were trained well and stumble along with a bit of help
here and there.

~~~
dbroockman
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 different
surgeon. This is the same challenge we face with evaluating drugs: many more
people who take aspirin survive than those who take anti-cancer drugs, but
this likely reflects the kind of person who is taking each (people with
headaches vs. people who have been diagnosed with cancer). To solve the
problem there's no way around randomized trials. So, one idea would be to
randomly assign patients to surgeons.

(Transparency might still be better on net, but important to keep these issues
in mind.)

~~~
nchammas
> 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.

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

~~~
nchammas
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.

------
aggieben
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.

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

~~~
mindcrime
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.

------
jpmattia
> _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?

~~~
xiaoma
>Do you really expect a person under a pile of medical-school debt to give you
an unbiased answer?

Yes. I expect lives to be put ahead of economic gain. Someone lacking the
ethical backbone to do this should never even be admitted to medical school.

~~~
TheCoelacanth
The gold standard for ethical behavior isn't to magically not let bias affect
you when making decisions. It's to identify conflicts of interest and avoid
them. Someone who knowingly allows a conflict of interest to exist is behaving
unethically, no matter how hard they try to avoid letting their bias affect
their decision.

------
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/...](https://www.researchgate.net/profile/Alan_Swann/publication/244481312_The_Medical_Alliance_From_Placebo_Response_to_Alliance_Effect/links/02e7e526c4be05b0d7000000.pdf)
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](http://www.annfammed.org/content/7/3/261.full)

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

~~~
conorh
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](http://www.nejm.org/doi/full/10.1056/NEJMsa012337)

~~~
thelettere
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...](http://www.sciencedirect.com/science/article/pii/S174391911301008X)

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

(3)
[https://www0.gsb.columbia.edu/mygsb/faculty/research/pubfile...](https://www0.gsb.columbia.edu/mygsb/faculty/research/pubfiles/1152/Process_and_performance_of_experts.pdf)

~~~
conorh
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.

~~~
thelettere
Ah, good point. That's why I try to stick to reviews or meta-analysis, but was
too lazy to look more that time, especially since it sounded right. Do you
know at what age surgical skill starts to drop due to aging? I found a review
that talked about how older surgeons stop taking on more challenging cases,
which was interesting - but it didn't mention anything about that.

------
uslic001
Maybe when the top doctors are away at meetings the sickest patients no longer
get transferred to the tertiary center for care and are kept at the local
hospitals.

~~~
pmiller2
I think this is an unlikely explanation, but you got an upvote from me for
even suggesting an alternative explanation for the findings.

------
pdonis
Very bad title: it implicitly equates "Good Doctors" with "famous doctors"
rather than with "doctors whose actions benefit patients". The real point of
the article is that one should ask questions and be personally involved in
care decisions, rather than just taking the doctor's word. But the linkbait
headline obfuscates that point.

~~~
nonbel
The authors suggest it is due to a reduced number of unnecessary treatments:

>"Our results echo paradoxical findings documented during a labor strike by
Israeli physicians in 2000, in which hundreds of thousands of outpatient
visits and elective surgical procedures were cancelled, but by many accounts
mortality rates dramatically fell during the year.27 Similar reports of
decreased mortality during physician labor strikes exist elsewhere, with most
hypotheses attributing mortality declines to lower rates of nonurgent surgical
procedures.28"

[http://archinte.jamanetwork.com/article.aspx?articleid=20389...](http://archinte.jamanetwork.com/article.aspx?articleid=2038979)

However, they do not seem to consider that mortality rates are seasonal and so
are the meeting dates. The seasonality differs for different causes of death.
A quick search came up with this for heart-related causes, so for example:

>"When grouped by season, we observed the distribution of the 449 coronary
heart disease fatalities to show a relative peak in winter (32%) and relative
nadir in spring (21%)."

[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3756551/](http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3756551/)

What they should have done is plot mortality by week so we can see if there is
a sudden dip around the conference dates.

~~~
pdonis
_> What they should have done is plot mortality by week so we can see if there
is a sudden dip around the conference dates._

Agreed, this would be a better test of what they are claiming.

~~~
nonbel
The day of week probably matters as well. For example, the conferences will
always span a weekend, giving a biased sample of days. I think it is a mistake
to try interpreting this data without considering it as a timeseries.

------
wrsh07
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?

~~~
TheCoelacanth
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.

------
mirimir
I highly recommend _Overtreated: Why Too Much Medicine Is Making Us Sicker and
Poorer_ (2008) by Shannon Brownlee.

When you have a hammer, everything looks like a nail. That's especially so
when you're deep in debt from buying that hammer, and can earn huge speaking
fees through promoting the brand to your peers.

~~~
m52go
#iatrogenics

Nassim Taleb discusses this concept from a broader perspective in
_Antifragile_.

------
carbocation
Because the journal article being discussed in this NYT piece is not actually
linked from within, let me share the link:

[http://www.ncbi.nlm.nih.gov/m/pubmed/25531231/](http://www.ncbi.nlm.nih.gov/m/pubmed/25531231/)

------
maj0rhn
I'd offer case-mix as a simple explanation of the findings. In other words,
when lots of cardiologists in a hospital leave for a conference, elective
procedures are deferred until their return... which means that emergency cases
constitute a larger proportion of the reduced number of cases that do come
into the hospital during the conference. It is completely reasonable to
believe that emergency cases have a higher mortality rate than elective cases.
This would raise the mortality rate, but not the mortality count. The same
effect would probably be seen over long holidays, when people tend not to
schedule elective cases.

------
dspeyer
When those senior doctors are out of town, are risky-but-necessary procedures
performed by less senior doctors or delayed until the senior ones return?

------
theworstshill
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 (large popular mall).

~~~
theworstshill
reiminiralize _

------
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.

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monkeyaround92
Residents won't want to do risky procedures that increase longevity more than
plain, supportive care that will help the patient live 30 days, but not 3-5
years or more.

------
unics
All professions have a focus on their strengths. Second opinions have a way of
opening the direction to take.

------
ultim8k
40% of people eating dark chocolate got hit by lightning. Come on people. No
more statistics.

~~~
JamesBarney
The problem with the statistic you bring up is that it lacks context like what
percentage of the general population eats dark chocolate. If only 20% of the
population eats dark chocolate then it's a very interesting statistic.

When I look at the article I don't see any crimes against statistics, and I'd
be curious what statistic you think is contextless or misrepresentative.

