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.
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.
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.
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.
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 :-)
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.
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.)
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!
> 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.
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.
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.
Medical doctors are like auto-mechanics or, to make a more HN-relatable comparison, software engineers trying to debug a program. Except there's a little more schooling, a lot more rigor with boards examinations, and you don't really have the full source-code available to debug. Just like in any profession, you're going to have crappy auto-mechanics who'll just pull up the ODB-II code and perform patch-work without rigorous root-cause analysis, or have engineers who'll also perform similar patch-work to get it "good enough", you'll have the same hacks who make it through medical school. I'm with you 100% in that they're consultants offering their opinion, but I'll take your analogy a step further and say that some consultants are 27 year old kids fresh out of Wharton who can put together a pretty PowerPoint deck, and some consultants genuinely know their field.
... after getting a bachelor's degree (3-5 years) a general practitioner takes at the bare minimum 7 years of schooling and internship. Surgeon far more than that. One can work as a professional software engineer without ever attending any university.
Yes, I do believe I addressed that-- "<from MS3, through residency, then fellowship for most surgeons, ~7-8 years>". (Though I'd argue a residency is far more time-intensive than a traditional "internship", and after you pass USMLE S3 you're a board-certified Medical Doctor until your 10 year card comes up)
My point was that you're going to have hacks at any sort of field which involves operational mechanics, or for that matter any craft that involves a mastery of a skill. I'm a life-long tennis player. Competent enough to hold my own against a recreational player pretty safely, but cognizant enough to know I'm not Roger Federer. If we were to graph any trade/craft/art/profession practitioner, I'd imagine "good" (for any metric of good) can be depicted by a normal Gaussian plot. You'll have geniuses, hacks, and average folk.
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.
> 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?
The scenario of the person "under a pile of medical-school debt" isn't what's being looked at here. The study behind the article is looking at senior cardiologists, who, presumably, have paid off their student loans already.
What we're looking at here isn't economic conflict of interest, but simple bias. Doing things feels better than not doing things, so they do it. Experience might even work against them because we're biased to remember the good outcomes from things rather than consider carefully the general success rate of a procedure.
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 turns into hammers and nails when you keep busy your handymans holding the door open.
Yes absolutely. People are capable of looking past economic concerns when the lives of another are at stake and we should absolutely expect them to in this case. What's disappointing is the notion that we've sunk so low in our expectations of humanity that we even assume doctors are constantly calculating min/max selfish economic expectation when they advise their patients.
Luckily while some doctors are scam artists the vast majority of them have a sense of duty that transcends "maximize profits".
If A and B are equivalent, and B makes you money, most people have a large unconscious bias to B. Which is perfectly reasonable. The problem is if A is ever so slightly better that bias is still there.
The is directly observed when doctors are for example incentivized or penalized for over prescribing medication. So, no expecting unbiased options it an unreasonable standard.
PS: This is often why second opinions are so valuable. If a doctor has no economic stake in the outcome they often give better advice for the patient.
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.
Most medical doctors in the US aren't paid as a function of patients seen. Unless they're in a niche subset of medicine (cosmetic surgery) or have their own practice setup (hint: you won't find surgeons buried in school debt operating their own practice; the overhead is insane [staff, material goods, and oh god the insurance] would bankrupt a surgeon straight out of residency/fellowship), they're going to be debtors regardless of whether or not that blood test or drug is administered, or whether or not they send out for that radiology consult. It's almost certainly "when all you've been trained with is a hammer <from MS3, through residency, then fellowship for most surgeons, ~7-8 years>, ..." syndrome as others here have said
Without derailing this discussion, yeah this happens but only at a later stage in your career where you have the 'name recognition' in your subset of surgery so that your colleagues trust you enough you to even bring you in as a partner. I'm limited to the NE region, but I've never once seen a surgeon or medical practitioner form his/her own association or join in as a JP into an already established association until they were well out of the burden of debt.
In the same way that attorneys generally don't go straight into the market and form Johnson, Thompson LLP until they have a few wins under their belt at Skadden or Cravath and a few clients they know they can bring over, your typical niche association won't hire you into their surgical association even with half a decade out with a bunch of articles with you as lead surgeon in high-impact journals. You're still considered a risk as a partner (nepotistic situations notwithstanding).
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 rather the disgusting culture we have built up surrounding medical care and expectations. When your obese octogenarian grandmother dies the first thought shouldn't be litigation because the doctor didn't "run enough tests".
That. Exactly that. That goes so far that even when it is only the choice between the original pharmaceutical product and a generic, doctors will think twice out of fear to be sued if something goes wrong. I have one very scientifically inclined doctor in my family who fully understands that the chance of a generic being less effective is negligible. But, depending on the patient, she will prescribe the much more expensive original. Financially she does not profit from this at all, writing a prescription can be billed in her country but the height of the bill does not depend on the price of the prescribed medicine.
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.
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.
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.
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:
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).
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.
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.
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.
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.
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"
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%)."
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.
The article uses "best" and "senior" as well, more often than "famous", and explains that the data refers to times when "the senior cardiologists were out of town" (anyone attending conventions, for example.)
It's unlikely there are enough "famous" cardiologists alone to have accounted for "tens of thousands" of admissions. If so, the meaning of "famous" is downgraded to those who are sufficiently senior, rather than how we usually think of "famous."
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 are only "good doctors" if you equate "good doctors" with "senior doctors" or something like that (as gdulli pointed out upthread, "famous", the term I used in my OP in this thread, is too narrow)--something which does not include the objective criteria about actual patient outcomes.
[1] At least, that's what the article is claiming. As others in this subthread have pointed out, there is other data that should be looked at to see how valid the claim actually is.
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.
> The good doctor the title refers to is one that attends a cardiologist conference.
And this is supposed to be the "objective criteria" that, in your words, many people use as a proxy for "doctor whose actions benefit patients"? That makes no sense to me; I doubt most people even know what conferences, if any, their cardiologist (or any other doctor) goes to. Nor do I see the article claiming that "attending conferences" is an objective criterion that patients use.
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.
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.
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.
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?
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).
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.
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.
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.
I find your complaint rather baffling: statistics is how we figure out what is going on in large populations when many variables are in play. How else would we advance medical science?
Yes, as the recent "reproducibility crisis" has shown us (http://blogs.discovermagazine.com/neuroskeptic/2015/11/10/re...), there is severe danger in playing with statistics, even mildly. But that does not mean we should stop using statistics altogether: it means we should come up with better protocols and procedures to prevent the biases we discover.
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.