Can Good Doctors Be Bad for Your Health?

When I was 19 I was diagnosed with something called hydronephrosis. It&#x27;s effect on my kidney function wasn&#x27;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&#x27; remember the specifics but the doctor immediately recommended invasive surgery. My father then took me to another urologist he knew from a friend&#x27;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.<p>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 &quot;You actually dare to waste the doctor&#x27;s time?&quot;. It was very surreal.<p>TLDR: Don&#x27;t get pressured into getting surgery, go get second opinions.

I&#x27;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&#x27;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 <i>entire</i> 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.<p>Speaking of things that I found strange - my wife was blown away at her current practice because for every operation they &#x27;pair-surgeon&#x27; 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&#x27;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&#x27;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.

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.

&gt; <i>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.</i><p>It&#x27;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 article conflates &quot;good&quot; 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).<p>The most important variable in your doctor is their personality and your relationship with them, and not their experience (3).<p>Addendum: The quality of your doctors organization and staff may be even more important than that of your doctor (4).<p>(1) McAlister, F. A., Youngson, E., Bakal, J. A., Holroyd-Leduc, J., &amp; Kassam, N. (2015). Physician experience and outcomes among patients admitted to general internal medicine teaching wards. Canadian Medical Association Journal, 187(14), 1041-1048.<p>(2) Southern, W. N., Bellin, E. Y., &amp; 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.<p>(3) <a href="https:&#x2F;&#x2F;www.researchgate.net&#x2F;profile&#x2F;Alan_Swann&#x2F;publication&#x2F;244481312_The_Medical_Alliance_From_Placebo_Response_to_Alliance_Effect&#x2F;links&#x2F;02e7e526c4be05b0d7000000.pdf" rel="nofollow">https:&#x2F;&#x2F;www.researchgate.net&#x2F;profile&#x2F;Alan_Swann&#x2F;publication&#x2F;...</a> and Wampold, B. E., Imel, Z. E., &amp; Minami, T. (2007). The story of placebo effects in medicine: evidence in context. Journal of clinical psychology, 63(4), 379-390; and <a href="http:&#x2F;&#x2F;www.annfammed.org&#x2F;content&#x2F;7&#x2F;3&#x2F;261.full" rel="nofollow">http:&#x2F;&#x2F;www.annfammed.org&#x2F;content&#x2F;7&#x2F;3&#x2F;261.full</a><p>(4) <a href="http:&#x2F;&#x2F;www.ncbi.nlm.nih.gov&#x2F;pmc&#x2F;articles&#x2F;PMC2586978&#x2F;" rel="nofollow">http:&#x2F;&#x2F;www.ncbi.nlm.nih.gov&#x2F;pmc&#x2F;articles&#x2F;PMC2586978&#x2F;</a> and <a href="http:&#x2F;&#x2F;www.ncbi.nlm.nih.gov&#x2F;pmc&#x2F;articles&#x2F;PMC3568449&#x2F;" rel="nofollow">http:&#x2F;&#x2F;www.ncbi.nlm.nih.gov&#x2F;pmc&#x2F;articles&#x2F;PMC3568449&#x2F;</a>

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 &quot;Good Doctors&quot; with &quot;famous doctors&quot; rather than with &quot;doctors whose actions benefit patients&quot;. 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&#x27;s word. But the linkbait headline obfuscates that point.

Is it possible that top doctors are just taking on the most challenging cases?<p>The implicit &quot;explanation&quot; [which seems testable and currently unverified] is that senior cardiologists attempt more interventions [eg angioplasties], and each intervention carries some risk.<p>It could be true, but why report something that wasn&#x27;t in the paper?

I highly recommend <i>Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer</i> (2008) by Shannon Brownlee.<p>When you have a hammer, everything looks like a nail. That&#x27;s especially so when you&#x27;re deep in debt from buying that hammer, and can earn huge speaking fees through promoting the brand to your peers.

Because the journal article being discussed in this NYT piece is not actually linked from within, let me share the link:<p><a href="http:&#x2F;&#x2F;www.ncbi.nlm.nih.gov&#x2F;m&#x2F;pubmed&#x2F;25531231&#x2F;" rel="nofollow">http:&#x2F;&#x2F;www.ncbi.nlm.nih.gov&#x2F;m&#x2F;pubmed&#x2F;25531231&#x2F;</a>

I&#x27;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&#x27;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&#x27;d rather take off healthy tissue to make a buck. I&#x27;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&#x27;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&#x27;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.

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

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