Bell Curve for Doctors
December 27, 2004 4:57 PM Subscribe
Is there a bell curve for doctors? How hard would it be to evaluate the performance of doctors and should this information be publicly accessible?
Yeah, picking a doctor is sort of a gamble. I propose a rate-my-doctor dot com or something, complete with ratings on the quality of waiting-room magazines and the hotness of the nurses.
But seriously, do they not make this information public? I'd like to know things like death-rates and whatnot. I'd also like to know how many self-proclaimed "angels of death" there have been at my local hospital.
posted by buriednexttoyou at 6:12 PM on December 27, 2004
But seriously, do they not make this information public? I'd like to know things like death-rates and whatnot. I'd also like to know how many self-proclaimed "angels of death" there have been at my local hospital.
posted by buriednexttoyou at 6:12 PM on December 27, 2004
Most "things" in life have a Gaussian distribution.
What a silly question. Or, perhaps, it was meant to be rhetorical?
If you went through your life thinking: Gaussian and Pareto, you would be well served.
,dave
posted by davebarnes at 6:14 PM on December 27, 2004
What a silly question. Or, perhaps, it was meant to be rhetorical?
If you went through your life thinking: Gaussian and Pareto, you would be well served.
,dave
posted by davebarnes at 6:14 PM on December 27, 2004
Most of us know the old joke: what do they call a guy who graduates at the bottom of his class in medical school" Doctor.
Doctors dislike testifying against or badmouthing each, and by contrast, every dentist tells you that they guy who last worked on your teeth is a butcher. Were the baddies rooted out, med insurance would not be so high ...as in driving, we often pay the tab for the bad drivers.
posted by Postroad at 6:15 PM on December 27, 2004
Doctors dislike testifying against or badmouthing each, and by contrast, every dentist tells you that they guy who last worked on your teeth is a butcher. Were the baddies rooted out, med insurance would not be so high ...as in driving, we often pay the tab for the bad drivers.
posted by Postroad at 6:15 PM on December 27, 2004
Fascinating article, but I think it completely misses the point. No evidence is presented of signficant differences in treatment, only differences in obtaining compliance from the patients. Getting compliance from difficult patients is certainly commendable, but not getting it points to bad patients more than bad doctors.
Is there a bell curve for patients? Yes.
posted by zanni at 6:19 PM on December 27, 2004
Is there a bell curve for patients? Yes.
posted by zanni at 6:19 PM on December 27, 2004
How do you propose evaluating the "performance" of doctors without giving them a disincentive for accepting the difficult cases? How are you going to avoid penalizing a doctor for pioneering a procedure?
Perhaps you are suggesting starting something similar to ratemyprofessors.com (ratemydoctors.com?)
posted by spock at 7:04 PM on December 27, 2004
Perhaps you are suggesting starting something similar to ratemyprofessors.com (ratemydoctors.com?)
posted by spock at 7:04 PM on December 27, 2004
Well, obtaining compliance is obviously tremendous. The most brilliant treatment can't work if the patient fails to comply. What the article illuminated, to me, was the Holmes-like brilliance that a truly great clinician like Warwick employs when deducing why his patient isn't complying, and the empathic skill required to draw his patient back to compliance. He understands data dynamically.
I understand this article with the same intuitive sense of rightness I felt reading in Death Be Not Proud so many years ago that many great brain surgeons are also poets. It's the same way I understand Oliver Sacks when he quotes an aphorism of the German poet Novalis: "Every disease is a musical problem, every cure is a musical solution." If you've ever read any of Sacks' books, you know he treats his patients as Warwick does: with a sensitive, highly alert mind, a poet's mind. He doesn't merely tick off the features of their illness, or research the particulars of their disease. He explores the interaction of disease with one's greater life. The article's description of Warwick's interaction with his patient was like listening to a great jazz musician: he knows his fundamentals so well that he can invent and improvise. That kind of clinical insight permits him to treat each patient at the microlevel, to invent devices with their predictable behaviors in mind, and to create undreamed of levels of success. It is great luck when such people, who tend to be iconoclasts, can rise to a position of authority and leadership so that they can teach others to do as they do.
Current healthcare business models do not allow for this kind of sensitive, time-consuming exploration of how patients' life conditions influence their illness. It's too inefficient. Most people take it as a given that this model is destructive to good care. But as this article remarkably points out, the most careful data analysis, the best intentions in the world, and the luxury of time with each patient is still no guarantee of clinical success. What's needed is a mindset, an investigative passion and true empathy for seeing disease as part of a life, not life as a subset of disease.
posted by melissa may at 7:12 PM on December 27, 2004
I understand this article with the same intuitive sense of rightness I felt reading in Death Be Not Proud so many years ago that many great brain surgeons are also poets. It's the same way I understand Oliver Sacks when he quotes an aphorism of the German poet Novalis: "Every disease is a musical problem, every cure is a musical solution." If you've ever read any of Sacks' books, you know he treats his patients as Warwick does: with a sensitive, highly alert mind, a poet's mind. He doesn't merely tick off the features of their illness, or research the particulars of their disease. He explores the interaction of disease with one's greater life. The article's description of Warwick's interaction with his patient was like listening to a great jazz musician: he knows his fundamentals so well that he can invent and improvise. That kind of clinical insight permits him to treat each patient at the microlevel, to invent devices with their predictable behaviors in mind, and to create undreamed of levels of success. It is great luck when such people, who tend to be iconoclasts, can rise to a position of authority and leadership so that they can teach others to do as they do.
Current healthcare business models do not allow for this kind of sensitive, time-consuming exploration of how patients' life conditions influence their illness. It's too inefficient. Most people take it as a given that this model is destructive to good care. But as this article remarkably points out, the most careful data analysis, the best intentions in the world, and the luxury of time with each patient is still no guarantee of clinical success. What's needed is a mindset, an investigative passion and true empathy for seeing disease as part of a life, not life as a subset of disease.
posted by melissa may at 7:12 PM on December 27, 2004
Also, what I love about Warwick is his common sense. Patients don't comply for two basic reasons: either the treatment is too difficult, or they think they are better. When the treatment for CF was too difficult -- ie, pounding yourself in the chest for several hours daily, which sounds pretty damn awful to me -- he invented a device to take that burden from his patients. When the patient described in the article thought she was better, he not only used deft psychology to convince her otherwise, he respected her enough to present her with her own data. He made her disease accessible to her. She rewarded his respect and interest with the truth.
There are plenty of "bad" patients in the world because most of us are bad at comprehending what we can't see. People who have to perform exhausting daily therapies or take a lot of meds balk because of nasty side effects, but also because taking them each day is a continual reminder of illness and difference. Also, it makes sense to suppose that if you feel better, you are better. Warwick obviously gets that human failing, and he speaks to his patients so that they get it, too. It's a very compassionate and realistic way to practice medicine, and it deserves great respect.
posted by melissa may at 7:30 PM on December 27, 2004
There are plenty of "bad" patients in the world because most of us are bad at comprehending what we can't see. People who have to perform exhausting daily therapies or take a lot of meds balk because of nasty side effects, but also because taking them each day is a continual reminder of illness and difference. Also, it makes sense to suppose that if you feel better, you are better. Warwick obviously gets that human failing, and he speaks to his patients so that they get it, too. It's a very compassionate and realistic way to practice medicine, and it deserves great respect.
posted by melissa may at 7:30 PM on December 27, 2004
Thank you, Melissa. You hit the nail on the head pretty well.
I have Cystic Fibrosis and I know first hand exactly what this article was talking about. Yes, there are "bad patients," but you wouldn't believe the range of doctors out there, especially for adult vs. pediatric CF care. And it makes a HUGE difference.
I left a terrible CF doctor in the middle of my high-risk pregnancy. My lung function (the primary way CF is measured...how much air a patient can breathe in and out. The sicker you are, the less you can intake/output) went from about 85% to about 25% in about 2 weeks. I couldn't walk across a parking lot without seeing spots. I called my doctor and he said "you pregnant, of course you're out of breath." To make a long story short, he was terribly wrong and it was the culmination of 4 years of crappy attention I got from the adult center at California Pacific Medical center in SF. So I paid, out of pocket, to go see my pediatric doctor (part of UCSF) from years ago who I've kept in touch with and she was HORRIFIED by the care I was receiving. At that visit was the first time I'd heard of the studies mentioned in this article-and realized that my doctor wasn't doing the BASIC things that successful centers do (certain tests and such that need to be done on every visit-as well as agressive care and even some different drugs I could have tried.) She gave me more things to do to change my health in that visit than I'd gotten in 4 years at CPMC. I also switched to UCSF.
I still think pediatric care is better because they are more agressive and frankly, the doctors have more knowledge because they've had more years of experience. Adult doctors don't know was much because there haven't been many adult patients to study and learn on because until recently, most died before 20. So I'm still not thrilled with my care, but it's better. I'd rather see a pediatrician.
Doctors makes a huge difference. Especially in a life-long, awful, time-consuming disease like CF. I guess I'm a "bad patient" because I got tired of doing all the therapy every day and would rather spend that time with my daughter. And occasionally I get so depressed because I continue getting sicker even when I do therapy so I just stop, because what's the point when I'm going to die young anyway? But I need a doctor to see that, find ways to motivate me or try different things, throughout my life. This isn't like finishing a course of antibiotics. This is hours of therapy a day, for the rest of your life, and it never cures you, it just slows the decline. And you still get sick and go on IV antibiotics and in the hospital, even if you do everything right. Doctors need to work with you all the time to get it right.
Personally, I don't think what I've done is as bad as a doctor not telling me about new drugs, not doing basic diagnostic procedures on me every visit, or saying "you're not nearly as sick as you could be" every time I ask him what I could be doing differently, then not providing any concrete ways to change. Which is what you get with a crappy care center. Compare that with what you read in the article and you tell me if it makes a difference.
In answer to the question of "is it better to know what you center rates vs. the possibility of them not gathering this information accurately to learn about the best ways to care?"...I think I would rather them gather the information than to know my center's status. I think I knew deep down for the last 4 years that my care was crap but I stuck with it, thinking it would get better. And it didn't, and meanwhile my health has deteriorated a lot. Way more than it should have. I'm just thankful I live in a place where I have the luxury to switch care centers. For many CF adults, there's maybe one adult care center in the state, sometimes less. There is no other option.
(Sorry for the long answer.)
posted by aacheson at 8:26 PM on December 27, 2004
I have Cystic Fibrosis and I know first hand exactly what this article was talking about. Yes, there are "bad patients," but you wouldn't believe the range of doctors out there, especially for adult vs. pediatric CF care. And it makes a HUGE difference.
I left a terrible CF doctor in the middle of my high-risk pregnancy. My lung function (the primary way CF is measured...how much air a patient can breathe in and out. The sicker you are, the less you can intake/output) went from about 85% to about 25% in about 2 weeks. I couldn't walk across a parking lot without seeing spots. I called my doctor and he said "you pregnant, of course you're out of breath." To make a long story short, he was terribly wrong and it was the culmination of 4 years of crappy attention I got from the adult center at California Pacific Medical center in SF. So I paid, out of pocket, to go see my pediatric doctor (part of UCSF) from years ago who I've kept in touch with and she was HORRIFIED by the care I was receiving. At that visit was the first time I'd heard of the studies mentioned in this article-and realized that my doctor wasn't doing the BASIC things that successful centers do (certain tests and such that need to be done on every visit-as well as agressive care and even some different drugs I could have tried.) She gave me more things to do to change my health in that visit than I'd gotten in 4 years at CPMC. I also switched to UCSF.
I still think pediatric care is better because they are more agressive and frankly, the doctors have more knowledge because they've had more years of experience. Adult doctors don't know was much because there haven't been many adult patients to study and learn on because until recently, most died before 20. So I'm still not thrilled with my care, but it's better. I'd rather see a pediatrician.
Doctors makes a huge difference. Especially in a life-long, awful, time-consuming disease like CF. I guess I'm a "bad patient" because I got tired of doing all the therapy every day and would rather spend that time with my daughter. And occasionally I get so depressed because I continue getting sicker even when I do therapy so I just stop, because what's the point when I'm going to die young anyway? But I need a doctor to see that, find ways to motivate me or try different things, throughout my life. This isn't like finishing a course of antibiotics. This is hours of therapy a day, for the rest of your life, and it never cures you, it just slows the decline. And you still get sick and go on IV antibiotics and in the hospital, even if you do everything right. Doctors need to work with you all the time to get it right.
Personally, I don't think what I've done is as bad as a doctor not telling me about new drugs, not doing basic diagnostic procedures on me every visit, or saying "you're not nearly as sick as you could be" every time I ask him what I could be doing differently, then not providing any concrete ways to change. Which is what you get with a crappy care center. Compare that with what you read in the article and you tell me if it makes a difference.
In answer to the question of "is it better to know what you center rates vs. the possibility of them not gathering this information accurately to learn about the best ways to care?"...I think I would rather them gather the information than to know my center's status. I think I knew deep down for the last 4 years that my care was crap but I stuck with it, thinking it would get better. And it didn't, and meanwhile my health has deteriorated a lot. Way more than it should have. I'm just thankful I live in a place where I have the luxury to switch care centers. For many CF adults, there's maybe one adult care center in the state, sometimes less. There is no other option.
(Sorry for the long answer.)
posted by aacheson at 8:26 PM on December 27, 2004
By the way, I sent my doctor at CPMC a letter detailing everything that I was concerned about, hoping we could work together to change. He basically said I was "high maintenance' and he wouldn't see me any more. So I switched and also notified the local and national CF Foundation about that center. They followed up with calls and a letter to me. I don't know what, if anything, has changed at CPMC, but I hope that perhaps the CF Foundation has at least put the adult center at CPMC on notice and will review their certification.
posted by aacheson at 8:30 PM on December 27, 2004
posted by aacheson at 8:30 PM on December 27, 2004
aacheson - wow. Honestly, I never really knew much about CF before and reading your account made it particularly real to me. I'm amazed at your strength and the fact that you were able to have a child - which is pretty taxing even for a completely healthy woman.
Its a good thing that you did to try to work with your previous doctor. Hopefully your actions will improve their care and will benefit other CF patients down the line.
Thanks for the illuminating comments!
posted by rks404 at 8:45 PM on December 27, 2004
Its a good thing that you did to try to work with your previous doctor. Hopefully your actions will improve their care and will benefit other CF patients down the line.
Thanks for the illuminating comments!
posted by rks404 at 8:45 PM on December 27, 2004
Interesting article--thanks, rks404. Warwick is definitely the doctor I'd want and I have a hard time imagining settling for an average program if I knew there were better. I see the office visit as part of the treatment and they sounded very different. One doctor dealt with symptoms, the other dealt with the person with the symptoms. It's more than getting compliance from the patient. melissa may, very eloquently put.
The idea of insurance only paying doctors for a procedure if they meet a "predefined success rate" sounds like a pandora's box, but then again why should they pay a crappy doctor to do crap work.
posted by lobakgo at 8:48 PM on December 27, 2004
The idea of insurance only paying doctors for a procedure if they meet a "predefined success rate" sounds like a pandora's box, but then again why should they pay a crappy doctor to do crap work.
posted by lobakgo at 8:48 PM on December 27, 2004
The curve for otolaryngologists is more sinusoidal.
posted by weapons-grade pandemonium at 8:53 PM on December 27, 2004
posted by weapons-grade pandemonium at 8:53 PM on December 27, 2004
I think that spock hit the nail on the head. There's a huge garbage-in, garbage-out factor here (to be a bit crude). Doctors who take tough patients will have worse outcomes, but it's impossible to fairly rate patient status on intake.
Funny how I can be diametrically opposed on one thread and 100% in agreement on another.
posted by thedevildancedlightly at 9:06 PM on December 27, 2004
Funny how I can be diametrically opposed on one thread and 100% in agreement on another.
posted by thedevildancedlightly at 9:06 PM on December 27, 2004
aacheson, thanks so much for that post. It is awful that you were treated in such a callous, unprofessional way, and that your condition was permitted to deteriorate to such an extent. I do not understand why a clinican with so little patience and feeling would opt for a practice treating people with such a complex chronic illness.
I respect you for not only for fighting for better care for yourself, but also for seeking to improve care at your former facility. You did a good thing when you could have justifiably dropped the whole matter once your own situation improved. As rks404 said, I truly hope it results in more positive outcomes for those still getting treatment at CPMC.
On preview: from the article, it's clear that there are plenty of tough patients in Minnesota, yet they manage consistently good outcomes, and the writer's visit shows why. Garbage in, garbage out? A good mindset if one is a garbageman; obviously, a destructive, grossly inappropriate one if your life's work is caring for people who are desperately ill.
posted by melissa may at 9:16 PM on December 27, 2004
I respect you for not only for fighting for better care for yourself, but also for seeking to improve care at your former facility. You did a good thing when you could have justifiably dropped the whole matter once your own situation improved. As rks404 said, I truly hope it results in more positive outcomes for those still getting treatment at CPMC.
On preview: from the article, it's clear that there are plenty of tough patients in Minnesota, yet they manage consistently good outcomes, and the writer's visit shows why. Garbage in, garbage out? A good mindset if one is a garbageman; obviously, a destructive, grossly inappropriate one if your life's work is caring for people who are desperately ill.
posted by melissa may at 9:16 PM on December 27, 2004
melissa may As you might have guessed, I'm no doctor. I wasn't suggesting that doctors should treat their patients that way at all. My point was that there are some legitimately tough cases out there that no doctor could save. If we post a big ranking site out there then doctors who take on more tough cases are going to appear to be less good, even if they are better than doctors who take on easier cases.
I have nothing but respect for doctors, especially those who take on cases that are tough.
posted by thedevildancedlightly at 9:25 PM on December 27, 2004
I have nothing but respect for doctors, especially those who take on cases that are tough.
posted by thedevildancedlightly at 9:25 PM on December 27, 2004
Some states have lists like this in NY, for all physicians, physician assistants and specialist assistants who have been disciplined since 1990. (it doesn't say if they're good, but at least you can know for sure they weren't butchers)
posted by amberglow at 9:30 PM on December 27, 2004
posted by amberglow at 9:30 PM on December 27, 2004
aacheson, thanks for sharing your story. I have multiple sclerosis (y'know, it never gets easier to write that), so I'm familiar with what you mean about how hard it can be to be compliant with therapies that make you feel like crap and will never cure what you have.
I've struggled with the expectations people have of medical professionals. As a student nurse, I see every day in myself and others the evidence that we are only human, fallible and never free from mistakes. At the same time, I don't think it's inappropriate for people to expect their doctor or nurse to be better than average. Taking care of people's health, and in some cases literally holding their lives in your hands, is an action that should be held to the highest possible standard.
Comparing outcomes in a study will, for reasons that escape me despite having taken a statistics class, result in a bell curve distribution of results; most will range somewhere in the middle, some will be better and some will be worse. The thing we as doctors and nurses must do is ensure that, to use CF as an example, the shortest lifespan in a given data set will have more years to it the next time someone does a study. The bell curve will still be evident, but the whole thing must never stop moving forward.
posted by jesourie at 9:35 PM on December 27, 2004
I've struggled with the expectations people have of medical professionals. As a student nurse, I see every day in myself and others the evidence that we are only human, fallible and never free from mistakes. At the same time, I don't think it's inappropriate for people to expect their doctor or nurse to be better than average. Taking care of people's health, and in some cases literally holding their lives in your hands, is an action that should be held to the highest possible standard.
Comparing outcomes in a study will, for reasons that escape me despite having taken a statistics class, result in a bell curve distribution of results; most will range somewhere in the middle, some will be better and some will be worse. The thing we as doctors and nurses must do is ensure that, to use CF as an example, the shortest lifespan in a given data set will have more years to it the next time someone does a study. The bell curve will still be evident, but the whole thing must never stop moving forward.
posted by jesourie at 9:35 PM on December 27, 2004
For crying out loud, the fact that there is a bell curve in terms of outcomes does not tell you anything, anything at all about the skill or capabilities of the doctors responsible. In the absence of other data, they can only be a hint.
First, if all doctors were equal in capability, there would still be a bell curve. "Successful" doctors would in fact be beneficiaries of luck.
Second, it's worse than that. If I were a highly skilled doctor, maybe I would see worse patients, because on account of my reputation, they would come to me. That would definitely skew my mortality rates. Whereas some quack who cherry-picks the least severe cases will look like Doctor God.
Third, (and this is kind of a corollary of my first point) even if grading objectively and fairly is possible, the curve is inevitable. Thus we will reach a point where only the best are in practise, doing the best that they can, but by definition half will still be below average.
I'm not saying there is no difference between doctors, but as in so many professional fields it is SO hard to measure objectively.
Finally, the writer is conflating two distinct meanings of "average". First, the writer says "half will be below average". Here, they mean this mathematically. Then, the writer argues that we don't want people in critical functions to be below average - and here, this is meant in a pejorative and emotional way. We are all schooled to believe that below average is shorthand for crappy.
Depending on where the average is, many "below average" performances may in fact be good enough. Not that you would know that from reading the article, because there would be no emotional appeal to the reader in investigating that.
I know magazine stories depend on the big string of anecdotes and the fetching story, but still. *feh*.
posted by i_am_joe's_spleen at 9:48 PM on December 27, 2004
First, if all doctors were equal in capability, there would still be a bell curve. "Successful" doctors would in fact be beneficiaries of luck.
Second, it's worse than that. If I were a highly skilled doctor, maybe I would see worse patients, because on account of my reputation, they would come to me. That would definitely skew my mortality rates. Whereas some quack who cherry-picks the least severe cases will look like Doctor God.
Third, (and this is kind of a corollary of my first point) even if grading objectively and fairly is possible, the curve is inevitable. Thus we will reach a point where only the best are in practise, doing the best that they can, but by definition half will still be below average.
I'm not saying there is no difference between doctors, but as in so many professional fields it is SO hard to measure objectively.
Finally, the writer is conflating two distinct meanings of "average". First, the writer says "half will be below average". Here, they mean this mathematically. Then, the writer argues that we don't want people in critical functions to be below average - and here, this is meant in a pejorative and emotional way. We are all schooled to believe that below average is shorthand for crappy.
Depending on where the average is, many "below average" performances may in fact be good enough. Not that you would know that from reading the article, because there would be no emotional appeal to the reader in investigating that.
I know magazine stories depend on the big string of anecdotes and the fetching story, but still. *feh*.
posted by i_am_joe's_spleen at 9:48 PM on December 27, 2004
The curve for otolaryngologists is more sinusoidal.
That really hurt.
posted by Faint of Butt at 10:03 PM on December 27, 2004
That really hurt.
posted by Faint of Butt at 10:03 PM on December 27, 2004
The notion of a ranking system is a fairly simple concept, and is already in practice, it's just not all that transparent. Many HMO's track physician's rates of mammography screening, their adherence to accepted norms in the treatment of congestive heart failure and diabetes as well as their tenacity regarding blood pressure outcomes in the hypertensive population.
Patients need to be able to access this information. Applying it to specialists is more difficult, but certainly not impossible. Survival rates may not be the best measure for all situations, but markers of general thoroughness and adherence to evidence based protocols in any specialty likely will be.
posted by docpops at 10:04 PM on December 27, 2004
Patients need to be able to access this information. Applying it to specialists is more difficult, but certainly not impossible. Survival rates may not be the best measure for all situations, but markers of general thoroughness and adherence to evidence based protocols in any specialty likely will be.
posted by docpops at 10:04 PM on December 27, 2004
docpops, isn't that a bit of a worry? I mean, if you have an unusual practise, you're going to be penalised.
I'd be all in favour of some kind of screening to identify people whose practise is potentially anomalous - but very reluctant for this to be anything more than a starting point for investigation. Especially in a litigious environment like the US, I see that as being the road to dogmatic practise, notwithstanding the requirement for evidence ('cos who's going to gather the evidence in clinical trials? Maybe you'll have to leave it to us folks in other jurisdictions...)
Actually, as long as we're screening on medical performance, I'd also be in favour of investigations of the sort used in financial fraud investigation where you look for suspicious patterns that indicate fiddling with the numbers.
posted by i_am_joe's_spleen at 10:20 PM on December 27, 2004
I'd be all in favour of some kind of screening to identify people whose practise is potentially anomalous - but very reluctant for this to be anything more than a starting point for investigation. Especially in a litigious environment like the US, I see that as being the road to dogmatic practise, notwithstanding the requirement for evidence ('cos who's going to gather the evidence in clinical trials? Maybe you'll have to leave it to us folks in other jurisdictions...)
Actually, as long as we're screening on medical performance, I'd also be in favour of investigations of the sort used in financial fraud investigation where you look for suspicious patterns that indicate fiddling with the numbers.
posted by i_am_joe's_spleen at 10:20 PM on December 27, 2004
amberglow - thanks for the link. Georgia has a similar listing. I looked up my doctor and learned that he had not been disciplined and had no criminal history. It was a nice to know, but I had hoped for more.
It does seem having any sort of rating system is liable to being "gamed" but if what docpops says is true, than it would be a service to the public to release the information.
I wonder if part of the reason that we have so many malpractice claims is because we expect doctors to be perfect and to perform as interchangeable units. Perhaps if we were to be more realistic about medical care and understand that some doctors are better than others, it would serve as reminder that there is always going to be some level of risk in pretty much any medical procedure.
posted by rks404 at 10:26 PM on December 27, 2004
It does seem having any sort of rating system is liable to being "gamed" but if what docpops says is true, than it would be a service to the public to release the information.
I wonder if part of the reason that we have so many malpractice claims is because we expect doctors to be perfect and to perform as interchangeable units. Perhaps if we were to be more realistic about medical care and understand that some doctors are better than others, it would serve as reminder that there is always going to be some level of risk in pretty much any medical procedure.
posted by rks404 at 10:26 PM on December 27, 2004
rks404, I agree.
Here is an example, FWIW. In New Zealand, where I live, midwives are degree-qualified medical practitioners. There was a case a few years ago where a midwife was "defrocked" because she left a breech birth way, way too long before calling for help and taking the mother to hospital. I was really interested in this case, because I was still married to a midwife.
Now, in my neck of the woods, infant mortality in childbirth is around 1%. The midwife in question had taken part in about 700 births, and this was only the second death. Naively, she was being victimised - she was actually a really good practitioner who just screwed up once.
What can you make of this? Statistically, sweet fuck all. First, you need to know that women with obviously difficult pregnancies don't go to midwives, they end up in hospital with obstetricians. Second, you don't know how many "near misses" she had, or outcomes that weren't fatal but also weren't recorded. Third, you don't know the composition of her clients normally, so it's moot whether this is an expected rate or not.
Finally, if things happen at about 1% frequency, then twice in 700 isn't really that odd - in fact, over a big group of practitioners, it's quite likely that you'll see a few like this, purely from chance.
So in sum, what can you say about this person's skill? Nothing. Statistics breaks down for individual practitioners (although I suspect it's more reliable for clinics and hospitals over a longer term). I have no idea whether this woman was fairly judged, and I'm not sure a medical statistics person could have helped, because what you really need to know is the detail of all her cases, not a simplified aggregate. The best I know is that in the case she was tried for she failed to follow best practise, and assuming that was a misjudgement, then all I can say is it might or might not have been an aberration.
I'm left with saying: are there bad doctors? Yes. Are there good doctors who have bad luck? Yes. Can you tell from statistics who's who? Probably (snicker) not. Can you tell from personal recommendation? Probably not. Will we try to use the imperfect means available unfairly? You bet. I know I will. But I won't feel good about it.
posted by i_am_joe's_spleen at 10:50 PM on December 27, 2004
Here is an example, FWIW. In New Zealand, where I live, midwives are degree-qualified medical practitioners. There was a case a few years ago where a midwife was "defrocked" because she left a breech birth way, way too long before calling for help and taking the mother to hospital. I was really interested in this case, because I was still married to a midwife.
Now, in my neck of the woods, infant mortality in childbirth is around 1%. The midwife in question had taken part in about 700 births, and this was only the second death. Naively, she was being victimised - she was actually a really good practitioner who just screwed up once.
What can you make of this? Statistically, sweet fuck all. First, you need to know that women with obviously difficult pregnancies don't go to midwives, they end up in hospital with obstetricians. Second, you don't know how many "near misses" she had, or outcomes that weren't fatal but also weren't recorded. Third, you don't know the composition of her clients normally, so it's moot whether this is an expected rate or not.
Finally, if things happen at about 1% frequency, then twice in 700 isn't really that odd - in fact, over a big group of practitioners, it's quite likely that you'll see a few like this, purely from chance.
So in sum, what can you say about this person's skill? Nothing. Statistics breaks down for individual practitioners (although I suspect it's more reliable for clinics and hospitals over a longer term). I have no idea whether this woman was fairly judged, and I'm not sure a medical statistics person could have helped, because what you really need to know is the detail of all her cases, not a simplified aggregate. The best I know is that in the case she was tried for she failed to follow best practise, and assuming that was a misjudgement, then all I can say is it might or might not have been an aberration.
I'm left with saying: are there bad doctors? Yes. Are there good doctors who have bad luck? Yes. Can you tell from statistics who's who? Probably (snicker) not. Can you tell from personal recommendation? Probably not. Will we try to use the imperfect means available unfairly? You bet. I know I will. But I won't feel good about it.
posted by i_am_joe's_spleen at 10:50 PM on December 27, 2004
Thankfully, my doctor is my wife. I'm pretty sure she's not an idiot. Though, embarassingly, she did go to some shitty med school in Boston.
posted by McBain at 11:15 PM on December 27, 2004
posted by McBain at 11:15 PM on December 27, 2004
If we had a national health insurance system, we'd be able to collect massive amounts of data on physician performance, and let physicians know where they're below average, and where they're currently doing great. Medicare just started releasing data for hospitals, and hospitals are starting to improve.
We'd also be able to get a handle on regional variations in health and health disparities, and handle fraud more effectively, too.
posted by gramcracker at 11:16 PM on December 27, 2004
We'd also be able to get a handle on regional variations in health and health disparities, and handle fraud more effectively, too.
posted by gramcracker at 11:16 PM on December 27, 2004
I wonder if part of the reason that we have so many malpractice claims is because we expect doctors to be perfect and to perform as interchangeable units.David Hilfiker has written some thoughtful essays and books about mistakes in the medical profession. i wish i could find some of the text of those on-line. He's a doctor who comes out strongly against the cult of medical infallibility, and he apparently caused quite a stir when his essay Mistakes was published in the New England Journal of Medicine in the mid-80's.
Doctors are just human, despite the magic we want them to work. But i think many of them don't want to cop to it because they are seduced by the feeling of power, too, not just made quiet by fear of malpractice suits. Guys like Hilfiker who admit to making mistakes shouldn't be the exception to the rule.
posted by dkg at 11:52 PM on December 27, 2004
Postroad: Doctors dislike testifying against or badmouthing each, and by contrast, every dentist tells you that they guy who last worked on your teeth is a butcher. Were the baddies rooted out, med insurance would not be so high ...as in driving, we often pay the tab for the bad drivers.
The dentists tearing each other apart and the doctors defending each other are both huge problems. Look at the ways aviation and engineering are regulated and you will see successful approaches to improved competency.
zanni: Fascinating article, but I think it completely misses the point. No evidence is presented of significant differences in treatment, only differences in obtaining compliance from the patients. Getting compliance from difficult patients is certainly commendable, but not getting it points to bad patients more than bad doctors.
Yes, there is bad concrete too. Skill is learning how to work with and around the materials you have.
spock: How do you propose evaluating the "performance" of doctors without giving them a disincentive for accepting the difficult cases? How are you going to avoid penalizing a doctor for pioneering a procedure?
Mostly money, sometimes credit... Engineers still try to accomplish difficult goals and develop innovative approaches, they just do it in an atmosphere that demands performance.
thedevildancedlightly: My point was that there are some legitimately tough cases out there that no doctor could save. If we post a big ranking site out there then doctors who take on more tough cases are going to appear to be less good, even if they are better than doctors who take on easier cases.
All you have to do is turn that statement around and you get a very good first guess at a workable solution. If we have a big ranking site out there that accounts for the difficulty of cases as determined by an unbiased panel doctors will be ranked appropriate to their skill level. In turn this has the added benefit that doctors with greater skill can be assigned to patients with greater need.
rks404: It does seem having any sort of rating system is liable to being "gamed" but if what docpops says is true, than it would be a service to the public to release the information.
That is a critical problem. The public needs to have access to the information, but they shouldn't be allowed to selfishly demand the best doctors for trivial health concerns.
Ranking systems in general are a problem. You need to objectively measure outcomes, you need to come down hard on failure, and you need to allocate resources intelligently. On the other hand, a ranking system ala tennis players would be very destructive. Something like a ranking system is going to be important, but it's all in the details.
It is astonishing that the medical profession is only just realizing that making doctors work 30 hours at a time impedes performance... Duh! But the professionals aren't the only problem. Patients privacy demands make it very hard to properly track all the factors that are significant.
posted by Chuckles at 2:00 AM on December 28, 2004
The dentists tearing each other apart and the doctors defending each other are both huge problems. Look at the ways aviation and engineering are regulated and you will see successful approaches to improved competency.
zanni: Fascinating article, but I think it completely misses the point. No evidence is presented of significant differences in treatment, only differences in obtaining compliance from the patients. Getting compliance from difficult patients is certainly commendable, but not getting it points to bad patients more than bad doctors.
Yes, there is bad concrete too. Skill is learning how to work with and around the materials you have.
spock: How do you propose evaluating the "performance" of doctors without giving them a disincentive for accepting the difficult cases? How are you going to avoid penalizing a doctor for pioneering a procedure?
Mostly money, sometimes credit... Engineers still try to accomplish difficult goals and develop innovative approaches, they just do it in an atmosphere that demands performance.
thedevildancedlightly: My point was that there are some legitimately tough cases out there that no doctor could save. If we post a big ranking site out there then doctors who take on more tough cases are going to appear to be less good, even if they are better than doctors who take on easier cases.
All you have to do is turn that statement around and you get a very good first guess at a workable solution. If we have a big ranking site out there that accounts for the difficulty of cases as determined by an unbiased panel doctors will be ranked appropriate to their skill level. In turn this has the added benefit that doctors with greater skill can be assigned to patients with greater need.
rks404: It does seem having any sort of rating system is liable to being "gamed" but if what docpops says is true, than it would be a service to the public to release the information.
That is a critical problem. The public needs to have access to the information, but they shouldn't be allowed to selfishly demand the best doctors for trivial health concerns.
Ranking systems in general are a problem. You need to objectively measure outcomes, you need to come down hard on failure, and you need to allocate resources intelligently. On the other hand, a ranking system ala tennis players would be very destructive. Something like a ranking system is going to be important, but it's all in the details.
It is astonishing that the medical profession is only just realizing that making doctors work 30 hours at a time impedes performance... Duh! But the professionals aren't the only problem. Patients privacy demands make it very hard to properly track all the factors that are significant.
posted by Chuckles at 2:00 AM on December 28, 2004
Atul Gawande is a very engaging writer. I heartily recommend his book "Complications", which deals with similar knotty issues from the medical field.
posted by sour cream at 6:56 AM on December 28, 2004
posted by sour cream at 6:56 AM on December 28, 2004
I have so much sympathy for these poor people. They really are in a tough place but I can't help but think that we could put more effort into treating diseases that aren't genetic and discourage those who are carriers of this problem from putting more children at risk with their unchecked zygote roulette.
It seems to me the height of our hubris that rather than acknowledge that some things may be beyond us and avoiding the disease in the first place, We spend millions of dollars creating treatment centers for the next 40 years of their life and still not fixing the cause, just the symptoms. A $200 test can determine if your partner and you are both carriers. Why not avoid creating a person programmed to die early? Perhaps we need to start charging people with child endangerment when they knowingly have kids who are at risk of having genetic disorders? If we can keep more of these victims from being created, we can save a lot of lives and money.
posted by Megafly at 7:54 AM on December 28, 2004
It seems to me the height of our hubris that rather than acknowledge that some things may be beyond us and avoiding the disease in the first place, We spend millions of dollars creating treatment centers for the next 40 years of their life and still not fixing the cause, just the symptoms. A $200 test can determine if your partner and you are both carriers. Why not avoid creating a person programmed to die early? Perhaps we need to start charging people with child endangerment when they knowingly have kids who are at risk of having genetic disorders? If we can keep more of these victims from being created, we can save a lot of lives and money.
posted by Megafly at 7:54 AM on December 28, 2004
You unbelievable heartless jerk-off, Megafly. Just because I'm sick I shouldn't have children? What about those with breast cancer...some cases are genetic so I guess they shouldn't be allowed to breed. Or pancreatic cancer. Or diabetes. Or obesity.
Aren't you lucky that you have a perfect gene pool and aren't passing anything bad along to infect the rest of the future children. (Of course, that's the strange thing about genes. You never know what's out there lurking, waiting to be. I am the first in my family to have CF.) So, who knows, maybe you will in fact pass some horrible thing onto your children and, if your wishes come true, hopefully no one will care enough to treat them because if they live and (god forbid) have children, they might pass what YOU gave them onto future generations. They should do us all a favor and just die.
We did take the genetic tests and there is no chance of our daughter having CF (both parents need to have the gene.) But she may be a carrier. Should she not be allowed to have children either?
You're a heartless asshole.
posted by aacheson at 8:21 AM on December 28, 2004
Aren't you lucky that you have a perfect gene pool and aren't passing anything bad along to infect the rest of the future children. (Of course, that's the strange thing about genes. You never know what's out there lurking, waiting to be. I am the first in my family to have CF.) So, who knows, maybe you will in fact pass some horrible thing onto your children and, if your wishes come true, hopefully no one will care enough to treat them because if they live and (god forbid) have children, they might pass what YOU gave them onto future generations. They should do us all a favor and just die.
We did take the genetic tests and there is no chance of our daughter having CF (both parents need to have the gene.) But she may be a carrier. Should she not be allowed to have children either?
You're a heartless asshole.
posted by aacheson at 8:21 AM on December 28, 2004
"A Young Doctor's Hardest Lesson: Keep Your Mouth Shut"
The biggest shock along the road to becoming a doctor is the revelation that you can ask and the patient will tell anything. (NYT)
posted by ericb at 8:50 AM on December 28, 2004
The biggest shock along the road to becoming a doctor is the revelation that you can ask and the patient will tell anything. (NYT)
posted by ericb at 8:50 AM on December 28, 2004
we could put more effort into treating diseases that aren't genetic
Megafly, I'm so relieved to hear that someone knows unerringly which diseases are genetic and which aren't. Share with the class, would you?
posted by jesourie at 9:30 AM on December 28, 2004
Megafly, I'm so relieved to hear that someone knows unerringly which diseases are genetic and which aren't. Share with the class, would you?
posted by jesourie at 9:30 AM on December 28, 2004
The problem isn't that a Gaussian distribution exists - the problem is that we don't know how large the standard deviation in the skill of doctors is. If it's small, then there is no problem, but the article implies that it may not be.
posted by Veritron at 11:32 AM on December 28, 2004
posted by Veritron at 11:32 AM on December 28, 2004
The article is a bit misleading as it doesn't address confounding factors that make one institution's numbers look better than the others' . The BMJ has done a bunch of papers on so-called "league tables" for neonatal icus, IVF clinics, hospital mortality, and others, pointing out the flaws in relying on simple ranking of institutions, without adjusting for differences in patient populations and random variation.
In the case of CF the confounders between institutions include the race, ethnicity, and median income of the institution's location, none of which are under the control of physicians or patients.
I think it's more realistic to focus more on whether doctors are "good enough" to practice rather than whether they are above or below average; just as I rely on my pilot to be "good enough" to fly rather than see his or her rank on the pilot list. That being said, it is indeed a blessing to have a really good doctor.
posted by v-tach at 12:39 PM on December 28, 2004
In the case of CF the confounders between institutions include the race, ethnicity, and median income of the institution's location, none of which are under the control of physicians or patients.
I think it's more realistic to focus more on whether doctors are "good enough" to practice rather than whether they are above or below average; just as I rely on my pilot to be "good enough" to fly rather than see his or her rank on the pilot list. That being said, it is indeed a blessing to have a really good doctor.
posted by v-tach at 12:39 PM on December 28, 2004
I think what you all are missing is the good that comes from ranking doctors. By gathering this information, they can learn what centers are doing better than others. And they can see what those doctors are doing differently and then let the other doctors know about it during the yearly CF meetings when all the doctors get together and talk about the disease. In this way, it's great.
Yes, there are variations such as race, income, and basic luck (who gets the healthier patients) that the clinics have no control over. But with this disease, what the doctors do really does matter, that's why I was trying to tell you earlier. Yes, most of the patients end up dying of CF eventually, but the agressiveness and creativity and responsiveness of the doctors and the ongoing practices of the clinics slows the decline a LOT. It makes a huge difference. Having an average doctor makes an enormous difference on quality of life and length of life.
posted by aacheson at 2:18 PM on December 28, 2004
Yes, there are variations such as race, income, and basic luck (who gets the healthier patients) that the clinics have no control over. But with this disease, what the doctors do really does matter, that's why I was trying to tell you earlier. Yes, most of the patients end up dying of CF eventually, but the agressiveness and creativity and responsiveness of the doctors and the ongoing practices of the clinics slows the decline a LOT. It makes a huge difference. Having an average doctor makes an enormous difference on quality of life and length of life.
posted by aacheson at 2:18 PM on December 28, 2004
The thing with long term treatments, and in general, just about any activity that is ongoing for a number of years, is that the key is in near perfection. It's the often quoted five-nines. 99.999%. 99% uptime means you're down 3.5 days a year.
This is the critical element, and one of the big reasons why doctors like Warwick are significantly more successful than other doctors. There is no such thing as a minor aberration from best practices when it comes to diseases like CF in the aggregate.
posted by Freen at 5:50 PM on December 28, 2004
This is the critical element, and one of the big reasons why doctors like Warwick are significantly more successful than other doctors. There is no such thing as a minor aberration from best practices when it comes to diseases like CF in the aggregate.
posted by Freen at 5:50 PM on December 28, 2004
I think the question of whether doctors can be effectively and usefully rated is a difficult one, as this thread makes clear. I do know that there is a great deal of variation between the quality of care provided by individual doctors (both my father and girlfriend are health care professionals so I have heard plenty of stories, good and bad).
Although there are always going to be variations between individual doctors, I suspect that there are some problems with, or conversely effective methods of, healthcare that could be positively affected by shining a bright and public light on them.
Megafly: You may have a valid point regarding society needing to avoid disease rather than treating it (although I'm not sure where your argument ends? 'sorry, you didn't feed your kids enough servings of fruit and vegetables so we're going to have to charge you with child endangerment now that they have cancer').
Giving you the benefit of the doubt, it may be that you had not read aacheson's open and moving comments about her experiences with CF in this thread. If that is the case then your comments can be seen as just heavy handed and only-partially informed rather than a direct and offensive attack on another living, feeling Mefite.
posted by pasd at 9:40 AM on December 29, 2004
Although there are always going to be variations between individual doctors, I suspect that there are some problems with, or conversely effective methods of, healthcare that could be positively affected by shining a bright and public light on them.
Megafly: You may have a valid point regarding society needing to avoid disease rather than treating it (although I'm not sure where your argument ends? 'sorry, you didn't feed your kids enough servings of fruit and vegetables so we're going to have to charge you with child endangerment now that they have cancer').
Giving you the benefit of the doubt, it may be that you had not read aacheson's open and moving comments about her experiences with CF in this thread. If that is the case then your comments can be seen as just heavy handed and only-partially informed rather than a direct and offensive attack on another living, feeling Mefite.
posted by pasd at 9:40 AM on December 29, 2004
I have a doctor buddy who has been sending me scary anecdotes about how crappy the non-video gaming doctors are at laproscopic surgeries.
posted by mecran01 at 1:23 PM on December 29, 2004
posted by mecran01 at 1:23 PM on December 29, 2004
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But, that's not what you meant and I think it's pretty obvious. The question is "are some doctors better then others" and obviously, the answer is yes.
But that isn't really what you meant either, the actual question is "are some doctors idiots." and to that I would have to say I think that some are, or that most are. Simply because most of the people in the world are idiots, including the ones who managed to get through years and years of school. Hard work and an average brain will get you into any profession (cept maybe kickboxing or football and other things like that). I'm sure there are many doctors much stupider then me. Much stupider then the average metafilter commenter, I'd bet.
It always bothers me that they say "talk to your doctor" in those ads, as if only a doctor is capable of making an informed decision. They're wrong, and I think that some people should be allowed to manage their own healthcare.
posted by delmoi at 5:58 PM on December 27, 2004