Comment by thelettere | Hacker News Reader

Comment by thelettere | Hacker News Reader

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The article conflates "good" doctor with experienced doctor. There is no such evidence that experience leads to better outcomes in most divisions of medicine (1), and indeed many have found (just like this one) that less experienced doctors provide better care (2).

The most important variable in your doctor is their personality and your relationship with them, and not their experience (3).

Addendum: The quality of your doctors organization and staff may be even more important than that of your doctor (4).

(1) McAlister, F. A., Youngson, E., Bakal, J. A., Holroyd-Leduc, J., & Kassam, N. (2015). Physician experience and outcomes among patients admitted to general internal medicine teaching wards. Canadian Medical Association Journal, 187(14), 1041-1048.

(2) Southern, W. N., Bellin, E. Y., & Arnsten, J. H. (2011). Longer lengths of stay and higher risk of mortality among inpatients of physicians with more years in practice. The American journal of medicine, 124(9), 868-874.

(3) https://www.researchgate.net/profile/Alan_Swann/publication/... and Wampold, B. E., Imel, Z. E., & Minami, T. (2007). The story of placebo effects in medicine: evidence in context. Journal of clinical psychology, 63(4), 379-390; and http://www.annfammed.org/content/7/3/261.full

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

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:

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

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

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

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

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

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

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.

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