[smackingly]

Maybe I'm biased because I'm a no-name physician at a community hospital, but the "best doctors" in my eyes are the ones with the best outcomes, lowest utilization, highest efficiency and highest patient satisfaction. These measures don't correlate well with the physician's credentials. I learned this in residency, which I did just down the street from a "top" university hospital. We out-performed that place on every level except our doctors went to "lesser" medical schools. They simply spent more money (on wild things like ECMO, which makes everyone feel they're making more of a difference even though the outcomes are the same without it).

Our profession is moving toward identifying these doctors and promoting their behavior to the entire field.

There's a study that showed lower heart attack mortality when all the "top" cardiologists were out of the hospital attending a cardiology meeting. Too many confounders to make any real conclusions from that, but it lines up with my point.

Of course, if your child has a serious life-threatening and/or rare disease, then you want her to be treated at a vanguard institution like the one you took yours to. No dispute from me on that one.

But in the system as a whole, we make the most difference reducing complications of cardiovascular disease, sepsis, pneumonia, COPD, and kidney disease (which are orders of magnitude more common). And we're starting to find out how to identify doctors that do it better, with fewer complications, and with much higher efficiency than others. I think those are the best doctors and it's what I'm striving to be.

[conorh]

> "These measures don't correlate well with the physician's credentials."

This. I think I've even posted about this here before. This has been my wife's experience too (surgeon). She trained with highly regarded academic surgeons that set the treatment recommendations and standards for her field. Then during her job search she went to a center with, well, surgeons not at all academic and she had a life changing moment because she realized their operations and outcomes (utilization, efficiency etc.) are far far better. At the academic centers you are recognized based on your research and publications, not on your surgical skills. These academic surgeons with relatively little experience are setting the standards for how the operation should be done and what the treatments should be. This is not at all recognized in her field unfortunately and is quite literally harming patients every day because of substandard treatment standards.

[clarkmoody]

This reminds me of Hayek's Knowledge Problem[1]: The most effective ways of solving problems are with those closest to the problems. In an economics setting, this means that central planning is inferior to distributed decision making.

Perhaps it's not a perfect analogy, since it sounds like the academic surgeons are maximizing the wrong utility function (publishing / research).

[1] https://en.wikipedia.org/wiki/Local_knowledge_problem

[epmaybe]

I think it depends on the academic center. Where I'm at some of the clinicians that don't do any research are some of the most highly regarded faculty.

I'd say a good combination of both academics and skills are needed. As another anecdote, where I am in school they have tried to teach us better clinical reasoning and procedural skills rather than solely preparing us for board exams.

The way I see it, your research and academic pursuits can wait until you have a good clinical background. You only have one chance to fully immerse yourself in the practice of medicine (residency), so why dilute that?

[rdlecler1]

I don't have the original source handy, but I recall a study showing a high correlation between hand dexterity and surgical outcomes.

[arethuza]

I was pleasantly surprised to find that applications by 17/18 year olds to medical school here in the UK require that you demonstrate manual dexterity - one person sending in a video of them plaiting their hair which apparently went down well!

[NB This is in addition to the very high academic standards that are required for places at medical school].

[Intermernet]

The problem with this is that dexterity beyond a certain level is very specific to what has been trained.

I have a friend who is an eye surgeon. I'm definitely better at playing guitar and piano than him, probably equal at things like juggling and card tricks, but absolutely inferior when it comes to cutting people's eyeballs apart.

It doesn't invalidate your point completely, but just because someone is good at plaiting hair doesn't mean they'll be good at surgery!

[hexane360]

It seems to me like there should be some middle ground. I don't think the best practicing surgeons are necessarily the best academic/theoretical surgeons (although there's definitely some overlap). That's not to say academic surgeons don't need experience, but I think there's definitely different skill sets involved.

[ThomPete]

Great insight.

Being a surgeon is more akin to performing arts. I.e you cant read your way to playing an instrument, you have to practice playing it.

[Sukotto]

  the "best doctors" in my eyes are the ones with the best outcomes,
  lowest utilization, highest efficiency and highest patient 
  satisfaction. 

As a lay-person, how can I tell which institutions or doctors have the best outcomes, and patient satisfaction? How can I make smarter choices about where I take my family for medical help?

  I think those are the best doctors and it's what I'm striving to be.

As a doctor, how do you measure this? How do you know you're becoming better and in which areas you need to focus?

Also, have you seen this article? It might interest you: http://www.newyorker.com/magazine/2011/10/03/personal-best

[obstinate]

I feel like I've read some research that patient satisfaction is sometimes inversely correlated with other measures of doctors' skill. This is because the sickest patients tend to seek out the most skilled doctors, but doctors are not miracle workers. If you receive a higher fraction of people in marginal condition, you may get worse outcomes, despite having better outcomes than a similarly situated, less skilled doctor. Patients don't know this, being able to see only their own situation, and knowing only that they had a bad outcome.

There is some name for this apparent statistical paradox, but I forget what it is. In any case, the main problem with your criteria is that the "best" doctor would be one that treated only the healthiest patients. They would have low utilization, high satisfaction, good outcomes, and very good efficiency.

[replicatorblog]

I agree 100%. I didn't mean this as a knock against doctors at local hospitals either. The pediatrician who diagnosed my daughter is a perfectly solid practitioner in a small town in New Hampshire. Not every doctor is going to make a breakthrough on the order of Marshall & Warren, Banting & Best, or other Nobel Laureates. That's ok. The middle of the road physician will save millions of man years worth of lives over the course of a career, any parent should be proud if that's "all" their child accomplishes.

[thomasfedb]

Interesting that you bring up Marshall & Warren - in my opinion the truly interesting part of that story is their fight for truth above dogma.

I think you want that in a doctor - a capacity and preparedness to fight the system when it is wrong, unfair, of hurting your patient. Is that a creative skill? I don't know but I doubt it's born out of conformity.

Incidentally I know Dr Marshall, he's an academic at my medical school. He actually paid me to teach him and his team Ruby.

[keldaris]

The problem for me as a reasonably educated patient (physics PhD, done some work in biological physics, amateur knowledge of medical literature which I enjoy reading) is that the "top" academically performing doctors leave a public track record of their expertise in the form of academic publications I can go through and evaluate. I fully realize that this doesn't necessarily (or even often) correlate with practical skills that determine patient outcomes, but at least it's a metric I can look at. With most doctors, there is no such metric, so I'm essentially playing the lottery. The salient question then becomes whether it's statistically better to play the lottery or go for the academically prominent doctors, and I'm not aware of any decent studies exploring that. Do you have a recommendation on how to approach that issue from the patient point of view?

[smackdingly]

You're right that there's no easy way to pick a physician. But when I or one of my loved ones is in the hospital, my only requirement for the hospital staff is that they communicate well with me. If they don't, I politely ask that they be removed from me/our care. I make this requirement clear up front (in a non-demanding kind of way; you don't want to piss people off or make it look like you're a difficult patient/family member).

Also, for every patient and family that I meet, I explain right away that the only promise I make is that I will be honest, upfront, and clear when I'm talking to them; that I will give them my best effort. This has served me very well and I've won numerous local accolades because of it. It also softens the blow when something goes wrong, even when it's my fault. When I was a resident, I frequently had patient's demanding to speak with me instead of the attending because they trusted me more.

Keep in mind that I'm a hospitalist/intensivist, so I don't know if things will necessarily generalize to the primary care/office setting.

[LostWanderer]

This may be a shot in the dark but try looking for doctors who interact and are cheerful(to their patients). The referral thing between the patients is very strong so more patients will come and will feel good which works as a catalyst(Both the parties will have a good amount of dopamine flowing). And eventually the variety and number of patients will increase and so the doctor will have more practice and become better!

In the far off rural areas where connectivity is almost nil,The doctors rarely go to the hospitals and the doctor's assistant does more work,becoming at par with the doctors in a few years.

[lsaferite]

> wild things like ECMO, which makes everyone feel they're making more of a difference even though the outcomes are the same without it

Knowing that my daughter wouldn't be here today without ECMO, I take issue with this assertion.

Edit: She was born with severe MAS and her lungs were practically non-functional. ECMO was the only way she had time to fight the infections and start breathing. She spent 12 terrifying days on ECMO and then 2 more weeks on ventilators.

[lsaferite]

My wife corrected me. ECMO for 10 days, ventilator for 3, then 7 more days on a nasal oxygen feed. Time gets fuzzy when you're in the NICU.

[pfarnsworth]

Out of curiosity, what brings a physician at a community hospital to a largely programmer forum? I'm genuinely curious, I love the fact that HN has such a diverse set of very intelligent people.

[smackingly]

I have an interest in technology. This place has a good offering of technology news and discussion that I can't find elsewhere.

Also, a significant number of my investment gains originated from stuff I read here (bought a bunch of Monero when it was $0.45/unit, for example).

Finally, I learned a little programming (mostly Go and C++) to automate some stuff at work and home (reports, backups, email notifications and things like that). HN is a reasonable litmus test for what people are using to do stuff like this.

[pfarnsworth]

That's very cool, thanks for sharing!

[barrkel]

I don't think reasonable developers use C++ or Go for any of those things. You might use a backup utility written in C++ or Go; but you don't write your own if you can help it, and you drive it with a scripting language like Python or Ruby or even bash.

No knock for learning. But if you want to get maximum bang for your learning buck, focus on higher level stuff with lots of third-party libraries that integrate with the things you want to automate, ideally with a interpreter REPL for exploratory coding.

[smackingly]

Yeah, I know, I was just trying to show that I have a broad set of interests and enjoyed learning Go and C++. I use "rclone" for most of the backup-related things.

[neutronicus]

They might be consuming some APIs that drive the choice.

\shrug. Hard to know.

[shouldbworking]

I've seems lot of people from other branches of engineering and medicine on HN. My guess is that biology is just an interest in the natural form of tech, seems to be a lot of overlap.

[Baeocystin]

I agree. I may earn my living in the tech field now, but I majored in Cognitive Science, not Computer Science. And I think it has served me well.

[luca_ing]

As the son of an excellent surgeon (and that assessment seems to be more than a son's pride), I think there's another paramount quality that should be mentioned: empathy.

I think that this is truly what made my father be not just "technically good", but a physician who could solve his patients' problems: he made an effort to understand their perspective, and adjust his treatment accordingly.

I've observed him interact with patients sometimes, and his effort at creating empathy was quite noticeable. It's particularly fascinating to watch with children.

I agree with you though that efficiency, and also just honing one's internal sense of what's going on inside a patient's body is important. My dad was department head at a first-world hospital. But every year he would go on a charity mission to some third-world place for two weeks and treat patients there. With essentially no modern technology (in fact, operations might have to performed in the shine of a flashlight), you are really forced to work with your instincts. I think these trips benefited his first-world patients just as much as his third-world ones.

[arethuza]

Your observation reminds me of the original negative definition of the term "meritocracy" which focused on "merit" as being something not terribly strongly linked to actual measurable performance in a field.

https://www.theguardian.com/politics/2001/jun/29/comment

[trusche]

OT - why do you consider ECMO a "wild thing"? I ask since our daughter was born with CDH and ECMO came up in the discussions at the time (she didn't need it, luckily). Ireland doesn't have one to date AFAIK.

[walshemj]

Doesn't this depend on the severity of cases the hospital gets ie top hospitals get the more acute life threatening cases

[H4CK3RM4N]

Do you have a link to that study somewhere? It think I might be able to use it to prove a point.

[koolba]

What's ECMO?

[wighty]

https://en.wikipedia.org/wiki/Extracorporeal_membrane_oxygen...

[koolba]

Whoa that's nuts! Sounds amazing for saving babies though after reading the article my next thought was using that plus a dialysis machine to create a Frankenstein body to cheat death.

[lsaferite]

My daughter owes her life to ECMO. Scary as hell, but I'm thankful for it every day. The team that saved her life just recently performed the first transport using a portable ECMO machine. The one they used on my daughter was the size of a vending machine. They now have the portable units down to the size of a small suitcase.

[nickthemagicman]

Sounds like somebody's a little jealous..