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December 27, 2004

BehindTheMedspeak: 'Medical care is one of those very strange parts of the economy where you get paid no matter what the quality of the service you provide'


So said Dr. Steven M. Asch, a health care researcher at the V.A. Greater Los Angeles Health Care System and the RAND Corporation in Santa Monica.

He was quoted in Gina Kolata's Saturday New York Times front-page story about how highly-regarded hospitals and physicians surprisingly often fail to follow well-accepted practice guidelines.

I've always been puzzled as to how medicine became structured such that a terrible doctor makes as much as - and in some cases much more than - an excellent one.

What gives?

How is this possible?

It's because there's really no way of assessing who's good and who's not.

Most things in medicine are routine, and so it doesn't matter who does them.

For the hard parts, well, any one patient generally only has one experience to report.

But to whom?

Family and friends?

And even then, what good is a series of one?

It's like the doctor who says, "In my experience..." when he's only done something once or twice.

Doesn't give you a whole lot of confidence in predicting future outcomes, does it?


The difference between a good or a bad doctor is so subtle to a civilian/patient, you'll never be able to know for sure.

Doctors know.

But for the most part, they won't trash a fellow physician.

And even bad doctors get away with their mistakes most of the time with no harm done: the human body is surprisingly forgiving, and gets over most things with or without medical intervention.

Now Medicare's starting to rate hospitals based on how often they use proven remedies for common ailments.

Within a few years, individual doctors are going to be rated as well.

That's the thrust of Kolata's article.

But I have a secret to let you in on: those ratings will not tell you whether the doctor who's treating you is any good or not.

Zero relationship.

I say this because for many years, I was in charge of Quality Assurance for the anesthesiology department at the University of Virginia.

I spent countless hundreds of hours gathering data and preparing statistics for our department and for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

All useless, all busy work in terms of making anesthesia better and safer at our hospital.

It's a paper-and-statistic-generating machine to create work and an illusion of measurement and progress.

As will be the hospital and doctor ratings put out by Medicare.

Because good hospitals and good doctors deal with sicker patients, and have higher rates of complications and deaths.

And no matter how much of a "fudge factor" you insert to allow for the increased "degree of difficulty," if you will, it simply won't let you compare doctors accurately in terms of whom you should choose to take care of you when you're well and in the event you get sick.

So what should you do?

I'll tell you exactly what I tell people who ask me: don't get sick.

That's really the long and the short of it.

Sure, if you were in Charlottesville I'd know who to send you to, but outside my town I don't have a whole lot to offer you.

You can get a recommendation from your local medical society, find out where your doctor went to school and did his residency, see if he's board-certified, but I'm sorry to tell you that all your efforts are not gonna get you what you want, which is the name of the doctor who's best for you.


Like I said - don't get sick.

December 27, 2004 at 03:01 PM | Permalink


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» On How Doctors Gets paid from Ask Bjørn Hansen
Joe Stirt writes about how strange it is that a bad, even terrible, doctor gets paid as much as a good one. Medical care is one of those very strange parts of the economy where you get paid no matter what the quality of the service you provide.... [Read More]

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» Don't Get Sick from abstraction
It's no secret that, like in any profession, there are those that are good at said profession and those that aren't so good. It seems that most people, myself included, try to put that thought in the back of their heads when visiting the doctor. T... [Read More]

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Really bad professionals usually don't survive long. If they aren't kicked out for malpractice they go the way of bad chefs.

Posted by: A Key | Dec 16, 2007 7:34:10 PM

The MOE that Gina Kolata writes about is how often proven beneficial medical procedures are performed. It's hard to see how the fact that some doctors see sicker patients than others could confound that MOE.

Posted by: Bernie Simon | Dec 28, 2004 7:48:18 PM

Swedish surgeon here, I can only say I agree 100%. No further comments :-)

Posted by: Jonyx | Dec 28, 2004 12:37:50 AM

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