* * Anonymous Doc

Tuesday, October 4, 2011

There's an article in the New York Times today about patients being overtreated and how they should ask more questions and see if there are alternatives to what the doctor recommends that involve less invasive procedures or fewer medications.

This may be a minority opinion, but I think the article is stupid.

It's stupid because if you need to push your doctor to talk about less invasive options that may be just as effective, or medications he or she prescribed you may not need to be taking, guess what?

You need to find a better doctor.

What the article basically says is you should bully your doctor into ordering fewer tests and letting you stop taking some of your medications.

Which is great advice, until you miss something that one of those tests would have picked up, and you end up in worse shape. If I'm a patient, I don't want a doctor who I have to bully into not ordering a CT scan. I want a doctor who's smart enough to know when a CT scan makes sense and when it doesn't. I want a doctor who knows when he can take me off certain medications. Not a doctor who I can nag until he gives in, and lets me, the uninformed patient, dictate my care whether or not I know anything useful.

If I've learned one thing these past two years, here it is:

All doctors are not the same. All hospitals are not the same. If you go to a mediocre doctor, you will get mediocre treatment, and you will encounter avoidable risks that you may not even know you're being exposed to, whether it's from the wrong medication, the wrong treatment plan, outdated advice, failure to think proactively, or just plain stupidity and carelessness.

Somehow, people understand that there's a difference between a diner and a four-star restaurant, that chefs have different levels of capability, and that if you want the best meal you can find, the diner is probably not the place to go....

And yet people pick a doctor with less care than they choose a restaurant.

People don't ask where their doctor went to school, did their residency, what hospitals they're affiliated with, how many patients with similar conditions they treat, and whether they have a financial incentive to push whatever treatment they're pushing.

If you have an upper respiratory infection and need an antibiotic, most doctors can probably deal with you appropriately. If you're young and healthy, and don't have a bunch of medical conditions, most doctors can probably deal with you appropriately. Beyond that, I'll take the one with the fanciest diploma, thank you. It's not a guarantee-- there are smart people who are bad doctors, and there are certainly people who went to ordinary schools who are excellent doctors, but at least it's something. It's a proxy for some level of competence. I want the smartest person I can find, with the most experience and training, dealing with my medical decisions. The stakes are often too high to risk anything less.

It is incredibly frustrating to see patients who come in with, say, a bleeding ulcer, and they in fact tried to do all the right things-- they went to their doctor, who sent them to a GI specialist, who did an endoscopy... and missed the ulcer completely. Or exacerbated the problem. Or didn't look at what other medications the patient was on. Or didn't check labs before doing the test. And then we get the result-- a patient with a BP of 80/50 bleeding into his intestinal tract. And, no, we may not have done any better if we were the first stop, but we probably would have. You can avoid problems if you start with the most competent doctors you have access to, and don't assume that every doctor is fine, and every doctor will give you the same answers.

If you have to rely on your own skepticism to force your doctor to think about whether he's recommending the best possible treatment, like the Times article assumes, you are in bigger trouble than just needing to ask a few questions. You need a different doctor.

You should not have to come armed with your own independent medical research in order to get satisfactory care. There is something wrong with the system if you need to know more than your doctor does.


  1. Hmm, coming from the UK, this whole 'choose/change a doctor' thing seems a bit surreal! If I'm sick, I go to my doctor (who I get to register with because he's the nearest to my home), I get to choose which of the doctors in the practice I see, but it tends to depend on who is available. If I get referred to a specialist (or his team) I have no idea who I will see, except I know I had better move heaven and earth to be there for that appointment, or I may have to wait 2, 6, 18 months for another appointment. On the plus side, it's free and they do tend to deal with urgent stuff pretty fast. I'm not sure that the idea of choice is so good - I'm not a doctor - who am I to judge which doctor is best based on my friends/ the newspaper's recommendation?

  2. Isn't that the real question, though? How are you supposed to know as a patient, then, how competent your doctor is? If you start out assuming you know more, you'll either bully the overtreating ones into treating you less, or you'll end up bullying a competent doctor (who you did not recognize as such) into treating you too little.
    I personally think the diploma is a lousy way, not because I didn't go to Harvard (my school is top 1/3 according to US News, not the best, but certainly not the worst, but should we even trust that?), but given the broad spectrum of competency and talent within my class, I would be very hesitant to use just the diploma as the judge.

  3. You make it very clear why one should get a better doctor, but exactly HOW does one do that?

  4. I think you make some very salient points. This seems to be part of the greater picture of scientifically and medically illiterate politicians and insurance companies trying to push responsibility off on the patient in order to save money so they can pay themselves better. The whole idea of medicine as a "free market" is so entirely silly, because when I need a pair of shoes, I'm pretty competent to find some that look nice, and that fit, at a price I can afford, and if I can't find a pair, I can skip it and try again later. None of this applies to medical care whatsoever at all. Medicine is just not a "shop and choose" endeavor. And when my blood sugar is 500 and I can barely stay awake, it's not the time to be considering whether you can give me a cheaper treatment. Just save my life, please.

  5. "People don't ask where their doctor went to school, did their residency, what hospitals they're affiliated with, how many patients with similar conditions they treat, and whether they have a financial incentive to push whatever treatment they're pushing."

    People don't know what medical schools are good, what residencies are hard, and how many patients with similar conditions is not enough/enough/a lot. Or whether the financial incentive actually conflicts with their best interest.

    You want people to know these things, have it be part of mandatory health class in high school. I'm applying to medical schools in less than a year and I still can only tell you the relative merits of about ten of them.

  6. This was very interesting. I always check to see where my doctors went to school, and I've wondered if I was being a bit of a snob to favor doctors with "name brand" training. I'm also stymied by the fact that many of my doctors went to medical school in their native countries (e.g., Iran, India, China), and I have zero sense of which schools are good in those countries. Some of them retrained after they came to the United States---does the fact that they've done TWO MDs and TWO residencies make them even better?

    I have a fairly academic background myself, and I know which schools have good programs in the humanities, but I don't know if that means that a medical school associated with a university known for excellence in, say, literature is also considered good.

    And it gets more complicated as I investigate later phases of training. I really don't know which hospitals have better residencies (does bigger = better?), and when it comes to fellowship training, I know nothing at all. In the non-medical world, there just isn't a lot of gossip about which gastroenterology or surgical oncology fellowship programs are superior!

  7. While your post was both interesting and well written, I, like most of the other commenters, have no idea HOW to choose the best doctor. And if you, or anyone else, can't explain it so that a lay person, like myself, can understand how to obtain such information, AND be able to easily access and understand such information, then your argument is moot.

    But we can both probably agree that the system needs some (or a lot of?) work.

  8. ...and what happens when you only have access to the worst of the worst? The sickest among us in the country typically get Medicaid or Medicare, and the doctors accepting those plans are bogged down, overworked and underpaid-- and generally not the best of the best, because the best of the best are making big bucks from higher-paying plans or cherry picking their patients.

    the system *is* broken, and i say that as a scientist, a patient advocate, and as a person whose health has been made worse by doctors practicing bad medicine-- but "just find a better doctor" is difficult when better doctors are in short supply-- if a patient is even lucky enough to be able to access one.

  9. Last line of your post. Read it again.

    And THAT is why there is a problem today. Because every doc doesn't know every thing. You aren't a specialist in me.

    I have the time and motivation to become a specialist in me.