# Is there such a thing as a "Good Doctor"? **URL:** \ **Category:** Great Debates\ **Created:** [May 29, 2011, 7:32pm UTC](https://boards.straightdope.com/t/is-there-such-a-thing-as-a-good-doctor/583689 "2011-05-29T19:32:06Z")\ **Posts on this page:** 20\ **Page:** 1
**Author:** ![Simplicio](https://avatars.discourse-cdn.com/v4/letter/s/c37758/32.png) [@Simplicio](https://boards.straightdope.com/u/Simplicio)\ **Post date:** [May 29, 2011, 7:32pm UTC](https://boards.straightdope.com/t/is-there-such-a-thing-as-a-good-doctor/583689/1 "2011-05-29T19:32:06Z")
The idea that there are widely divergent health-outcomes that depend on the doctor that you see, and that people who see “good doctors” will live while those who don’t mind as well start planning their funeral seems pretty popular. To pick a random pop-culture example, in the TV show Breaking Bad, the main character gets cancer and his wife is convinced that he’ll be a dead man unless they can pay extra to get a super-oncologist, if he’s stuck seeing the guy his insurance will pay for, he’s doomed. Similarly, if your sick with a mysterious disease, you better hope you get to see House and not Doctor Nick. But I’ve never seen any real evidence that this is the case. While I’m sure that like any profession there are a couple true incompetents in the medical profession that really do kill their patients where in the hands of an average doctor, they might live, my suspicion is that the medical outcomes for the very large majority of doctors for identical patients are more or less identical, averaged over enough patients, anyways. If your Doc was 20 out of 100 as opposed to 80 out of 100 at his medical school, does that really make an empirical difference in likely outcomes? So my question is, are there any studies that compare outcomes of similar patients seeing different doctors, and found whether the identity of the doctor made a meaningful difference on average? If it did make a difference, were there any characteristics that were shared by the “good doctors”. ---
**Author:** ![Simplicio](https://avatars.discourse-cdn.com/v4/letter/s/c37758/32.png) [@Simplicio](https://boards.straightdope.com/u/Simplicio)\ **Post date:** [May 29, 2011, 7:37pm UTC](https://boards.straightdope.com/t/is-there-such-a-thing-as-a-good-doctor/583689/2 "2011-05-29T19:37:50Z")
Also, to head this off at the pass, I’m not really interested in anecdotes. Health issues seem uniquely vulnerable to poor subjective reasoning, so while I’m glad your Aunt Sally got better soon after she switched from one doctor to another, I don’t think it really tells us anything one way or another. Indeed, I’ve seen studies that when people are asked to rate their doctors by competence, the doctors at the top are usually not those with the best outcomes, but rather those with good intrapersonal skills who are good at relating to their patients. But of course, just because people are poor at picking out who is a Good Doctor doesn’t mean such doctors don’t exist. Which is why I’m interested in studies and the like that actually correlate objective outcomes with the doctor a patient is seeing. ---
**Author:** ![Chronos](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/chronos/32/134_2.png) [@Chronos](https://boards.straightdope.com/u/Chronos)\ **Post date:** [May 29, 2011, 8:25pm UTC](https://boards.straightdope.com/t/is-there-such-a-thing-as-a-good-doctor/583689/3 "2011-05-29T20:25:20Z")
I suspect that what you’ll find is that for the vast majority of ailments, it won’t matter, but that there are a handful of cases (mostly involving rare diseases) where doctor skill makes a huge difference. Even if a doctor only has skill in treating a relatively small number of problems, those problems will generally be the most common ones: The reason he has skill with them is that that’s what he almost always deals with. ---
**Author:** ![MandaJo](https://avatars.discourse-cdn.com/v4/letter/m/ac91a4/32.png) [@MandaJo](https://boards.straightdope.com/u/MandaJo)\ **Post date:** [May 29, 2011, 8:30pm UTC](https://boards.straightdope.com/t/is-there-such-a-thing-as-a-good-doctor/583689/4 "2011-05-29T20:30:24Z")
“Soft” skills are also not irrelevant to how good a doctor is: compliance is a huge issue in the treatment of many diseases, and a doctor’s bedside manner/skill at explaining things might have a lot to do with the degree of patient compliance that results. ---
**Author:** ![DSeid](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dseid/32/20194_2.png) [@DSeid](https://boards.straightdope.com/u/DSeid)\ **Post date:** [May 29, 2011, 8:47pm UTC](https://boards.straightdope.com/t/is-there-such-a-thing-as-a-good-doctor/583689/5 "2011-05-29T20:47:54Z")
Well there is much evidence for very different sorts of care, often regionally segmented, sometimes even blocks apart. The different standards may have different costs yet similar outcomes or even higher costs associated with poorer outcomes. See for example [here](http://www.chcf.org/publications/2009/07/chcf-experience-examining-medical-care-variation), [here](http://www.annals.org/content/138/4/288.short), [here](http://jama.ama-assn.org/content/281/7/627.short), [here](http://jco.ascopubs.org/content/13/1/93.short), [here](http://jama.ama-assn.org/content/273/19/1503.short), and [here](http://care.diabetesjournals.org/content/24/5/860.short). It would be easy to keep going. Local standards vary greaty. More specialists in a region translates into more aggressive care and more expensive but not usually better outcomes, in fact often the opposite. OTOH some primary care generalists functioning by themselves have not kept up with evidence based guidelines. It seems the best quality care often is not the most aggressive care or the most costly care and a large multispecialty group dominated by primary care is most likely to deliver the best care overall. Many of those groups are currently positioning themselves as “accountable care organizations” and plan on proving via metrics that they can deliver overall better care for less total costs (and therefore deserve a piece of that which they save). ---
**Author:** ![Implicit](https://avatars.discourse-cdn.com/v4/letter/i/6a8cbe/32.png) [@Implicit](https://boards.straightdope.com/u/Implicit)\ **Post date:** [May 29, 2011, 9:21pm UTC](https://boards.straightdope.com/t/is-there-such-a-thing-as-a-good-doctor/583689/6 "2011-05-29T21:21:12Z")
> **[Physician Board Certification and the Care and Outcomes of Elderly Patients...](https://pmc.ncbi.nlm.nih.gov/articles/PMC1828098/)** > > Patients and purchasers prefer board-certified physicians, but whether these physicians provide better quality of care and outcomes for hospitalized patients is unclear. We evaluated whether care by board-certified physicians after acute myocardial... > [@](#): > > Treatment by a board-certified physician was associated with modestly higher quality of care for AMI, but not differences in mortality. Death is not the only metric of successful treatment, perhaps recovery time or quality of life measurements might have been better suited. They did find that “Board-certified physicians had significantly higher use of quality indicator therapies than nonboard-certified physicians in each of the specialties…”. For what it’s worth, my husband did a fellowship in the United States and based on what he learned about the medical system there, I would only choose treatment by a physician who was board certified. Approximately 30% of US doctors are not board certified, many of those received their training outside of North America. There is also nothing preventing a physician who has no special training in surgery from hanging up a shingle and calling themselves a surgeon. Buyer beware. ---
**Author:** ![Simplicio](https://avatars.discourse-cdn.com/v4/letter/s/c37758/32.png) [@Simplicio](https://boards.straightdope.com/u/Simplicio)\ **Post date:** [May 29, 2011, 9:47pm UTC](https://boards.straightdope.com/t/is-there-such-a-thing-as-a-good-doctor/583689/7 "2011-05-29T21:47:57Z")
> [@Implicit](#): > > [Physician Board Certification and the Care and Outcomes of Elderly Patients with Acute Myocardial Infarction - PMC](http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1828098/) > > Death is not the only metric of successful treatment, perhaps recovery time or quality of life measurements might have been better suited. They did find that “Board-certified physicians had significantly higher use of quality indicator therapies than nonboard-certified physicians in each of the specialties…”. Interesting. Though note that even amongst board certified physicians, the use of the recommended therapies were in the 40-60% range. Which I guess is in keeping with **Dseid** s link that there are recognized optimal standards of care that aren’t necessarily used by doctors, even board certified ones. So I guess the question becomes: why do some docs stick to these standards and some not? Board certification appears to make some difference, but only by less then 10% or so. Honestly, its kinda bizarre that a profession that requires so much training and has so much in the way of resources is seems so slip-shod. ---
**Author:** ![DSeid](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dseid/32/20194_2.png) [@DSeid](https://boards.straightdope.com/u/DSeid)\ **Post date:** [May 29, 2011, 10:04pm UTC](https://boards.straightdope.com/t/is-there-such-a-thing-as-a-good-doctor/583689/8 "2011-05-29T22:04:09Z")
Of those links, one in my first cite, [The Dartmouth Atlas](http://www.dartmouthatlas.org/pressroom/newsandpress.aspx), may be of most interest for you to play with. As to research that correlates personal characteristics of physicians with patient outcomes data, I am not aware of such studies. My personal opinions include that being a good communicator is essential and not only for the reason expressed by **Manda JO** but also because listening and eliciting the story is how a doctor gets diagnostic clues more than by scattershot testing. You may want to look for a doctor [who enjoys his/her job](http://onlinelibrary.wiley.com/doi/10.1046/j.1525-1497.2000.02219.x/full). And my personal opinion is one who is comfortable answering that they don’t know an answer but that they can call someone they know who does. Part of the slipshod is that our guidelines are themselves sometimes pretty slipshod. For all the lip service given to evidence based medicine many guidelines are still opinion pieces with evidence squeezed in as it fits the desired conclusion. Some guidelines really deserve to be ignored, and often are. Some make few allowances for individual circumstances in which they do not apply. Some docs just keep practicing how they were trained and never change. Some areas have many specialists who convince themselves that doing more is doing better. Also many people do not have primary care provider who serves as their “medical home” so care gets fragmented. There are lots of reasons. One big plus of the healthcare reform act is trying to incentivize developing real outcomes measurements. Currently that which is truly the best quality is not recompensed anywhere near as well as that which is not; true outcomes measurements may help change that. ---
**Author:** ![DSeid](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dseid/32/20194_2.png) [@DSeid](https://boards.straightdope.com/u/DSeid)\ **Post date:** [May 29, 2011, 10:52pm UTC](https://boards.straightdope.com/t/is-there-such-a-thing-as-a-good-doctor/583689/9 "2011-05-29T22:52:20Z")
[This article](http://archinte.ama-assn.org/cgi/content/abstract/160/1/98) helps illustrate why defining quality exclusively as following a guideline may not be such a good idea: > [@](#): > > Overall nonadherence with the guideline was 43.6% … Physicians with more pneumonia experience were more likely not to follow the guideline (P\<.001). [This one also](http://qualitysafety.bmj.com/content/19/6/1.41.abstract) makes the point that a simple guideline followed metric (“quatitative data analysis”) may miss the boat. > [@](#): > > Quantitative data analysis of treatment regimens in patients with CHF is an inaccurate method for measuring guideline adherence. Combining quantitative prescribing data with semistructured interviews shows a 90% match concerning guideline adherence compared to an only 60% match based on quantitative data alone. Thus, neither quality nor economical assessments of the treatment strategy in patients with chronic diseases should be solely based on quantitative analysis. Understanding non-adherence is crucial for defining and improving quality of care. Methods to [improve compliance](http://jac.oxfordjournals.org/content/55/4/550.abstract) are being studied. Physician buy-in, viewing the guideline as credible, seems essential. Your last question is a very good and very important one. The answer though is hard to get at. Sometimes it is the best docs who ignore the guidelines and sometimes it is the docs who have not heard of them or who can’t be bothered to change. The op answer though is clear: there are indeed wide variations in how different MDs handle the same circumstances, with wide cost variations and wide outcomes variations. And it is hard for a patient to tell who is who. Having systems that promulgate the best outcomes for the least cost throughout the system will be a key part of any deflection of the healthcare cost curve. ---
**Author:** ![DSeid](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/dseid/32/20194_2.png) [@DSeid](https://boards.straightdope.com/u/DSeid)\ **Post date:** [May 30, 2011, 12:00am UTC](https://boards.straightdope.com/t/is-there-such-a-thing-as-a-good-doctor/583689/10 "2011-05-30T00:00:15Z")
> [@Simplicio](#): > > … If your Doc was 20 out of 100 as opposed to 80 out of 100 at his medical school, does that really make an empirical difference in likely outcomes? Sorry for the multiposting, but obviously this is a question of some interest to me. I strongly doubt that class ranking has any correlation with future skills. The docs I know who were at the top of their class at a big name institution are often outshined by the docs I know who graduated mid pack from a less impressive program or who went out of country to get their MD. The actual practice skills of observation, active listening, compulsiveness, a balance of confidence and self-doubt, and as noted, the willingness to admit that which you do not know and to shamelessly call someone else who does to ask, those skills have no correlation, positive or negative, with academic success. Even the critical thinking skills, key to being a good clinician, often barely correlate with class rank, as medical school performance is often based on rote memorization skills more than analysis. The joke is that you want to avoid going to the doctor who was at the very top of his or her class and the one who was at the very bottom. The others may be okay. Yes it is a joke. There is some truth in it though. ---
**Author:** ![Simplicio](https://avatars.discourse-cdn.com/v4/letter/s/c37758/32.png) [@Simplicio](https://boards.straightdope.com/u/Simplicio)\ **Post date:** [May 30, 2011, 12:26am UTC](https://boards.straightdope.com/t/is-there-such-a-thing-as-a-good-doctor/583689/11 "2011-05-30T00:26:56Z")
> [@DSeid](#): > > Part of the slipshod is that our guidelines are themselves sometimes pretty slipshod. For all the lip service given to evidence based medicine many guidelines are still opinion pieces with evidence squeezed in as it fits the desired conclusion. That makes sense, though in **implicit’s** link, they claim the recommended treatments togeather reduces mortality from 25% to 14% for the 30 day period following an AMI. Thats a pretty large effect, so I imagine its real. And still even amongst the board certified doctors, it seems large chunks of docs weren’t recommending the two medications (and presumably thus killing some 10% of their AMI patients). So at least some of the guidelines are both worthwhile and ignored by doctors. Presumably for the various reasons other reasons you suggested. But thanks for the links. Its an interesting topic. ---
**Author:** ![gonzomax](https://avatars.discourse-cdn.com/v4/letter/g/e8c25b/32.png) [@gonzomax](https://boards.straightdope.com/u/gonzomax)\ **Post date:** [May 30, 2011, 1:37am UTC](https://boards.straightdope.com/t/is-there-such-a-thing-as-a-good-doctor/583689/12 "2011-05-30T01:37:13Z")
Doctors get paid for doing procedures. They do not get paid for good outcomes. They also make more money by seeing more patients. That means less time per patient is rewarded. I believe the Mayo clinic has doctors on salary. They get better results. They can spend the time necessary to do their job properly. ---
**Author:** ![Shodan](https://avatars.discourse-cdn.com/v4/letter/s/9f8e36/32.png) [@Shodan](https://boards.straightdope.com/u/Shodan)\ **Post date:** [May 30, 2011, 3:14am UTC](https://boards.straightdope.com/t/is-there-such-a-thing-as-a-good-doctor/583689/13 "2011-05-30T03:14:05Z")
> [@Simplicio](#): > > IIf your Doc was 20 out of 100 as opposed to 80 out of 100 at his medical school, does that really make an empirical difference in likely outcomes? Do you know what you call the guy who graduated last in his class in medical school? Doctor. Most medical complaints are self-limiting. I expect that in most cases, it is not going to make any statistical difference in outcomes if you get the best in the field vs. the average doctor. Another factor is that if the best doctors get the toughest cases, then more of their patients are going to have adverse outcomes. By which I mean, 20% of their patients die. For the average doctor, only 10% die. Does that mean the best doctors are the worst to go to? Not necessarily - maybe 30% of the tough cases would have died if treated by the regular docs. Regards, Shodan ---
**Author:** ![DoctorJ](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/doctorj/32/2904_2.png) [@DoctorJ](https://boards.straightdope.com/u/DoctorJ)\ **Post date:** [May 30, 2011, 3:46am UTC](https://boards.straightdope.com/t/is-there-such-a-thing-as-a-good-doctor/583689/14 "2011-05-30T03:46:22Z")
> [@Simplicio](#): > > Interesting. Though note that even amongst board certified physicians, the use of the recommended therapies were in the 40-60% range. > > Which I guess is in keeping with **Dseid** s link that there are recognized optimal standards of care that aren’t necessarily used by doctors, even board certified ones. > > So I guess the question becomes: why do some docs stick to these standards and some not? Board certification appears to make some difference, but only by less then 10% or so. Honestly, its kinda bizarre that a profession that requires so much training and has so much in the way of resources is seems so slip-shod. Different reasons. Part of it is that doctors tend to look down on what we call “cookbook medicine”. The nursing home I work at explicitly doesn’t allow us to use standing orders and most protocols, even though it would probably improve outcomes and definitely save us a lot of hassle, because their umbrella group believes that care should be “individualized”. Also, a lot of the nonadherence with guidelines comes from _overtreating_ the patient. In one of **Dseid’s** links above, a lot of patients with community-acquired pneumonia who could have been treated as outpatients according to the guidelines were admitted instead. That happens at every hospital, including mine, and it probably doesn’t hurt outcomes–it just gets to the same end far more expensively. Plus, a lot of guidelines need to be updated. At a meeting I was at recently, a doc showed some data he had gathered at his hospital on treatment of hospital-acquired pneumonia. The guidelines generally recommend a three-drug regimen for that, and a lot of their docs were only using two. But the patients who were only getting two drugs were doing a little better. There might be a confounder or two that they weren’t able to correct for, but it could mean that the third drug is just unnecessary. Even so, I’d rather have a doc who thoughtfully but faithfully applies guidelines than one who believes he can outthink them, because most can’t. ---
**Author:** ![Simplicio](https://avatars.discourse-cdn.com/v4/letter/s/c37758/32.png) [@Simplicio](https://boards.straightdope.com/u/Simplicio)\ **Post date:** [May 30, 2011, 3:54am UTC](https://boards.straightdope.com/t/is-there-such-a-thing-as-a-good-doctor/583689/15 "2011-05-30T03:54:44Z")
> [@Shodan](#): > > Another factor is that if the best doctors get the toughest cases, then more of their patients are going to have adverse outcomes. By which I mean, 20% of their patients die. For the average doctor, only 10% die. Does that mean the best doctors are the worst to go to? Not necessarily - maybe 30% of the tough cases would have died if treated by the regular docs. Maybe, but I think there’s probably enough situations where doctors are assigned patients more or less randomly for statisticians to sink their teeth into. Plus, the idea that the best doctors are assigned the hardest cases already pre-suposes that someone out there has a way of classifying doctors as “good”. ---
**Author:** ![gonzomax](https://avatars.discourse-cdn.com/v4/letter/g/e8c25b/32.png) [@gonzomax](https://boards.straightdope.com/u/gonzomax)\ **Post date:** [May 30, 2011, 4:11am UTC](https://boards.straightdope.com/t/is-there-such-a-thing-as-a-good-doctor/583689/16 "2011-05-30T04:11:23Z")
I saw a program on a hospital that was willing to treat Jehovah’s Witness patients and not give them transfusions. After doing it for a few years , they discovered that the Witness patients were getting better results. So the hospital cut back drastically of their use of blood and the results were better for patients and cheaper for the hospital. Strange how smart we think we are sometimes and are wrong. In this case, doctors acting against prescribed methodology learned something and became better doctors. ---
**Author:** ![DoctorJ](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/doctorj/32/2904_2.png) [@DoctorJ](https://boards.straightdope.com/u/DoctorJ)\ **Post date:** [May 30, 2011, 4:13am UTC](https://boards.straightdope.com/t/is-there-such-a-thing-as-a-good-doctor/583689/17 "2011-05-30T04:13:31Z")
> [@](#): > > If your Doc was 20 out of 100 as opposed to 80 out of 100 at his medical school, does that really make an empirical difference in likely outcomes? A quick PubMed search suggests that this has not been empirically studied. (Damn good thing, too, because I wasn’t quite at the bottom of my class, but I wasn’t far from it. It took me a while to get the hang of med school.) There are definitely docs I think of as “good” and “bad”, but I don’t know if you could tell the difference with outcome data. It’s more a matter of efficiency–the “good” doc will treat something with an overnight stay and an office visit while the “bad” doc keeps him in for seven days and consults six other doctors. Same outcome, but one doc got there much more easily and cheaply. ---
**Author:** ![DoctorJ](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/doctorj/32/2904_2.png) [@DoctorJ](https://boards.straightdope.com/u/DoctorJ)\ **Post date:** [May 30, 2011, 4:20am UTC](https://boards.straightdope.com/t/is-there-such-a-thing-as-a-good-doctor/583689/18 "2011-05-30T04:20:43Z")
> [@gonzomax](#): > > Doctors get paid for doing procedures. They do not get paid for good outcomes. They also make more money by seeing more patients. That means less time per patient is rewarded. > I believe the Mayo clinic has doctors on salary. They get better results. They can spend the time necessary to do their job properly. Docs on salary still have to make their numbers if they want to keep their jobs or have a chance at a raise. It’s a different kind of pressure from being on your own, but there’s definitely still pressure to produce. There are a lot of efforts out there to provide incentives for docs who follow established guidelines, but paying for good outcomes would just lead to docs not taking on tough cases. ---
**Author:** ![treis](https://avatars.discourse-cdn.com/v4/letter/t/bc79bd/32.png) [@treis](https://boards.straightdope.com/u/treis)\ **Post date:** [May 30, 2011, 4:20am UTC](https://boards.straightdope.com/t/is-there-such-a-thing-as-a-good-doctor/583689/19 "2011-05-30T04:20:48Z")
There may not be “good” doctors, but there are certainly bad doctors. I forget the exact numbers, but a shockingly high percentage of malpractice suits and discipline come from a small percentage of doctors. So super Doc probably does not exist, but there are definitely “drunk on the job” and “completely incompetent” Docs. ---
**Author:** ![Measure\_for\_Measure](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/measure_for_measure/32/557_2.png) [@Measure\_for\_Measure](https://boards.straightdope.com/u/Measure_for_Measure)\ **Post date:** [May 30, 2011, 4:48am UTC](https://boards.straightdope.com/t/is-there-such-a-thing-as-a-good-doctor/583689/20 "2011-05-30T04:48:28Z")
There are worse hospitals. When NY State released outcomes data for heart conditions, the hospitals at the bottom took notice. One hospital discovered it didn’t have so much bad doctors but bad procedures. They had a health care _management_ problem, one that could be corrected. Frequency of hand washing and antibiotic resistant illnesses are other factors that can vary by facility. [Next page](https://boards.straightdope.com/t/is-there-such-a-thing-as-a-good-doctor/583689.md?page=2)