Who Makes a Good Doctor?

A recent study in the September 13 issue of the Archives of Internal Medicine found that it's difficult to for patients to accurately measure the quality of care a doctor might provide. The study of 10,408 Massachusetts physicians, along with claims data from over 1 million adults from 2004 to 2005, found that information about doctors that is made available to patients does not reveal much about how good the doctor will be.

The data available to patients includes a doctor's gender, education, certification, and malpractice claim history. The Archives of Internal Medicine study found that doctors who are female, board-certified, and trained in the U.S. provide slightly better care than other doctors, with board certification carrying the most weight. These distinctions, however, were not statistically very large.

Setting aside physicians who should not be practicing medicine because they have abandoned, neglected, or abused their patients, though, I wonder how exactly to define "quality of care" among physicians. In the doctor/patient relationship, different patients value different qualities: some might prefer a doctor who is the same gender as them, or who has a certain bedside manner, or who received training from an institution they admire, or whose office staff are easy to work with.

A patient who has a strained relationship with their doctor might avoid calling or visiting their doctor or revealing some medically-relevant personal information, even when they were ill or needed follow-up care. Even if the doctor provided excellent care, this patient would probably be better off with a less competent doctor who worked with the patient better.

I'm all in favor of the practice of evidence-based medicine, in which treatment decisions are made based on the best available science. But to some extent, "quality of care" is about the quality of the relationship between the patient and the doctor, which is why it is difficult to measure.

In the end, I like The Lancet's take on this topic in its August 28 issue: that the answer to the question "what makes a good doctor?" depends on who is asking it:

The attributes of a good doctor vary according to the population surveyed. Patients value communication and care, colleagues seek competence and camaraderie, medical students prize cheerfulness. By contrast, admission panels focus on chemistry grades, as if knowledge of ionic bonds is somehow a proxy for the complex human and organisational bonds between doctors, their patients, and colleagues.

Lessons from Cesarean Section Rates

Evidence-based (data-driven) medicine, or EBM, is gaining momentum as an antidote to the perils of of groupthink in medicine. Just because something has "always been done this way" doesn't mean it is right; EBM argues that research data should better inform how medicine is practiced day-to-day.

It's interesting to apply EBM principles to cesarean surgery rates in this country. Far more women deliver by cesarean section now than in the past. Why? Some researchers, such as Dr. Frederic Frigoletto, Jr. at Harvard Medical School, argue that the increased rate is primarily due to complications caused by increased obesity rates and advanced maternal age. Some women also choose elective cesareans in order to control the timing and nature of the birth, he explained in a 2006 WebMD article.

Although cesarean rates have increased across the country, not every area has the same rate. Rates are generally higher in more conservative areas of the country and lower in more liberal areas. A study of California cesarean rates presented at a health policy meeting in 2000 found that the cesarean rate was up to 2.5 times higher in some regions of the state than in others. These facts have made cesarean rates a political and feminist issue as well as a medical one.

Cesarean sections are also extremely profitable for hospitals. The California study noted that cesareans are more common among for-profit hospitals than not-for-profit and teaching hospitals, which suggests a profit motive behind the surgeries as well.

On the other hand, are obesity rates (and/or maternal age) simply higher than average in some areas, potentially leading to a local increase in medically-necessary cesarean sections? If this is true, does a hospital with high cesarean rates have an ethical obligation to put some of these surgical revenues toward programs to decrease the obesity rates in its community? (Trying to decrease maternal age in a community is a thornier issue, I think). And how would this ethical obligation undermine a hospital's bottom line? A decrease in cesareans, after all, means a decrease in revenue.

Medical data is a starting point for these discussions, not an end point. All data needs some context. It's good to remember this as the presidential elections approach and the candidates try to summarize their views on the health care system into marketable sound bites. A few sentences, or a single anecdote, rarely tell the whole story.