Wednesday, July 25, 2012

"Best Doctors In New York" - Are They Really "The Best?"

New York Magazine, Castle-Connolly, U.S. News and World Report - all, and I'm sure many more, increase readership by creating lists of "The Best Hospitals" and "The Best Doctors."

As a physician let me caution you about relying solely on such information.  Though U.S. News and World Report gathers rather good statistical data on which to base its hospital rankings, this is not at all true for lists of "Best Doctors."  No real evaluations go into these lists - these "Doctor" lists rely almost exclusively on surveying physicians themselves and asking the respondents to recommend physicians they personally would favor.  So, "I'll be happy to recommend you, if you recommend me" is one way to claw your way onto these directories - directories which lead to increased referrals and plaques for the office (if you purchase them!)

As I read these lists I see many physicians with whom I am rather familiar - and I also note others who are missing!  There are quite a few "missing," very highly regarded practitioners of their specialty, whose absence astounds me!  And, of course, quite a few of the "best" hardly qualify for such acclamation.  I have had personal acquaintance with some of these "featured" physicians who, in my opinion, are mediocre at best.

If you are searching for "the best"physician,  rest assured there is no "one best."  But there are many who are excellent, many who are just OK, and those who are adequate, if not worse - and everything in between.  Lists include them and exclude them - no matter what the level.

So what to do?  A problem, for sure.  Your best chance to find "one of the best doctors" is by researching the highly-regarded academic medical centers in your area or in an area within reasonable geographic proximity.  In searching for the "right" physician, check to see how active and successful the center is in his/her specialty and if the facility has an approved training program within the specialty.  Find a physician on that faculty and review his/her training.  Physicians' (including surgeons) most critical education is acquired during the residency and post-residency (fellowship) years.  A residency in a highly-regarded university teaching program is usually the most competitive, graduating well qualified practitioners.  Ideally, the physician or surgeon should have completed his training at least five years prior to your consultation.

When consulting a physician in a non-surgical specialty, it often helps to see if he is affiliated with a well regarded institution whose faculty includes skilled surgeons in his specialty.  Patients may require surgical consultations and/or surgical procedures.  If this is the case, finding a major medical center where both referring physician and surgeon have privileges can be very advantageous.

What you have here is my opinion - I have no statistical data to support these recommendations.  But there is data that show that morbidity (complications) rates and mortality rates are lowest at centers with high volume in a particular specialty - and these centers are almost universally those described above.

Full disclosure - I have been on lists of "Best Doctors" and have also been excluded from some.

Thursday, July 19, 2012

Cologne and the Prohibition of Circumcision

There has been a recent court ruling in Cologne, Germany prohibiting circumcision in its jurisdiction.  The  court ruled that the procedure violated a child's fundamental right to be protected from bodily harm.  This, as expected, has caused an uproar among the Jewish and Muslim populations in Germany, and some have even considered this judicial decision to carry anti-Semitic and anti-Muslim overtones, and to have caused doubts, in general, about religious tolerance in Germany.

Let's assume, for this discussion, that there are no religious or ethnic traditions which call for circumcision, and that circumcision is a procedure with which the general public is not familiar.  You read about a mother who, because of instructions received in a dream, went ahead and circumcised her week old baby boy.  Another mother, having a similar epiphany, circumcised her baby girl.  A third mother, also hearing voices, pierced her baby's nasal septum in order to insert a ring.  And yet one more mother, following an inspirational commandment, permanently tatooed a large star on her infant's buttocks.  All the mothers were competent to perform these procedures and did a perfect job in each case.  No infant suffered complications, and none are expected in the future.

What would your reaction be?  Does a mother have the parental right to have these purely elective procedures carried out on her infant?     Should these procedures be construed as "bodily harm," or are they non-harmful, (though painful) and therefore acceptable.  Is it also not possible that when the infant reaches maturity, resentment at having been subjected to the procedure may develop?  Should the parent be required to seek counseling and wait 24-48 hours before being permitted to proceed (as is the case with elective abortion in some states.)

However, when we consider religious or ethnic tradition as the rationale for these "alterations" to an infant's body, the procedures may take on a wholly different appearance.  What may have been considered unacceptable now achieves acceptability.  After all, they are basically "harmless."  What sounds like a crazy, if not an actually cruel, procedure becomes justifiable under those circumstances.  So we continue the tradition.  ......But should we?

Friday, July 13, 2012

A Child Died - Could A Computer Have Helped

I am a physician. A physician's job is to obtain information from a patient using various techniques, then to input the accumulated data into his brain, and finally arrive at a diagnosis via mental algorithmic analysis. But we physicians are human! We err. We err as a consequence of these human variables.

I feel quite certain that a medically sophisticated Watson (Dr. Watson, I presume) will outscore the diagnostic acumen of the physician in the near future, and will become the physician's most valued "partner." Dr. Watson will "outdiagnose" all of us. Not only outdiagnose - but "outmanage" as well, because the management of a medical problem is also an algorithmic conclusion. We physicians won't accept Watson, at first. Like so many advances in medical management, we will have to be dragged to it "kicking and screaming," but eventually accepting it in the end.

The above is taken from a Feb. 17, 2011 Blog entry discussing the value of computer-aided diagnosis (Watson) in medicine.

An Infection, Unnoticed, Turns Unstoppable (Jim Dwyer, New York Times July 12, p. A15) describes the shocking story of Rory Staunton, a 12 year old boy who was not properly diagnosed, and who consequently went on to die of an overwhelming bacterial infection, causing complete failure of his bodily organs (liver, kidney, etc.) to function.

I think that many physicians may have initially missed Rory's diagnosis.  We physicians are taught to think of the most obvious answer to a diagnostic problem, and tend to relegate the outside possibility of the the very infrequent, or improbable  diagnosis to the "back of the brain."  But, we are to be faulted if we do not critically consider all of the "differential diagnoses" and take reasonable steps to eliminate the rare ones.  But we err.  We are human.  Though I am unaware of all the details of Rory's case (I wasn't in the ER), it certainly raises a serious question of diagnostic error and associated medical mismanagement.

Could 'Watson' have assisted in preventing this unfortunate outcome?  A properly programmed computer would have alerted the physicians and demanded accountability for the abnormalities detected in Rory's blood tests relative to the signs and symptoms which he presented.

Future use of these electronic assistants may not totally eliminate this human tragedy, but should certainly help in avoiding them.