By Phil Denniston, President, Denniston Data Inc.
What is more important to you in choosing a doctor: (1) Bedside manner; or (2) Medical outcomes, i.e., success in performing a service that will get you better and/or keep you healthy? Most people would choose #2, but virtually all the doctor finder services available in the U.S. focus on criteria like #1. There is a lack of concrete accurate information on how well doctors do, when doing what we hire them to do. There are over a dozen doctor finder services, including Definitive Healthcare, Doctor.Com, Doximity, Healthcare Bluebook, Healthgrades, Md.Com, Quantros, Ratemds, Sharecare, Vitals, Webmd, and Zocdoc. They typically assign ratings of one to five stars to each doctor, based on characteristics like friendliness of the doctor and staff, comfort of waiting room, ease of getting an appointment, insurance coverage, and bedside manner, etc. These doctor finder services are all supported by advertising, and a doctor may even be able to improve his positioning by paying for advertising on the site. And the site will even make an appointment for you. Other than anecdotal evidence, there is a lack of aggregate data on how successful a doctor is, in whatever procedures he or she does. For example, there are tens of thousands of doctors who implant knee replacements. There is a great deal of variation in their success, but we do not have an easy way to separate the most successful ones from the less successful ones. Since we do not have this information on outcomes, maybe there is other information that could be a proxy for the information we need. Let us review the high-quality medical evidence to see if that is a possibility.
The highest quality evidence comes from peer reviewed studies that are published in recognized medical journals. After reviewing these studies, we found that there is one common denominator, experienced doctors have better outcomes than doctors who are less experienced, or especially those who are just learning a procedure. While this makes sense, in fact it is intuitive, we need to be sure by looking at the data. These results cut across every medical specialty and every type of procedure. Key examples are cited below.
In joint replacements, complication rates are dependent on surgeon volume and surgeon experience, not gender. The higher the surgeon volume with a specific procedure, the lower the complication rates. (Chapman, 2020)
There is a need for sufficient patient caseload to ensure frequent practice of a specific procedure, in this case pancreatic surgery. The experienced (versus novice) categories were related to a decreased risk of postoperative pancreatic fistulas (odds ratio [OR] 0.46) and in-hospital mortality (OR 0.45). Frequent practice was associated with a significantly lower risk of delayed gastric emptying (OR 0.56), postpancreatectomy hemorrhage (OR 0.64) and in-hospital mortality (OR 0.45). (Krautz, 2019)
According to the Leapfrog Group and Johns Hopkins Medicine, patients undergoing high-risk surgeries are more likely to suffer complications, harm, or even death when the surgeon and hospital are inexperienced at that procedure. An analysis examining five common procedures in 2019 found 11,000 volume-related deaths might have been prevented for those procedures alone. For one low-volume provider, the analysis showed that patients were 24 times more likely to die from a knee replacement surgery than with the highest-volume providers. (Leapfrog, 2020)
In facial repair, the level of surgeon experience affects the accuracy of implant placement; even the use of computer-guided surgery does not completely compensate for the level of operator experience. (Marei, 2019)
Age alone does not prove experience, but experience does tend to increase with age, and this study debunks the idea that older surgeons may decline in performance. For all types of medical services, increasing surgeon age was associated with decreasing rates of postoperative death, readmission, and complications in a nearly linear fashion after accounting for patient-, procedure-, surgeon- and hospital-level factors. “We evaluated the association between surgeon age and a composite outcome of death, readmission and complications. We found 1,159,676 eligible patients who were treated by 3,314 surgeons and ranged in age from 27 to 81 years. Modelled as a continuous variable, a 10-year increase in surgeon age was associated with a 5% relative decreased odds of the composite negative outcome (adjusted odds ratio 0.95, p = 0.002).” (Satkunasivam, 2020)
Even in robotic surgery, experienced operators are needed. Minimum numbers of cases needed to achieve plateau performance were wide-ranging but overlapping for different kinds of operations: up to 128 cases for colorectal, 95 for foregut/bariatric, 48 for biliary, and 80 for solid organ surgery. (Pernar, 2017)
In urinary laser surgery, surgeon experience contributed to shortened operative time and enucleation time, and to decreased postoperative urinary incontinence. (Shigemura, 2017)
Experienced surgeons can operate on their own, but inexperienced surgeons should not. The plan in that case should be to retain two surgeons. A high-volume surgeon does not benefit from a dual surgeon approach, whereas standard-volume surgeons have better outcomes with a dual surgeon approach. Junior surgeons benefit operating with an experienced surgeon. (Sarwahi, 2020)
Laparoscopic liver resection for lesions in the difficult posterosuperior segments and major hepatectomies, especially in cirrhosis, should only be attempted by surgeons who have acquired a minimum of experience. (Goh, 2018)
In thyroid surgery, higher operative volumes improve cure rates and decrease the rates of complications, recurrent disease, and perioperative costs. (Erinjeri, 2019)
The dislocation of a total hip endoprosthesis is an emotionally traumatizing event that should be prevented if possible, and this is frequent with inexperienced surgeons. The operation should be performed with an adequately experienced orthopedic surgeon. (Dargel, 2014)
It has been shown that less experienced doctors tend to most over-estimate their diagnostic accuracy. Diagnostic errors have recently begun to receive more attention as a preventable source of patient harm. Diagnostic errors are estimated to account for as much as 160,000 deaths per year. Misdiagnosis has been the leading cause of medical malpractice payments over the last 25 years, making up 28.6% of claims and 35.2% of total payouts. Missed, incorrect, or delayed diagnoses are estimated to occur in 15% of clinical cases, accounting for 8%-20% of adverse medical events. Diagnosis is the most critical of a physician’s skills. To reduce cognitive errors in making the correct diagnosis, it is necessary to select doctors with increased knowledge and experience. (Sajid, 2014)
Additional Studies 4/29/21
According to referring medical doctors, experience is the most important missing factor in making referral decisions. The Stax study concluded that two-thirds of physicians do not have all the information they need to make optimal referral decisions, with the most important missing information being doctor’s experience (85 percent), hospital quality (57 percent) and patient satisfaction (56 percent). Healthgrades suggested that recent studies show that better patient outcomes occur with higher volume, across a variety of physician specialties and procedures, ranging from childbirth to angioplasty. (Healthgrades, 2014)
Patients who have a total shoulder arthroplasty or hemiarthroplasty performed by a high-volume surgeon or in a high-volume hospital are more likely to have a better outcome, including lowered mortality rates, postoperative complications, and hospital lengths of stay (p < 0.001). (Jain, 2004)
In total hip arthroplasty (THA), the latest technique is the direct anterior approach (DAA), and patients having that technique had better outcomes within 6 months and shorter hospital stay. However, the DAA group often required longer operative time and had more blood loss. Therefore, the direct anterior approach is a more difficult technique. The surgeon should be a well-trained joint surgeon with extensive prior hip replacement experience before performing THA through a DAA, and DAA is not suitable for beginners performing THA. (Sun, 2021)
There is an association between surgeon experience and outcomes after cardiac surgery. In this study of how surgeon experience relates to patient risk in coronary artery bypass grafting (CABG) surgery and how this impacts patient outcomes, Cox regression identified surgeon experience as a protective factor (hazard ratio, 0.99, P = .027). Greater experience correlates with improved outcomes, especially with higher-risk cases. (Han, 2021)
In summary, the preponderance of high-quality medical evidence shows that experience, the number of times a service has been provided by a doctor, determines the outcome, both the benefits of a successful result and the risks of an adverse effect. This was true for all conditions and all types of medical services. There were no studies found that showed less experienced providers performed as well or better than more experienced providers.
As an important consideration, when meeting with a new surgeon about a complicated procedure, you should ask the surgeon how often he has done this procedure in the past, and what the outcomes have been. You may receive some helpful information, but you will probably not find out how surgeons rank among their peers, and whatever information you get will be hard to verify. Before even meeting with a doctor, you might find useful anecdotal information from talking to others in the local healthcare community, such as nurses who work with these surgeons, and other referring doctors.
Another approach is to look at claims data if you have access to it. This would be very difficult to get, but there is an existing source. You could ask your health insurance company, or if you work for a large, self-insured employer, your benefits department or your case manager, if their organizations have access to the Provider Ranking System™ (PRS) from Denniston Data Inc.