2007 August 09 Thursday
Experience Improves Prostate Surgeon Performance
Medicine is deficient in how practitioners are incentivized to improve quality. Buyers lack information. There aren't just a few providers with consumers guides to quality ratings as is the case with cars for example. If you get prostate cancer find a surgeon who has done 250+ prostate cancer operations.
Andrew Vickers, Ph.D., of Memorial Sloan-Kettering Cancer Center in New York and colleagues analyzed data from 72 surgeons at four institutions and 7,765 of their prostate cancer patients treated with radical prostatectomies between 1987 and 2003. They measured surgeons’ experience by the number of times they had performed the procedure before each operation.
More surgical experience was associated with a greater likelihood that the patient’s cancer would not return after their operation. The learning curve for this procedure was very steep—there was dramatic improvement in patient outcomes as surgeons’ experience increased up to 250 operations, after which increasing experience had little influence on cancer recurrence. Patients treated by inexperienced surgeons (for example, those with 10 prior operations) were nearly 70% more likely to have evidence of recurrence of their prostate cancer within five years than those whose surgeons had performed 250 operations (17.9% vs. 10.7%).
Our medical industry ought to measure outcomes for all surgeons and other medical practitioners and publish track records. We ought to be able to pay more to get treated by doctors who score higher success rates.
An industry with big incentives to improve quality will find ways to produce better outcomes. Overall quality will rise.
I had lasik surgery a few months ago. Since it is a "non-medical" procedure in the sense that insurance doesn't cover it, I had the luxury of going to one of the top doctors in the field. In fact, I insisted on using him when I was planning the procedure. Since insurance/healthcare nonsense isn't involved, it was a buyers market. I had as much information as I needed or wanted to make the choices that would effect me. It was also the most pleasant experience I have ever had in a doctor's office. I was actually seen at the time I had scehduled my appointment for and people were quick, polite and skilled. They are this way because you have a choice. Imagine that, the free market works! For something like cancer treatment, go to the best guy you can find, period, even if you have to sell the car. In the final analysis, it is your life. Insist on it and don't take no for an answer. As for this,
"Our medical industry ought to measure outcomes for all surgeons and other medical practitioners and publish track records."
They do track it, but it is not often public knowledge as the medical profession is a guild and they protect their own.
You're right. However, the situation presents social problems as well as an economic one. Suppose we freed the market for doctors' services. If we made sure all doctors' qualifications were published and told all patients how to choose the best doctors, then patients who could not afford the best would lobby for more subsidy. As with college admissions, over time all of the subsidy would go into price inflation and waste. We might end up with more doctors but we would always have a shortage of "best" doctors, just as there are many colleges but a shortage of Ivy League schools. At the same time, it would get harder to train new prostate surgeons (or whatever specialists you care about). Before a surgeon has performed 250 operations he must have performed 200, 150, and so-forth. If no patient will consult a surgeon who has done only 10 operations, how will he ever gain experience?
It's hard to implement a nice clean market for medical care because the whole mess is so politicized. Congress and Lyndon Johnson destroyed the US market for medical services forty-odd years ago with Medicare and Medicaid. Every legislative and regulatory change since then has made things worse. Millions of Americans now think that they "deserve the best care" with someone else paying for it. Since politicians can win votes by promising to subsidize medical care they will keep meddling.
I think we can gain more in the short run by trying to improve medical practice. We should gather a lot of information about treatments and outcomes, identify the best techniques, and spread those more efficiently by updating standards of care to motivate doctors to pay more attention to continuing education. We can't all have prostate surgeons who have done more than 250 operations, but perhaps we can have junior surgeons who emulate the methods of the more experienced ones more closely. We should also push harder to develop technical aids to help with that. Suppose (hypothetically) that more experienced surgeons are better able to recognize tissue that should be excised. Well, perhaps we could develop a stain which could be applied to living tissue in the surgical field to mark the portions of it which ought to be removed. Then a less experienced surgeon could do a better job out of the gate. In the long run we can improve medicine (and medical productivity) more by technical means than by adding doctors.
We'd gain more than you might expect. We'd get a larger net plus for everyone because doctors who are really good at particular procedures would stop doing other procedures that do not require as much skill. So, for example, we might see more specialty surgeons who are good at a very small list of things (just one thing in many cases) whereas some surgeons who do not do well at, say, prostate cancer surgeries would do surgery such as appendicitis where skill differences create less difference in level of outcome.
Doctors would also have a higher incentive to figure out what they are doing wrong and to improve their performance. With greater market incentives for competence I'd expect more effort to improve competence, a shifting of doctors around between areas that require more or less competence, and more technological advances to improve quality.
The article defines recurrence as a rising PSA level, which is probably OK. However, this does not measure the extent of the recurrence or distinguish between local recurrence and metastatic disease. A better measure of surgical skill would probably be the incidence of impotence and incontinence following surgery. Also, I wonder how many prostatectomies were performed using the Da Vinci robot. Bottom line, if you need this rather difficult operation, have it done a a major center where they do a couple a day, not a couple a month.