Years ago, while doing an ICU Quality Improvement Project, I stumbled upon a method to quantitatively assess the life-saving skills of a group of ICU doctors. The amount they varied was shocking.
This is a truly terrible post. On the one hand you argue for medical "freedom" to prescribe whatever junk you want, on the other that there should be more protocols (as their should) to drive quality of care. This is pure opportunism. No wonder you have lost your board approval.
I have been a bedside ICU RN for 25 years now and I can’t thank you enough for taking the time and opportunity to highlight how important this is. Our Critical Care physicians will determine the best possible outcome for our patients or the worst possible outcome. Even your average nurse can appreciate how important it is to have a top notch Critical Care Physician running the show. When the nurses start to question the Critical Care physicians orders and train of thought, you know the best outcome for your patient is now in question. When I come on shift for the night, my first question always is.. “who is the Critical Care physician covering the shift”. When the nurses moan at the name of the physician covering, you know we are privately saying a prayer for the patient and for the physician to make the right decisions.
Dr. Kory what I was observing is the term "Normal" but my motivation was something I think there is a problem with the casual use of that term by doctors.
You doubtless have technical terms in medicine that also are used in common everyday conversations but with a different meanings. In data analysis "Normal," "significant," and often enough "average" are words that mean something different outside of data discussions. So, as I said, a "Normal distribution" is not normal. It is not the expected distribution outside of the analysis that creates it. It is found in sampling distributions.
Distributions are a way of characterizing a set of data or the results of analyzing something. They are very useful in many situations to generalize and to predict. For instance, the Gaussian Normal distribution is one foundational element of Inferential Statistics, which is used in analyzing carefully drawn samples from large populations. This branch of Statistics is used in much medical research. To be picky, your study is a study in what could be called Population Statistics. You have all of them--the entire population of ICU docs in that hospital. The tools of the two branches overlap but they differ in what they can do.
Now, the reason I stuck my nose into this is that I keep finding doctors--many many of whom I greatly admire and from whom I have learned so much, are misdirected by the term and think a Gaussian Normal distribution is normal as in typical and they go from there. No.
What's the problem I see? I don't believe that "most human characteristics roughly approximate the Bell curve." I believe that fact--well, I believe it to be a fact--has implications in treatment. I'd love to get 1,000,000 observations of ALT and maybe a few other blood tests and test my notion. If I am right, think of the implications if ALT (or others) are skewed? If the doctor bases his or her treatment on the assumption of a symmetrical pattern in the numbers reported by blood tests, say, will that affect treatment? I think so. But, I am not a medical doctor.
In any case, her you don't need it for this analysis. It stands on its on and I'd consider it an excellent and interest example of exploratory data analysis. But, why not do a histogram of the various tables and see if they look like a bell curve. I bet they don't.
Thank you, Dr. Kory for your work. This takes a lot of time to put together. I too am a retired RN with a retired license for 2 years because of the COVID Debacle and my husband’s medical issues. I was a CVICU nurse my last 15 years of 45. It is disturbing to me that we have people in the medical profession who are below standard care of patients. I never understood how RN’S younger than I was could sit at the desk when I was running!
Recently, a family member has been in the ER twice because of an issue that runs in our family. One mention that her aunt was a retired nurse and she was running information by me changed how they cared for her! Her last visit she had an awesome nurse who showed empathy and explained to her that she was not dying! Amazing as I listened to him.
After CMS bonus bounty still in place right now, on the patients and the fraud in many hospitals have become very distrustful of the majority of the system. I am very grateful to good ICU doctors and nurses that perform their job well and save many lives. The bell curve in the stats sometimes can be twisted around it does appear different. The high dose vitamin C, D3, quercitrin, ivermectin are keeping me alive with the methotrexate, Orencia, and some more medicines that are cancer promoters especially 10 years in body system.
I thank you for the recommendations what to do for I am alive today thank to you for your courage and truth in this Pharmacia dominated world.
I can only hope that some well meaning Australian doctors are planning on following in your footsteps with regard to cancer care especially. I know too many friends and family who are going through the usual SOC. On a side note with regard to 3 & 4 above. My step sister had a gall bladder operation and passed with septicaemia after a staple was found where it shouldn't have been and sent home with a temp of 104°. Apparently this doctor/surgeon had had several previous instances and was still there. My father before he left us managed I think to speak to the shadow 'health' minister at the time to get a layperson on the tribunal to query the death whereas it was all old school tie stuff. I don't now if it is still that way.
My experience of working with intensive care specialists (which is two years nursing in a level 4 ICU 30 years ago) is that their expertise and intuition varies from solidly competent to the best doctors you will find anywhere ever, from solid to superstar. Their floor is much much higher then with GP's, obgyns and psychiatrists (the other groups of doctors who I have experience of), all of whom range from frankly incompetent to solidly competent in an unimaginative and limited sort of way with a few, very few, who are something better. (All of the something better are either GP/naturopaths or Psychiatrists with significant training and experience in psychodynamic psychotherapy, by the way, and none of them are currently practicing in the public system).
Nurses are as important as Doctors in hospital care.
Six years ago I had a G.I.Bleed and 911 Call brought me to a local University Teaching Hospital. I was transferred to the main location..after several blood transfusions..the medical teams were exceptional.
One nurse caught a pulmonary embolism situation and X-rays confirmed her observation.
Prayers I requested from students in training as well as a janitor were answered.
I will never forget the kindness and love from the dedicated teams at 2 Hospitals, Physical Therapy Rehab, Nursing home.
I'm a leukemia patient and would like to share Paul Marik's work with my doctor regarding sepsis. (I'm likely to get it during my next bone marrow transplant in a couple of weeks.)
1. Please give me a link to the peer reviewed medical article that published Dr. Marik's IV vitamin C sepsis protocol. I think it was in CHEST. (It had been rejected by many others before.)
2. Is his current protocol SEPSIS CARE A Guide to Inpatient and Outpatient Treatment September 2023? (available on the FLCCC.net website)
As an introduction to my doctor, please help me with the right words for this statement: Paul Marik, MD is the most published ICU surgeon in the world. His sepsis protocol decreased the mortality rate by a factor of four (??).
If you have a naturopathic doc in your area, he or she might offer IV C treatments. My naturopath (I’m in Las Vegas) offers them, and also treats cancer patients. You could also try an online search to see what’s available in your area.
Park my friend, IV Vitamin C, like ivermectin, both were victims of Big Pharma Disinformation campaigns such that few medical centers will allow or offer it, just like ivermectin. They published several large studies showing IV vitamin C "doesnt work" (yeah right) which has discredited all of Paul's work. Even if you are armed with Pauls study, they will pull 5 larger "higher quality" (yeah right) studies showing it doesn't work. If you have to rely on a hospital to give you IV vitamin C, you are in serious trouble because you will fail. I would look into antimicrobial therapies that you dont have to depend on anyone else for like chlorine dioxide (theuniversalantidote.com)
Thank you. We need more Doctors like you. Join RFK's team and make this a requirement of all doctors and it needs to accessible for patients to read before selecting a doctor. I just recently lost a friend to bladder cancer she thought it was a bladder infection Three doctors from three different practices told her she had a bladder infection and just gave her different antibiotics. She was so frustrated and in pain for a year. We have ways to vet businesses when we buy a car, a house or insurance but not doctors.
From all the experiences reported here by patients or their wards, it is clear that we need the day to day working systems and attitudes of hospitals to become more user friendly, more caring, more professional, not to speak of affordability for a majority of the population. Neither Trump or RFK Jr have spoken anything about what they would do about these. There is not even a hint of what is in their mind, busy only kicking up the dust on vaccines, fluoride, FDA and the like. Please bank only on yourself to take care of yourself. Do you believe RFK Jr would be reading here about all your experiences ?
Being user friendly isn’t enough Dr’s need to be able to be Dr’s again without corporate insurance and Gov tying their hands. We see Dr’s leaving to become concierge Dr’s so they can practice without Gov over reach, insurance hold backs and big Pharma. If enough people speak out they can’t be ignored. So yes we can be heard. I say keep telling the truth. If RFK Jr can do that great. I read so much on the Covid vaccines and how big Pharma and Gov lied to all of us. Read Dr. Malone Dr Peter McCullough you eyes will open and understand why we need changes.
If you were to go back into that kind of work, do these results give you ideas about how to do...well,
better? Or score higher? Or did you do fine and your method of analysis needs adjusting?
Re: "Normal" distribution. The Gaussian "Normal" distribution is not normal in the sense of customary or expected. It is a distribution that comes from a characteristic of population data. I don't know medical data but in my data life analyzing measures of human activity, I have never seen anything that looks like that bell curve. A more common distribution is skewed in some way and the Pareto Distribution (80-20) is a common one. Comparing the two means is not a test. I don't think your data even look symmetrical.
The bell curve is great for teaching characteristics of population and is necessary to understand the thinking behind Inferential Statistics.
You are probably exceeding my knowledge/insight here but I have always thought most individual human characteristics roughly approximate the Bell curve and I thought the performance metric above did as well. Let me know what I am missing - did you read the 2nd part of the article where I show all the data?
One common way to depict the performance is via a funnel plot which shows which performances fall outside the 90% and 95% confidence interval as they are the ones that matter. Another one is a caterpillar plot showing the failure or success rate per doctor and their confidence interval, ordered by the rate. The question most asked when doctors' performance is measured is who is statistically significantly worse than the average.
Rarely the question is asked who the best performers are and what could be done to benefit from their exceptional ability. I was completely surprised when I started my PhD in 2019 that hardly anybody ever asked about the best performers. In fact, my experience is that there is a prevalent opinion among evidence-based medical researchers that most of the time doctors make no difference to their patients’ health as they follow guidelines for diagnostics and interventions (treatments)
The overall conclusion is that doctors make a difference ranging from the very small to the very large depending on what intervention and outcome are measured. The more detailed the measure often the bigger the differences in outcomes between doctors as exceptionally good doctors have more ways to shine when the measure is a composite rather than a single variable such as readmission.
The methodological study shows that there are lots of existing cleaned-up datasets that can be reviewed for doctors' performance.
There is also a Norwegian study that shows conclusively that Norwegian GPs affect the life expectancy of their older patients substantially, either subtracting (the bottom 5%) or adding (the top 5%) an estimated 9 months in life expectancy on average for each of their patients aged 55+ while being cheaper for the healthcare systems. Further, the bottom 5% had a 12.2% higher 2-year mortality rate and the top 5% a 12.2% lower mortality rate than the average doctor. Interestingly, the effectiveness of a GP in terms of life expectancy is almost uncorrelated with patients’ rating and all the information the researchers had about the GPs and patients did not explain the difference between GPs. https://www.cesifo.org/en/publications/2022/working-paper/does-your-doctor-matter-doctor-quality-and-patient-outcomes
Doctors themselves are the most 'prescribed' intervention of all as they are present and active in billions of medical interactions each year and they do make a difference in themselves, separate from diagnosis and treatment.
Fascinating that you are deeply studied on this subject and your data is compelling. I dont have the reference off hand but are you aware of a study that showed overall mortality decreased in some country (I think it was Israel)... during a nationwide strike of doctors? Thought provoking no?
1. Jena AB, Prasad V, Goldman DP, Romley J. Mortality and treatment patterns among patients hospitalized with acute cardiovascular conditions during dates of national cardiology meetings. JAMA Internal Medicine. 2015;175(2):237-44,10.1001/jamainternmed.2014.6781. Available from: http://dx.doi.org/10.1001/jamainternmed.2014.6781.
Importance Thousands of physicians attend scientific meetings annually. Although hospital physician staffing and composition may be affected by meetings, patient outcomes and treatment patterns during meeting dates are unknown.Objective To analyze mortality and treatment differences among patients admitted with acute cardiovascular conditions during dates of national cardiology meetings compared with nonmeeting dates.Design, Setting, and Participants Retrospective analysis of 30-day mortality among Medicare beneficiaries hospitalized with acute myocardial infarction (AMI), heart failure, or cardiac arrest from 2002 through 2011 during dates of 2 national cardiology meetings compared with identical nonmeeting days in the 3 weeks before and after conferences (AMI, 8570 hospitalizations during 82 meeting days and 57 471 during 492 nonmeeting days; heart failure, 19 282 during meeting days and 11 4591 during nonmeeting days; cardiac arrest, 1564 during meeting days and 9580 during nonmeeting days). Multivariable analyses were conducted separately for major teaching hospitals and nonteaching hospitals and for low- and high-risk patients. Differences in treatment utilization were assessed.Exposures Hospitalization during cardiology meeting dates.
Main Outcomes and Measures Thirty-day mortality, procedure rates, charges, length of stay.
Results Patient characteristics were similar between meeting and nonmeeting dates. In teaching hospitals, adjusted 30-day mortality was lower among high-risk patients with heart failure or cardiac arrest admitted during meeting vs nonmeeting dates (heart failure, 17.5% [95% CI, 13.7%-21.2%] vs 24.8% [95% CI, 22.9%-26.6%]; P < .001; cardiac arrest, 59.1% [95% CI, 51.4%-66.8%] vs 69.4% [95% CI, 66.2%-72.6%]; P = .01). Adjusted mortality for high-risk AMI in teaching hospitals was similar between meeting and nonmeeting dates (39.2% [95% CI, 31.8%-46.6%] vs 38.5% [95% CI, 35.0%-42.0%]; P = .86), although adjusted percutaneous coronary intervention (PCI) rates were lower during meetings (20.8% vs 28.2%; P = .02). No mortality or utilization differences existed for low-risk patients in teaching hospitals or high- or low-risk patients in nonteaching hospitals. In sensitivity analyses, cardiac mortality was not affected by hospitalization during oncology, gastroenterology, and orthopedics meetings, nor was gastrointestinal hemorrhage or hip fracture mortality affected by hospitalization during cardiology meetings. Conclusions and Relevance High-risk patients with heart failure and cardiac arrest hospitalized in teaching hospitals had lower 30-day mortality when admitted during dates of national cardiology meetings. High-risk patients with AMI admitted to teaching hospitals during meetings were less likely to receive PCI, without any mortality effect.
A paradoxical pattern has been suggested in the literature on doctors' strikes: when health workers go on strike, mortality stays level or decreases. We performed a review of the literature during the past forty years to assess this paradox. We used PubMed, EconLit and Jstor to locate all peer-reviewed English-language articles presenting data analysis on mortality associated with doctors' strikes. We identified 156 articles, seven of which met our search criteria. The articles analyzed five strikes around the world, all between 1976 and 2003. The strikes lasted between nine days and seventeen weeks. All reported that mortality either stayed the same or decreased during, and in some cases, after the strike. None found that mortality increased during the weeks of the strikes compared to other time periods. The paradoxical finding that physician strikes are associated with reduced mortality may be explained by several factors. Most importantly, elective surgeries are curtailed during strikes. Further, hospitals often re-assign scarce staff and emergency care was available during all of the strikes. Finally, none of the strikes may have lasted long enough to assess the effects of long-term reduced access to a physician. Nonetheless, the literature suggests that reductions in mortality may result from these strikes.
My comment: Elective surgery comes with risks. If no elective surgery happens, fewer people will die due to that effect. That confounder should be taken into account.
We just had a gigantic experiment of reduced population care - there were other big influences such as the mRNA preventive measures so it may take some time to disentangle when and how reduced medical care is beneficial and when it is harmful.
This is a truly terrible post. On the one hand you argue for medical "freedom" to prescribe whatever junk you want, on the other that there should be more protocols (as their should) to drive quality of care. This is pure opportunism. No wonder you have lost your board approval.
I have been a bedside ICU RN for 25 years now and I can’t thank you enough for taking the time and opportunity to highlight how important this is. Our Critical Care physicians will determine the best possible outcome for our patients or the worst possible outcome. Even your average nurse can appreciate how important it is to have a top notch Critical Care Physician running the show. When the nurses start to question the Critical Care physicians orders and train of thought, you know the best outcome for your patient is now in question. When I come on shift for the night, my first question always is.. “who is the Critical Care physician covering the shift”. When the nurses moan at the name of the physician covering, you know we are privately saying a prayer for the patient and for the physician to make the right decisions.
I love this Dr. Kory. I just wrote this article about hypoglycemic emergencies in acute and long-term care. https://open.substack.com/pub/nursethatknows/p/hypoglycemic-emergencies-avoiding?r=1pks2u&utm_campaign=post&utm_medium=web
Dr. Kory what I was observing is the term "Normal" but my motivation was something I think there is a problem with the casual use of that term by doctors.
You doubtless have technical terms in medicine that also are used in common everyday conversations but with a different meanings. In data analysis "Normal," "significant," and often enough "average" are words that mean something different outside of data discussions. So, as I said, a "Normal distribution" is not normal. It is not the expected distribution outside of the analysis that creates it. It is found in sampling distributions.
Distributions are a way of characterizing a set of data or the results of analyzing something. They are very useful in many situations to generalize and to predict. For instance, the Gaussian Normal distribution is one foundational element of Inferential Statistics, which is used in analyzing carefully drawn samples from large populations. This branch of Statistics is used in much medical research. To be picky, your study is a study in what could be called Population Statistics. You have all of them--the entire population of ICU docs in that hospital. The tools of the two branches overlap but they differ in what they can do.
Now, the reason I stuck my nose into this is that I keep finding doctors--many many of whom I greatly admire and from whom I have learned so much, are misdirected by the term and think a Gaussian Normal distribution is normal as in typical and they go from there. No.
What's the problem I see? I don't believe that "most human characteristics roughly approximate the Bell curve." I believe that fact--well, I believe it to be a fact--has implications in treatment. I'd love to get 1,000,000 observations of ALT and maybe a few other blood tests and test my notion. If I am right, think of the implications if ALT (or others) are skewed? If the doctor bases his or her treatment on the assumption of a symmetrical pattern in the numbers reported by blood tests, say, will that affect treatment? I think so. But, I am not a medical doctor.
In any case, her you don't need it for this analysis. It stands on its on and I'd consider it an excellent and interest example of exploratory data analysis. But, why not do a histogram of the various tables and see if they look like a bell curve. I bet they don't.
Thank you so much for your work.
Thank you, Dr. Kory for your work. This takes a lot of time to put together. I too am a retired RN with a retired license for 2 years because of the COVID Debacle and my husband’s medical issues. I was a CVICU nurse my last 15 years of 45. It is disturbing to me that we have people in the medical profession who are below standard care of patients. I never understood how RN’S younger than I was could sit at the desk when I was running!
Recently, a family member has been in the ER twice because of an issue that runs in our family. One mention that her aunt was a retired nurse and she was running information by me changed how they cared for her! Her last visit she had an awesome nurse who showed empathy and explained to her that she was not dying! Amazing as I listened to him.
This paper needs to be brought to the attention of RFK Jnr for further expediting into the system.
Well done Dr. K. It's a privilage to read about your work. Had it not been for Covid, many of
us would not have known about you or your mighty efforts. Best Regards
Off topic and thanks.
After CMS bonus bounty still in place right now, on the patients and the fraud in many hospitals have become very distrustful of the majority of the system. I am very grateful to good ICU doctors and nurses that perform their job well and save many lives. The bell curve in the stats sometimes can be twisted around it does appear different. The high dose vitamin C, D3, quercitrin, ivermectin are keeping me alive with the methotrexate, Orencia, and some more medicines that are cancer promoters especially 10 years in body system.
I thank you for the recommendations what to do for I am alive today thank to you for your courage and truth in this Pharmacia dominated world.
With humble thanks.
Janet Hofbauer
I can only hope that some well meaning Australian doctors are planning on following in your footsteps with regard to cancer care especially. I know too many friends and family who are going through the usual SOC. On a side note with regard to 3 & 4 above. My step sister had a gall bladder operation and passed with septicaemia after a staple was found where it shouldn't have been and sent home with a temp of 104°. Apparently this doctor/surgeon had had several previous instances and was still there. My father before he left us managed I think to speak to the shadow 'health' minister at the time to get a layperson on the tribunal to query the death whereas it was all old school tie stuff. I don't now if it is still that way.
My experience of working with intensive care specialists (which is two years nursing in a level 4 ICU 30 years ago) is that their expertise and intuition varies from solidly competent to the best doctors you will find anywhere ever, from solid to superstar. Their floor is much much higher then with GP's, obgyns and psychiatrists (the other groups of doctors who I have experience of), all of whom range from frankly incompetent to solidly competent in an unimaginative and limited sort of way with a few, very few, who are something better. (All of the something better are either GP/naturopaths or Psychiatrists with significant training and experience in psychodynamic psychotherapy, by the way, and none of them are currently practicing in the public system).
Can I please give you my late husband’s icu team/dr to see what was says abt them?
Nurses are as important as Doctors in hospital care.
Six years ago I had a G.I.Bleed and 911 Call brought me to a local University Teaching Hospital. I was transferred to the main location..after several blood transfusions..the medical teams were exceptional.
One nurse caught a pulmonary embolism situation and X-rays confirmed her observation.
Prayers I requested from students in training as well as a janitor were answered.
I will never forget the kindness and love from the dedicated teams at 2 Hospitals, Physical Therapy Rehab, Nursing home.
God bless them all .
Since so many have now taken the COVID injections, I’m praying I never need an emergency blood transfusion.
Off topic help needed...
I'm a leukemia patient and would like to share Paul Marik's work with my doctor regarding sepsis. (I'm likely to get it during my next bone marrow transplant in a couple of weeks.)
1. Please give me a link to the peer reviewed medical article that published Dr. Marik's IV vitamin C sepsis protocol. I think it was in CHEST. (It had been rejected by many others before.)
2. Is his current protocol SEPSIS CARE A Guide to Inpatient and Outpatient Treatment September 2023? (available on the FLCCC.net website)
As an introduction to my doctor, please help me with the right words for this statement: Paul Marik, MD is the most published ICU surgeon in the world. His sepsis protocol decreased the mortality rate by a factor of four (??).
Thanks in advance,
Park Burrets
If you have a naturopathic doc in your area, he or she might offer IV C treatments. My naturopath (I’m in Las Vegas) offers them, and also treats cancer patients. You could also try an online search to see what’s available in your area.
Park my friend, IV Vitamin C, like ivermectin, both were victims of Big Pharma Disinformation campaigns such that few medical centers will allow or offer it, just like ivermectin. They published several large studies showing IV vitamin C "doesnt work" (yeah right) which has discredited all of Paul's work. Even if you are armed with Pauls study, they will pull 5 larger "higher quality" (yeah right) studies showing it doesn't work. If you have to rely on a hospital to give you IV vitamin C, you are in serious trouble because you will fail. I would look into antimicrobial therapies that you dont have to depend on anyone else for like chlorine dioxide (theuniversalantidote.com)
I think a naturopath MD that gives B12 IVs and injections would give Vit C ones, no?
Thank you. We need more Doctors like you. Join RFK's team and make this a requirement of all doctors and it needs to accessible for patients to read before selecting a doctor. I just recently lost a friend to bladder cancer she thought it was a bladder infection Three doctors from three different practices told her she had a bladder infection and just gave her different antibiotics. She was so frustrated and in pain for a year. We have ways to vet businesses when we buy a car, a house or insurance but not doctors.
From all the experiences reported here by patients or their wards, it is clear that we need the day to day working systems and attitudes of hospitals to become more user friendly, more caring, more professional, not to speak of affordability for a majority of the population. Neither Trump or RFK Jr have spoken anything about what they would do about these. There is not even a hint of what is in their mind, busy only kicking up the dust on vaccines, fluoride, FDA and the like. Please bank only on yourself to take care of yourself. Do you believe RFK Jr would be reading here about all your experiences ?
Start with this https://open.substack.com/pub/vigilantfox/p/mel-gibson-drops-two-medical-bombshells?r=oygk8&utm_medium=ios
Being user friendly isn’t enough Dr’s need to be able to be Dr’s again without corporate insurance and Gov tying their hands. We see Dr’s leaving to become concierge Dr’s so they can practice without Gov over reach, insurance hold backs and big Pharma. If enough people speak out they can’t be ignored. So yes we can be heard. I say keep telling the truth. If RFK Jr can do that great. I read so much on the Covid vaccines and how big Pharma and Gov lied to all of us. Read Dr. Malone Dr Peter McCullough you eyes will open and understand why we need changes.
Nice study.
If you were to go back into that kind of work, do these results give you ideas about how to do...well,
better? Or score higher? Or did you do fine and your method of analysis needs adjusting?
Re: "Normal" distribution. The Gaussian "Normal" distribution is not normal in the sense of customary or expected. It is a distribution that comes from a characteristic of population data. I don't know medical data but in my data life analyzing measures of human activity, I have never seen anything that looks like that bell curve. A more common distribution is skewed in some way and the Pareto Distribution (80-20) is a common one. Comparing the two means is not a test. I don't think your data even look symmetrical.
The bell curve is great for teaching characteristics of population and is necessary to understand the thinking behind Inferential Statistics.
You are probably exceeding my knowledge/insight here but I have always thought most individual human characteristics roughly approximate the Bell curve and I thought the performance metric above did as well. Let me know what I am missing - did you read the 2nd part of the article where I show all the data?
Here you can download a paper that has several doctors' performance graphs. https://www.dovepress.com/the-doctors-effect-on-patients-physical-health-outcomes-beyond-the-int-peer-reviewed-fulltext-article-CLEP
One common way to depict the performance is via a funnel plot which shows which performances fall outside the 90% and 95% confidence interval as they are the ones that matter. Another one is a caterpillar plot showing the failure or success rate per doctor and their confidence interval, ordered by the rate. The question most asked when doctors' performance is measured is who is statistically significantly worse than the average.
Rarely the question is asked who the best performers are and what could be done to benefit from their exceptional ability. I was completely surprised when I started my PhD in 2019 that hardly anybody ever asked about the best performers. In fact, my experience is that there is a prevalent opinion among evidence-based medical researchers that most of the time doctors make no difference to their patients’ health as they follow guidelines for diagnostics and interventions (treatments)
My 2023 PhD is about doctors' performance on patients' physical health, doctors of any specialty. No ICU specialists were included but I found 73 published papers, out of 10,063 I checked, that showed doctors' performance after accounting for all known factors. The systematic and methodological reviews are here: https://www.dovepress.com/search_advance.php?id=72785, PhD: https://research.bond.edu.au/en/studentTheses/what-makes-an-exceptionally-good-doctor
The overall conclusion is that doctors make a difference ranging from the very small to the very large depending on what intervention and outcome are measured. The more detailed the measure often the bigger the differences in outcomes between doctors as exceptionally good doctors have more ways to shine when the measure is a composite rather than a single variable such as readmission.
The methodological study shows that there are lots of existing cleaned-up datasets that can be reviewed for doctors' performance.
There is also a Norwegian study that shows conclusively that Norwegian GPs affect the life expectancy of their older patients substantially, either subtracting (the bottom 5%) or adding (the top 5%) an estimated 9 months in life expectancy on average for each of their patients aged 55+ while being cheaper for the healthcare systems. Further, the bottom 5% had a 12.2% higher 2-year mortality rate and the top 5% a 12.2% lower mortality rate than the average doctor. Interestingly, the effectiveness of a GP in terms of life expectancy is almost uncorrelated with patients’ rating and all the information the researchers had about the GPs and patients did not explain the difference between GPs. https://www.cesifo.org/en/publications/2022/working-paper/does-your-doctor-matter-doctor-quality-and-patient-outcomes
Doctors themselves are the most 'prescribed' intervention of all as they are present and active in billions of medical interactions each year and they do make a difference in themselves, separate from diagnosis and treatment.
Fascinating that you are deeply studied on this subject and your data is compelling. I dont have the reference off hand but are you aware of a study that showed overall mortality decreased in some country (I think it was Israel)... during a nationwide strike of doctors? Thought provoking no?
Hi Pierre, this is one study:
1. Jena AB, Prasad V, Goldman DP, Romley J. Mortality and treatment patterns among patients hospitalized with acute cardiovascular conditions during dates of national cardiology meetings. JAMA Internal Medicine. 2015;175(2):237-44,10.1001/jamainternmed.2014.6781. Available from: http://dx.doi.org/10.1001/jamainternmed.2014.6781.
Importance Thousands of physicians attend scientific meetings annually. Although hospital physician staffing and composition may be affected by meetings, patient outcomes and treatment patterns during meeting dates are unknown.Objective To analyze mortality and treatment differences among patients admitted with acute cardiovascular conditions during dates of national cardiology meetings compared with nonmeeting dates.Design, Setting, and Participants Retrospective analysis of 30-day mortality among Medicare beneficiaries hospitalized with acute myocardial infarction (AMI), heart failure, or cardiac arrest from 2002 through 2011 during dates of 2 national cardiology meetings compared with identical nonmeeting days in the 3 weeks before and after conferences (AMI, 8570 hospitalizations during 82 meeting days and 57 471 during 492 nonmeeting days; heart failure, 19 282 during meeting days and 11 4591 during nonmeeting days; cardiac arrest, 1564 during meeting days and 9580 during nonmeeting days). Multivariable analyses were conducted separately for major teaching hospitals and nonteaching hospitals and for low- and high-risk patients. Differences in treatment utilization were assessed.Exposures Hospitalization during cardiology meeting dates.
Main Outcomes and Measures Thirty-day mortality, procedure rates, charges, length of stay.
Results Patient characteristics were similar between meeting and nonmeeting dates. In teaching hospitals, adjusted 30-day mortality was lower among high-risk patients with heart failure or cardiac arrest admitted during meeting vs nonmeeting dates (heart failure, 17.5% [95% CI, 13.7%-21.2%] vs 24.8% [95% CI, 22.9%-26.6%]; P < .001; cardiac arrest, 59.1% [95% CI, 51.4%-66.8%] vs 69.4% [95% CI, 66.2%-72.6%]; P = .01). Adjusted mortality for high-risk AMI in teaching hospitals was similar between meeting and nonmeeting dates (39.2% [95% CI, 31.8%-46.6%] vs 38.5% [95% CI, 35.0%-42.0%]; P = .86), although adjusted percutaneous coronary intervention (PCI) rates were lower during meetings (20.8% vs 28.2%; P = .02). No mortality or utilization differences existed for low-risk patients in teaching hospitals or high- or low-risk patients in nonteaching hospitals. In sensitivity analyses, cardiac mortality was not affected by hospitalization during oncology, gastroenterology, and orthopedics meetings, nor was gastrointestinal hemorrhage or hip fracture mortality affected by hospitalization during cardiology meetings. Conclusions and Relevance High-risk patients with heart failure and cardiac arrest hospitalized in teaching hospitals had lower 30-day mortality when admitted during dates of national cardiology meetings. High-risk patients with AMI admitted to teaching hospitals during meetings were less likely to receive PCI, without any mortality effect.
This is a second study:
1. Cunningham SA, Mitchell K, Venkat Narayan KM, Yusuf S. Doctors' strikes and mortality: A review. Social Science & Medicine. 2008;67(11):1784-8,http://dx.doi.org/10.1016/j.socscimed.2008.09.044. Available from: http://www.sciencedirect.com/science/article/pii/S0277953608005066.
A paradoxical pattern has been suggested in the literature on doctors' strikes: when health workers go on strike, mortality stays level or decreases. We performed a review of the literature during the past forty years to assess this paradox. We used PubMed, EconLit and Jstor to locate all peer-reviewed English-language articles presenting data analysis on mortality associated with doctors' strikes. We identified 156 articles, seven of which met our search criteria. The articles analyzed five strikes around the world, all between 1976 and 2003. The strikes lasted between nine days and seventeen weeks. All reported that mortality either stayed the same or decreased during, and in some cases, after the strike. None found that mortality increased during the weeks of the strikes compared to other time periods. The paradoxical finding that physician strikes are associated with reduced mortality may be explained by several factors. Most importantly, elective surgeries are curtailed during strikes. Further, hospitals often re-assign scarce staff and emergency care was available during all of the strikes. Finally, none of the strikes may have lasted long enough to assess the effects of long-term reduced access to a physician. Nonetheless, the literature suggests that reductions in mortality may result from these strikes.
My comment: Elective surgery comes with risks. If no elective surgery happens, fewer people will die due to that effect. That confounder should be taken into account.
We just had a gigantic experiment of reduced population care - there were other big influences such as the mRNA preventive measures so it may take some time to disentangle when and how reduced medical care is beneficial and when it is harmful.
Pierre, thank you for that feedback!