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Is seeing a so-called "top doctor" possibly a BAD idea? (Article says yes)

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Posted 12/9/2015 2:49 PM (GMT 0)
In a recent New York Times op-ed piece, a physician claims that, contrary to expectation, cardiac patients of so-called "top doctors" had a higher survival rate when their doctors were out of town. That is, they survived their cardiac issues better when they were not seeing their doctors.

The article maintains that statistical evidence supports this claim, and it also states:

"One of the more surprising — and genuinely scary — research papers published recently appeared in JAMA Internal Medicine … found that patients with acute, life-threatening cardiac conditions did better when the senior cardiologists were out of town."

Also,

"Overall for all heart conditions examined, patients cared for at the teaching hospitals did significantly better than those cared for in community hospitals. So choosing a teaching hospital, when possible, makes a difference."

And

"It is not clear why having senior cardiologists around actually seems to increase mortality for patients with life-threatening heart problems. One possible explanation is that while senior cardiologists are great researchers, the junior physicians — recently out of training — may actually be more adept clinically. Another potential explanation suggested by the data is that senior cardiologists try more interventions. When the cardiologists were around, patients in cardiac arrest, for example, were significantly more likely to get interventions, like stents, to open up their coronary blood vessels."

Granted this article discusses cardiac patients, where cardiac events could lead to sudden death, something less likely to occur with cancer patients. But, still, the same principle may still apply in general to "top" doctors specializing in other areas, including cancer. So, the idea that it could happen is at least worthy of attention.

Controversial, to be sure. But it may point to the conclusion that seeing a doctor who is a good clinician, but maybe not have the "big" reputation, isn't so bad after all.

Article:

www.nytimes.com/2015/11/22/opinion/sunday/are-good-doctors-bad-for-your-health.html?partner=rss&emc=rss&_r=0
Posted 12/9/2015 4:17 PM (GMT 0)
In a field where top physicians in the field openly state there is 30% overtreatment of PCa, it is my personal thinking those who go with a "local" uro and do well are quite fortunate.

I cannot remember a post here at HW, where someone regretted going to one of the top practictioners in Pca. I have seen a number of posters who wished they had not used their physician.

There clearly are people who do not see a top urologist and do well. However, when you take into consideration the overall percentages it appears to me they were lucky.

I personally want to have the best odds possible.
Posted 12/9/2015 5:18 PM (GMT 0)
I clearly remember about 40 years ago doctors in the US went on strike for a few days and the death rate dropped dramatically. This supports the theory of unnecessary interventions.
Posted 12/9/2015 5:45 PM (GMT 0)
In PC, we see the opposite - the top doctors at top institutions do a better job in terms of cancer control and side effects, in spite of the fact that they may get tougher cases. PC rarely presents with disease that requires on-the-spot life or death decisions that occur in cardiology.
Posted 12/9/2015 7:27 PM (GMT 0)
In my case, I feel I was very lucky to have one of the top PC Docs in the country followed by one of the best Surgeons even if it was only for my peace of mind.
Posted 12/9/2015 7:52 PM (GMT 0)
I prefer to see a top doctor.
I've been to bottom doctors.
At least with a top doctor you get to keep your pants on.
At the bottom doctor they make you take your pants off.
I don't like where bottom docs like to stick things.
All things considered, I prefer the top doc to the bottom doc.

Andrew
Posted 12/9/2015 9:56 PM (GMT 0)
I don't necessarily agree. I think that for good CLINICAL results, the big teaching hospitals are best, because you have the benefit of multiple looks by multiple people who can then (in theory at least) share their insights to come up with a consensus result. (Think "House" without the zingers). For treatment, I do feel you want the advantage of lots of experience. One of the things that I found attractive in my choice of surgeon was the fact that he had the benefit of years of open surgery before he transitioned to the DaVinci. This gave the impression, at least, that he could use that experience to his advantage if things went awry...which a 'robot only' surgeon might not do so well at.
Posted 12/9/2015 11:34 PM (GMT 0)
As an interesting spin-off of one of halbert's comments, here's a couple of the key points made at the annual meeting of the Society of Urologic Oncologists (SUO) who looked into their crystal balls out 10-years:

**10 years from now, open surgery for prostate cancer will probably never be carried out any more.

**There is likely to be a significant decrease in the numbers of radical prostatectomies carried out each year here in America.


Read more about the SUO meeting at the Infolink, here: prostatecancerinfolink.net/2015/12/04/some-more-interesting-insights-from-the-annual-meeting-of-the-suo/
Posted 12/10/2015 12:07 AM (GMT 0)
JackH, good points. I imagine that not treating G6s will account for most of the drop. Not treating G6s should drastically reduce the number of procedures (surgeries and radiation). It will likely also drop the number of PCa top docs.

I think we are already seeing this happen. Anecdotaly, a local brachytherapy doctor was advertising and stated that brachytherapy was superior to AS. I feel that as AS makes inroads into the potential patient population practioners may need to make significant career adjustments .... even top docs.
Posted 12/10/2015 2:34 AM (GMT 0)
What I see more of is the disappearance of the single or two doctor practice and movement towards much larger clinics at the PCP or general surgeon level. At the same time, the old "community" hospitals are turning into glorified urgent/emergency care facilities with major treatment moving into large hospital facilities in major metropolitan areas. As well, in the major cities, hospitals are merging into single mega-medical care entities.

Is this a good thing? I'm not so sure.
Posted 12/10/2015 3:53 AM (GMT 0)
First of all, we need to define "top doctors". Yes, there are some very good prostate cancer experts around. There are also some great self promoters, some who are mentioned on this forum. I would hope we could avoid the "self promoters" and find the true experts.

I have tried to avoid the "cancer institute" and "great success" claims that often cloud good treatment. The really competent doctors don't need to tell us how good they are. This doesn't usually effect us, but I suspect the lesser known practitioners treat more carefully and with less rushing around. Something to think about. ...
Posted 12/10/2015 11:46 AM (GMT 0)
My cardio doc is also a cardio patient. His knowledge seems to help make up for his lack of bedside manners.
Posted 12/10/2015 11:59 AM (GMT 0)
lifeguyd, absolutely. What is the definition?

To expand on my earlier thoughts, I think for clinical/diagnostic work, finding a clinician who has access to and understanding of the current information and diagnostic tools is vital. They don't HAVE to be at a "major center", but they probably are. Someone who still says, "your PSA is over 5, therefore you have PC" is WAY behind the times.

Treatment is a little dicier. Because PC, except in late-stage situations is not generally the province of the Medical Oncologists, the standard chemotherapy practice is not somewhere we'll wind up going. And, the capital expense of the latest "ray guns", DaVinci robots, or even the systems to insert seeds are high enough that the smaller community hospitals are not able to play. Again, we're going to wind up at the major facilities for these reasons.

When it comes to treatment, experience counts for a lot. Maybe not as much as some would claim, and then there is the dilemma: if the only docs who do treatment are the highly experienced ones, how do the young doctors get over the hump?

I struggle with the question of whether it's better to be treated by a great researcher or not. When it comes down to it, I don't really care how many papers they've got out there. I want to know what his/her peers are saying about how good he/she is at what they do...and what other patients are saying about them.
Posted 12/10/2015 3:36 PM (GMT 0)

halbert said...
... I think that for good CLINICAL results, the big teaching hospitals are best, ...

A guy (Eliot) on yananow had a horrible experience at a teaching hospital, UC Davis. Operated on by the head of surgery, he has had a long a horrid journey that could be eye-opening to anyone who reads his somewhat long post of his treatment as a Gleason 6 with 2 cores at 5%.

I'm driving about four hours each way to Duke, and if it turns out that I am greater from G6 will go to a top US Dr at a top facility for treatment.

Even a top Dr at a top Facility has no guarantee of zero side effects so why someone would not do everything within their ability to increase their odds of cure, side effects and overall care is something that is hard for me to understand. I guess that is just me, though.

I am well aware that work schedules, insurance issues and various factors enter into someone's ability to choose what path they pursue.

However, since you only get _one_ shot, it seems ludicrous to me to suggest taking less than the best possible shot available to you.
Posted 12/10/2015 3:55 PM (GMT 0)
Many of the top doctors are not at an "institution or facility". They are in private practice and do excellent work.

We all have to conduct our searches in our own way, but to limit a search to "institutions or facilities", in my opinion, is too limiting and would exclude many doctors that may be better then the ones at the given "facilities or institutions".

I also wonder what the exact definition or "institutions and facilities" is. I assume it includes university hospitals, doctor owned hospitals like Cleveland Clinic and Mayo, and government owned clinics like the NIH. But what else would be considered? Cancer Treatment Centers of America? and other for-profit centers?

Specifically Ken mentions he is going to Duke, which has a very strong PCa reputation. But adds that he will go somewhere else, "to a top US Dr at a top facility" for treatment. If I may ask, where would that be and why aren't you there now?
Posted 12/10/2015 5:20 PM (GMT 0)
An opposing argument for going to institutions rather than private specialists is that there is a lot of "group think" at these centers. Also there are institutional restrictions on the kind of treatments available and "out of the box" thinking on individual cases is discouraged.

A private specialist is much more free to try different things.
Posted 12/10/2015 7:11 PM (GMT 0)
Are we not being a bit silly.
Put another way:

I'd rather have a doctor who graduated in the top 10% than one who finished in the bottom 10%.

As another poster said we have seen ample evidence of folks right here in HW who regretted (or should have) seeing their local yokel. There are always exceptions, but if you look at the totality of posts, the best doctors/surgeons seem to have decent success

Mel
Posted 12/11/2015 3:08 AM (GMT 0)

JNF said...
Many of the top doctors are not at an "institution or facility". They are in private practice and do excellent work.......a search to "institutions or facilities", in my opinion, is too limiting and would exclude many doctors that may be better then the ones at the given "facilities or institutions"...

To me, a private practice physician operates in a facility. Whether it is leased or owned, a physician must treat in physical facilities of some sort. I was trying to be inclusive with that wording and did not intend to exclude anyone, be they associated with hospital, clinic, private practice, for profit or whatever.

Perhaps I made a poor choice of words, I certainly didn't mean to exclude any area or option.

JNF said...
...why aren't you there now?

I am not at another facility now because I have not been diagnosed. Once diagnosed, I will move in the direction of a top Dr in the field that will be appropriate for whatever area appears to be best for the diagnosis.

Without question, I will include private practice physicians, for profit, or whoever is a top Dr in the particular area and I have the ability to feasibly work it out.

I think Tall Allen posted to the effect that he talked with 6 different Dr's before making a final decision on treatment and Dr. I may go that far if that is what it takes to feel comfortable.

I also agree with John T, that there may be a bit too much "group think" and "institution restrictions that limit out of the box thinking" at some of the larger institutions.

And maybe I'm overthinking it, because I would certainly rather it not be taking this long prior to biopsy. However, since biopsy may not be definitive I am taking my best shot on that.
Posted 12/11/2015 2:48 PM (GMT 0)
Thanks Ken. Great information. I applaud your search for a dx and then the open attitude toward finding the most appropriate practitioners for your situation. I wish more men would be as investigative and don't think you are overthinking it.

As you say, we only get one shot at this. Putting it another way, measure twice, cut once. Sometimes we even measure many more times before cutting. Works in the workshop and with health treatment management.
Posted 12/11/2015 2:52 PM (GMT 0)
Compiler,

Good point. I too would rather be treated by a doctor that finished in the top 10% of their class. However, advice given on this forum continues to measure a doctor's performance by how many procedures they performed (I.e. Must have performed a bazillion surgeries before you should use them).

How do you measure who is a top doc? Word of mouth? Whoever TA or some other authority says is a top doc? Or, maybe as Ken says, you work with someone you feel comfortable with? I sure don't know ... but I do wonder if a top doc isn't really someone who has done a lot of procedures, published a bunch of papers, and/ or advertised a lot and has a good bedside manner.
Posted 12/11/2015 4:27 PM (GMT 0)

RCS said...
....How do you measure who is a top doc? Word of mouth? Whoever TA or some other authority says is a top doc? ... but I do wonder if a top doc isn't really someone who has done a lot of procedures, published a bunch of papers, and/ or advertised a lot and has a good bedside manner.

Therein lies the rub.

My top Dr, may well be different from your or someone else's top Dr.

If warranted and appropriate, HDR monotherapy is quite high on my list. As near as I can tell, there are only a handful of people doing large volumes of these in the US. One of course is UCLA, involving flights and lodging for me. Another is JNF's Dr in Atlanta. They use slightly different protocols. Also, at age 70 my concerns may be different than those of someone aged 50. Who will be more willing to slant or slightly modify treatment towards my specific situation? If JNF's physician has received national acclaim I am unaware of it. However, they have been smart enough to get heavily into HDR brachy some years ago, have done a large amount of people and a good sized backlog of experience. If diagnosis warrants I will at least have a discussion with them in order to determine what path I chose.

Also, I have family in CA, that I have never visited and have for years needed to make a trip there. That may well factor into my decision.

Also, bedside manner apparently means little or nothing to me. The last two Uro's I have seen, I was warned by previous patients that they had quite poor bedside manners and I thought highly of both of them. I prefer a direct manner and if they answer questions and address concerns is all that matters.

Not to mention, "non-profit" for many practical purposes are quite comparable to "Big Business" in many ways. Although I must mention that the more heavily marketed any provider is, the more skeptical I become because someone must pay the marketing bill.

We all have different situations, concerns, patient specifics and diagnoses. Work, family, insurance considerations, other financial considerations, not to mention convenience.

As seems to be the case for so many other aspects of PCa, it appears to me that there is no definitive answer for a "top Dr." also. We each have to follow our own path.

Post Edited (Ken) : 12/11/2015 10:02:55 AM (GMT-7)

Posted 12/11/2015 4:34 PM (GMT 0)
RCS:

I actually found it fairly easy to find a top surgeon and a top medical oncologist.
I found it really hard to judge the radiation guys.
One of the problems I had with the radiation guys was that it was impossible to find lists of SE from their practices. In fact, my local RO (who I used) made it clear that any SE I should see a medical expert in that area. For example, if I got GI issues, see a GI person, not the RO. He made this clear AFTER I started my SRT. I then realized that he kept his hand clean of ANY SE. No wonder he claimed so few SE from his patients!

With surgeons, they had web pages. Of course, I had to wade through the marketing but over time, by studying/reading a few folks came to the fore as having good successes. I ended up using Mani Menon as my surgeon. When I read through stuff, a number of surgeons said "studied under Manyi Menon." So, why not get the real thing. I also met with Dr. Menon and one other top-notch surgeon at Umich. I would have been comfortable with either one, but Mani seemed to have more of a team approach.

When I looked at medical oncologists, it soon became apparent that Drs. Hussein, Scholz, Strum, and Meyers seemed to be in a class by themselves. To begin with, they ONLY treated PC. I did more research and after talking with actual patients I eliminated Meyers and Strum as just not being a good fit for me. I ended up seeing both Hussein and Scholz (eventually switched to Dr. Lam in the same office). Hussein always seemed very irritated that I was consulting Dr. Scholz/Lam. She kept asking "who are they"? Yet, she had spoken at one of their conferences. So, just not the best fit for me.

I was fortunate that my surgeon was in my State, albeit 120 miles away. Dr. Lam is 2200 miles away.

Anyway, clearly far from an exact science, but by reading a lot and trying to sift through the BS, I think I did find some fine practitioners. Not a simple nor exact process, but do-able.

Mel
Posted 12/11/2015 4:40 PM (GMT 0)
Ken:

May I ask if Dr. Chris King is your UCLA guy?

I will be consulting with him during a Ca. vacation (considering SBRT to pelvic node mets, if such is the case after a future C-11 choline scan)

Mel

P.S.: I assume we are allowed to mention doctor names here?
Posted 12/11/2015 5:23 PM (GMT 0)
I am thinking Kamrava if Demanes has already retired, for HDR Brachy.

I also have been thinking about seeing who might be the best fit for Medical Oncologist. I'm a long way from CA, and Meyers is in Charlottesville, which is about six hours from me.

Am uncertain if medicare pays, or if skype visit could be done with Scholz, et al.

Actually, all premature for me at this point.
Posted 12/11/2015 6:42 PM (GMT 0)
Great response by InTheShop. Humor is in a league of its own for treatment.

I was treated quite effectively by a local uro in a group in a mid sized city. No big names involved. I did ask about his experience and did enough research to know he was well versed. One could argue my stakes were not so high as a G6, but it mattered to me. Still scoring zeroes at 4.5 years, continence recovery was good, and ED came around in time. I have since learned a bit more about him and know he is quite good and well respected.

My experience is all I can offer, and I am happy with a skilled local doc who keeps current but does not have 'Top Doc' stitched on his scrubs.
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