My friend Jay Parkinson MD, MPH tweeted recently, “In America you want to go to the surgeon or dentist who makes the least amount of money.”
Below I explain why you may want a second opinion on this advice.
I met Jay when I was doing fellowship in New York City in 2009. Jay lived in Brooklyn at the time and I followed what he was doing in the online healthcare space.
Jay is a phenomenal healthcare innovator and artist at heart. He went through 2 residencies and decided the system was too F’d up for him to practice in it, so he was going to change it.
He has designed at least 3 separate health platforms that leverage well designed technology (good design being key) and combined that with the in-person experience when necessary. His insight is knowing how to put the whole thing together.
He doesn’t just throw the shiny tech into the broken system and expect new results. He understands the tech, the human element, and the necessity of a business model that must fit them all together.
I admire Jay because he lives his values and has taken risks for them. He doesn’t just talk the talk, he walks the walk.
Why would I criticize my friend’s tweet then? Let’s not call it a criticism. Let’s just say I’m going to elaborate on it a bit. Twitter doesn’t give us enough characters to do that comfortably so I am putting it here.
Jay’s tweet implies that in America your odds of a successful outcome when choosing a surgeon or dentist are negatively correlated with the amount of money that professional brings home.
I think there is a nugget of truth to what he is saying. The business model of healthcare in the U.S. is flawed. The dentist or surgeon’s success indicators do not always correlate with the patient’s own success indicators. In other words, surgeons and dentists often get incentivized on volume not on keeping patients out of the OR.
Certainly this model has its holes. One way to increase volume is simply to have looser standards for whom you choose to operate on in the first place thus increasing your volume and paycheck. This works as long as the system just pays you for total number of operations with no check on quality.
Of course there’s a downside to that and that is iatrogenics. The more people you operate on whose problems do not meet a certain threshold, the more unnecessary bad outcomes you will have. Presumably your reputation will suffer and less patients will come knocking at your door (but maybe some won’t know any better).
I have a heuristic that speaks to this issue: “If a surgeon tells you not to get surgery, DON’T get surgery.”
Where Jay misses the mark is over generalizing. Volume isn’t always a bad thing.
If you really want to be literal, the surgeons that make the least amount of money in America are the ones that just graduated from residency. and/or do the least number of cases. this translates into minimal experience.
I don’t know about you, but I’d rather go to a surgeon who has some experience rather than one who just got of school or barely operates.
Who are the surgeons who make the most amount of money? The surgeons who make the most amount of money in America often are making money from invention royalties or from doing a high volume of cases.
Doing a high volume of cases is not necessarily a bad thing as long as the means by which the surgeon or dentist screens those cases is sound and conservative (in other words as long as the surgeon does not have loose standards for whom they take to the operating room).
Here it’s important to distinguish the path by which patients make it to the OR and the end volume of surgeries that a surgeon performs.
Personally, I want my surgeon doing a high volume of cases. Surgery is a technical endeavor. You want your surgeon to have seen every kind of problem and gotten out of every trouble scenario before they get to your case.
In fact I had surgery last year. When I chose my surgeon I chose the surgeon who had been doing my type of case for 20 years and who does a LOT of them. And I am happy I did.
Choosing the surgeon who makes the least amount of money is not necessarily a good thing just like choosing the one who makes the most amount of money is not necessarily a good thing. It’s a balance.
My best advice if you are considering surgery is to get more than one opinion about whether you need surgery or not. Then find the one in your area with specialization and experience for your particular surgical need.
Disclosure: as a surgeon I don’t make the least amount of money and I certainly don’t make the most.