The more mammograms a radiologist reads, the more obscure tumors she will find. Just so, I hope you’ll become better attuned to spotting counterintuitivities in everything you read as the semester proceeds.

Here are some you may have missed when I assigned you each to find and describe examples of counterintuitive thinking in the “Advertising Failures” reading about Dr. Adcock at Kaiser Permanente.

WHAT DO DATA REALLY MEAN?
Even thorough and meticulous data only leads to knowledge when it’s interpreted correctly. From the article: “Some researchers suggested, however, that other factors might have driven down the death rate. They questioned the soundness of the data. They warned that surgeons might be increasing their scores by avoiding higher-risk patients, a criticism that prompted the state to refine its system.”

Is it possible? Certainly. Doctors routinely refer patients to specialists for the benefit of the patients. They also routinely refer, it stands to reason, for their own benefit, to avoid being sued later for failing to spot illnesses they’re not qualified to diagnose. Might they overreact at times and refer patients they really could help themselves—tricky cases that require tough judgment calls—to protect their success rates? Would their improved scores mean they were suddenly better diagnosticians, or that they had learned to avoid failures?

DOES THE ADCOCK SYSTEM REDUCE CANCER DEATH?
One of you could do a followup. When the article first appeared, the answer was unclear. Kaiser Permanente Colorado keeps good records, as we know from the article. Have they been able to conclude that all the extra effort has saved lives in the long run? More diagnosis should save lives, right? Does it? From the article:

What that means, in the simplest terms, is that the Denver doctors are finding about 15 more cancers a year than they would have at their previous accuracy level. (Kaiser says it does not know if that improvement has affected its breast-cancer death rate.) In a country where 192,000 breast-cancer cases are diagnosed each year, that same increase in accuracy could mean finding upwards of 10,000 more annually.

DOES SCRUTINY IMPROVE PATIENT CARE?
From the article: “Even so, when experts talk about doctors’ skills, the discussion almost always circles back to the conundrum federal officials wrestled with when they wrote the mammography rules a decade ago: How to improve quality without diminishing access to care. If doctors start dropping out of mammography because they score badly in tests or performance audits, where will women go?“

Where indeed. It’s just about impossible in South Jersey to find an obstetrician/gynecologist to deliver your baby in a hospital. So many are sued that none can afford the malpractice insurance. Does that mean Philadelphia ob/gyns are less prone to failure? How does “holding the doctors accountable” through malpractice claims serve the pregnant women who can’t or won’t or don’t go to Philly?

Again from the article: “The balancing act gets trickier and trickier. New research is stoking concern about doctors’ competency. At the same time comes anguished talk about doctors driven away by skyrocketing malpractice rates and shrinking reimbursement.“

DOES PRACTICE MAKE PERFECT?
Doctor Adcock himself, surely the one man most likely to benefit from his particular approach to learning from his mistakes, expressed serious misgivings about its effectiveness for him.

From the article: “Then his latest scores came in, and he really started to worry. He was dumping more X-rays into an ambiguous pile, having failed to decide if they showed cancer or not. Holding his charts, he said, ‘I look at that and think, my goodness, have I forgotten how to read mammograms?”’

HOW DO YOU FIND A GOOD ONE?
This one really troubles me. Does the way we try to enforce accountability actually result in good judgment? We like to go online and read “real customer reviews” about everything from toaster ovens to vacation spots to wedding planners. Sometimes, we think we can outsmart the process by ignoring bad reviews from reviewers who aren’t credible or who have objections we don’t share. But can anything we learn from public records, or patient reviews, really help us choose a radiologist when our life is at stake? Are we competent to judge what we read?

Lawsuits against a doctor, even malpractice judgments against a doctor, might be evidence she’s extraordinarily capable. She’s the surgeon everybody goes to when nobody else can help; she’s the doctor others refer their toughest cases to; she’s the one who will take the chance of failing when every other doctor thinks the patient is a lost cause. So she loses more patients than anybody else. But she might be your best choice.

From the article: “Don’t judge doctors by the lawsuits they have lost for misreading mammograms. Even the best doctors will miss some cancers.”