Is Doctor’s knowledge the major limiting factor to quality healthcare?

Why is the quality of medical care substandard in India? Is it because of a lack of medical professionals, or the fact that the public sector improperly trains many of them? One paper that has recently been published tries to test out the assumption that the major reason why the quality is generally low is because of a lack of knowledge on the parts of the doctors. The paper, which is explained on Ending Poverty in South Asia, separates along two criteria — that which doctors know and that which doctors do.

What doctors know—measured by testing doctors—represents the maximum care that a doctor could provide. What doctors do—measured by watching doctors—represents the care they actually provide to real patients. We call the first “competence” and the second “practice quality”.

The paper’s findings are after the jump.

First, public sector doctors always do a lot less than their private sector counterparts—between 66 and 50 percent less depending on how competent they were to begin with. Second, even in the private sector, there is a large gap between knowledge and practice. Doctors who correctly covered 60 percent of essential tasks when tested ended up covering just over 30 percent when dealing with actual patients. Third, about the only “doctors” who are practicing at the frontier of their knowledge are those with very low competence—those who covered 20 percent or less of essential tasks when tested.

These conclusions raise some troubling issues. First, the utility of additional training for doctors seems limited beyond the most basic levels, since they are unlikely to use this additional knowledge in practice. Second, this suggests that doctors need exogenous pressures to improve quality of care as their own desire to provide the highest level of affordable care is insufficient to ensure quality control.

The paper suggested other factors that may contribute to this such as a lack of well-defined malpractice laws and legal liabilities. However, the paper does recognize that before such hypotheses can be confirmed, a similar study on rich countries must also be conducted.


8 Responses

  1. In india doctors know a lot but many dont perform 100% beacuse of poor pay in public service! But they are super knowlegable.

  2. I have worked as a doctor in both government and private setups, and I feel that doctors here are not incompetent compared per se to western countries. In fact, our doctors are skilled clinicians and very good diagnosticians compared to the doctors of western countries, whom I find greatly dependent on a huge plethora of investigations, as these are paid by insurance. See this link

    There is no dearth of incompetent doctors in the west also, and anyone closely following the news in USA or UK would know that.

    However, an extremely poor infrastructure and heavily corrupted health ministry (from the top to the grass root levels) in India is responsible for the lack of instruments, medicines, and other equipments, leading to circumstances hardly conducive for any individual to practice “good medicine”. The paramedics, nursing staff and other workers of the health program, like MPWs are not provided with good regular training or continued education. The doctors also need a good free continued medical education (CME) program. While the ideas and concepts embodied in the Indian health programs are fundamentally strong, the execution of the programs is grossly deficient on many fronts, leading to failure of achievement of goals and targets.

    And I have seen many impassioned and motivated young doctors to ultimately accept defeat in this “system” and lose their devotion and drive, and just go with the flow.

    In spite of these constraints, the people who are doing a good job, need to be commended and deserve a study on them to show how so much can be achieved with so little, and in such trying circumstances.

    However, I would like to clarify that I do not speak for all the states of India, and I have had the good fortune to work in good states as a part of very dedicated teams.

  3. While the quality of care in America is a little beyond the scope of this blog, your observations brings to light an excellent point about how too many cooks can spoil the medical broth. Also, you bring up the systemic forces that affect doctors in this situation, which are important. But that still does not explain why their performance still occurs at a level below what they know. One area you do bring up — awards and recognition — do highlight this, and could help.

  4. As the paper concludes, ultimately, we do not know whether the results of the study are applicable to just India or medicine in general. I am curious how well American physicians would test — considering their financial incentives encourage them to practice a medicine that is far different than what we learn in medical school [the amount you can learn from a simple patient history and auscultation is astounding… to bad we don’t pay physicians to talk to their patients…]. But Vinay, you are right, as much as we put doctors on a pedestal… it seems many a “noble physician” needs ‘exogenous pressures to improve quality of care as their own desire to provide the highest level of affordable care is insufficient to ensure quality control’ .

    Did the authors have a take on what we could learn from the high performing physicians?

  5. Interesting analysis.

    Could it be that the medical institutions where the training happens, are much better equipped (both facilities and staff) compared to private settings (nursing home, small hospitals etc). I wouldnt even talk about the Primary health centres here.

    The real challange in my mind is to create the right atmosphere for doctors to improve their practice quality.


  6. Great points. Incentivizing the improvement of practice quality, both through external means (ie through awards and recognition), has the potential to impact level of care. What you mentioned Anoop – learning from high performing physicians – is also a great point.

    The other factor mentioned – providing adequate facilities and resources is another issue altogether. But I wonder whether furnishing doctors that don’t value “practice quality”, as defined by this article, would do better in a setting where they are furnished with better facilities. In their case, it seems as if a combination of better facilities/resources and recognition would be key.

    It would be interesting to see this study broken down according to different regions, specifically rural and urban India, and even moreso, by demographic of the patient population.

  7. I agree with Vinay and Prernasri, there is a lack of motivation to perform “the best one can”, and I really don’t know if incentivizing can do away with the “chalta hai” attitude that pervades all spheres of life in India.
    Somehow, life here is a bit cheaper than how people value life in developed countries. Of course that calls for more debates, but the fact is, the doctors could be more bothered about doing the best that is possible. The mortality and morbidity rates are more than statistics, and a single “number” for us is a person, whose death or illness has a huge impact on them and their families. I have found this sense to be lacking in many medics.

  8. Hi, its a good analysis, I think few more factors affecting quality of healthcare.. I have analysed many hospitals they do invest on the methods and instruments which has good ROI but not a thought on the patient safety.. I havnt seen any of the hospital in India who is invested in the Clinical decision support system which is mainly for patient safety but do not have direct ROI…
    Its time to evaluate on balanced approach…..

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