I’ve seen a lot of doctors in my time. What makes my experience different is the lengths I went to source them. I’ve travelled to different states, countries, and continents to see them. Sometimes they needed to be the best I could find, for any price and any distance. I’ve done this several times for different problem domains. As you can imagine, there’s a lot of diversity in how good they were, or to put it a different way, how useful they were. These meetings were usually just to discuss a single service. Could they do it, or not?
The best doctors were able to render services outside of something called the standard of care. The standard of care is just medical consensus for how doctors should approach various problems, and it tends to lag leading medical research by 20+ years. There’s a joke in medical school that 50% of what’s in medical texts (read: standard of care) is wrong, but we just don’t know which parts. Well, the best doctors tend to be medical researchers and they know which parts are wrong in their research domain. Instead of administering existing treatments they administer experimental ones. They try things that nobody else will, so they get results that nobody else gets. This could mean a curative treatment, or a drastic change in some important outcome (e.g. mortality rate).
Average doctors follow the standard of care too closely to get above average or below average results. The smarter they are, the more consistently average results. At best they may have earlier awareness of updates to the standard of care, but can never go beyond it. If they happen to also be medical researchers then they’re working on marginal improvements to the standard of care. Questions like whether to administer 4 or 5 days of antibiotics just doesn’t have the same impact as limb reconstruction or nerve decompressions. They may know of more impactful and interesting research problems but deliberately avoid the risk and uncertainty that comes with it. And sometimes they just happen to be overly optimistic about the accuracy of the standard of care, or perhaps not knowledgeable enough to confidently challenge it. They feel maybe other fields of medicine have made obvious, backwards mistakes but probably not their field in this day and age.
The reason average doctors exist and are useful is that dumb patients also exist. They’re the people who naturally aren’t familiar medicine, and also lack good intuition. If they flout the standard of care they often choose a much worse treatment option, like homeopathy for a serious, progressive disease. Sometimes they can get things right, but only because the standard of care got it wrong. It turns out that if the standard of care is wrong, it’s not hard for a patient to beat it. An underappreciated aspect of being a patient is you have much better data quality than doctors do. Doctors read about symptoms from books, but patients experience them. If you’re a patient and you stumble on an effective treatment, you’ll know. But as a doctor, do you really the guy who can’t tell the difference between a ligament and a tendon?
By the existence of dumb patients you might also guess the existence of smart patients. They’re the most competent of all. They have the trifecta of high data quality, medical knowledge, and good intuition. Because they experience the actual pathology, it’s 10x easier for them to identify medical knowledge that’s wrong. Is condition X really caused by stress or lack of sleep? If Y is the cause then Z should also be true, but it’s not. Patients also have 10x more confidence in data quality. Imagine the concept of sun sneezing (aka photonic sneeze reflex). It’s such a bizarre concept, that exposure to sunlight can trigger a sneeze reflex. As a patient you can be assured it’s a real thing. Maybe it’s happened dozens of times. But as a doctor hearing this from a patient? I’m not sure it’d be considered credible without independent confirmation, and even then you’d wonder if it was true. Lastly, patients don’t experience conflicts of interest, or have legal concerns, etc. Doctors may say they act in the best interests of the patient but they quietly practice defensive medicine and accept grant money from pharmaceutical companies. A doctor’s judgment can be easily swayed by external forces, but much less so for a patient.
In summary what differentiates the really good doctors just comes down to the knowledge and judgment to selectively abandon the standard of care and try something better. Effective medical researchers sometimes fall into this category and also smart patients. By doing what nobody else does, they can get results nobody else can get. Sometimes these results are exceptional. Doctors who rigorously adhere to the standard of care get approximately the same results as any other doctor employing the same strategy. Often there is good reason to adhere to the standard of care, but when it’s wrong, the outcomes will never be exceptional. Dumb patients exercise independent judgment like smart patients but lack the knowledge and intuition to outperform the standard of care. By doing what nobody else does, they can also get results nobody else can get. Sometimes these results are poor.