Of the many factors that make improving the health system difficult, few challenges are greater than the misty-eyed recollection - often from genuinely distinguished practitioners - of how great things used to be.  Doctors were highly regarded authority figures, pure and beloved, while patients were meek and grateful in the presence of such brilliance and expertise.

Of course, this caricature has been thoroughly debunked - perhaps to an excessive degree (I've actually argued that many of those jumping on the desperately hip "disrupt medicine" bandwagon may be missing or at least undervaluing important elements of the "traditional" doctor-patient relationship).

Nevertheless, it's still surprising how frequently we reference, and pine for, the supposedly good old days of medicine, a misinformed comparison that tends only to muddy the waters and prevent us from focusing in on the real problems to be solved.

A representative case in point is an article today from Smart Money describing the emerging business of specialist referrals.  The basic idea is that if you see your primary care doctor, and need expert evaluation in a particular area (such as surgery or endocrinology), you get referred to an appropriate specialist.  The article makes the point that while patients believe these referrals are on basis of their doctor's opinion of the expert's quality, in fact they may be based on the aggressive marketing of a dedicated consultant who the expert hired to increase business.

Unfortunately, rather than arguing both of these approaches are misguided, the author fondly invokes "a now-retired Nobel Prize winning cardiologist who practiced for more than five decades in the Boston area who says the emphasis [in the old days] was usually on someone's medical bona fides - where they trained, what they published and what they've accomplished as a healer. The bottom line, he says: ‘They looked for patient outcomes.'"

Say what?  If there's one thing abundantly clear about the practice of medicine (and look no further than this op-ed in today's NYT, and this recent HBR contribution by same authors), it's the nearly total lack of visibility into actual outcomes, and beyond that, to physician quality.  

It's true: we may have a sense of how knowledgeable other doctors may seem in conversation, we know where they trained and who they trained with, and we can figure out pretty quickly if their patients tend to like them or not; but do we know the quality of the care they ultimately are providing?  Generally, the answer is no - and to believe otherwise suggests profound physician overconfidence, of exactly the sort described by Kahneman in so many other domains.

The key take-away from the medical referral story shouldn't be: let's go back to the old days when doctors cared enough to refer patients to the best specialists  - or at least the specialists they knew best. 

Instead, let's use this opportunity to think a bit more carefully about how to measure the quality of care (non-trivial), and particularly the ability of doctors to achieve improved patient outcomes.  Such an approach could not only help primary care physicians give the best advice to their patients, but could also help the specialists themselves improve the care they provide, and elevate the overall quality of our medical system.