Practicing medicine in the shadow of numbers
One of the most striking aspects of the Ministry of Health’s efforts to reduce cesarean section rates is treating high primary (first-birth) cesarean rates as the primary criterion for questioning a doctor’s professional competence. Today, many obstetricians and gynecologists are subjected to professional competence reviews and directed to competency training simply because of high cesarean rates, during which time they are effectively unable to practice their profession.
Reducing a student’s future to an exam score, an employee’s value to a performance score, a university’s success to the number of publications, or a hospital’s quality to a few colorful indicator boards … There’s no need to think at length, examine the context, or evaluate different variables to understand people, institutions, or even professions. Isn’t it comforting?
These days, the Ministry of Health is also enjoying the ease of turning complex things into simple numbers.
Such numbers don’t like arguments. They don’t have to defend themselves. They have no business in telling a patient’s story, a doctor’s years of accumulated experience, or the uncertainty behind a decision. They are simply there. And most of the time, they are believed to be much more than what they say. Moreover, numbers have no conscience; they don’t object, don’t ask for explanations, and never say, “but my patient was different.”
A striking example of this recently occurred when six obstetricians and gynecologists were prevented from practicing for six months due to high cesarean section rates. Reducing cesarean rates is an important goal for maternal and newborn health. Preventing unnecessary cesarean sections is on the health policy agenda in many countries. In pursuit of this goal, the Ministry of Health has taken a remarkable step: now, a doctor’s primary cesarean ratio is seen as an indicator of that doctor’s professional competence.
Article 23 of Decree with Force of Law No. 663 regulates that healthcare professionals found to be professionally incompetent may be subjected to competency training. The decree does not clearly define the concept of “professional incompetence.” What knowledge, skill, or behavioral deficiency will be considered incompetence? What is the criterion? So, we have a concept of incompetence, but there is serious ambiguity about how to define it. What’s more, it is assumed that a doctor who has completed years of medical and specialty training can regain competence through a training program whose duration and content are not clearly defined.
Here, one inevitably wonders: If fourteen years of medical education and specialty training did not provide competence, how will a few months of courses do so? Perhaps the Ministry of Health has discovered a new formula for today’s educational philosophy: Forget the years of specialty training, just update the medical software with a few months of reprogramming.
The real issue is a scientific one before it is a legal debate. A doctor’s professional competence can only be determined by evaluating clinical knowledge, technical skills, decision-making ability, complication management, patient safety approach, ethical attitude, communication skills, and clinical outcomes together. But all these are laborious; meanwhile, the cesarean rate discovered by the ministry works like a traffic light: green if the rate is low, red if it is high. However, nowhere in the world is a single performance indicator alone accepted as proof of professional competence.
To understand this, it is enough to look at other fields of medicine. A long surgery time does not make an orthopedic surgeon a bad surgeon. A cardiologist’s high rate of angiography requests does not mean unnecessary procedures – perhaps riskier patients are referred. The frequency with which a family practitioner prescribes antibiotics cannot alone indicate whether they are a good or a bad doctor. An intensive care specialist’s mortality rate alone does not show incompetence. Why? Because medicine doesn’t operate by mathematical rules like systems in controlled environments. These indicators can be examined, questioned, and monitored for quality improvement, but none alone can justify disciplinary action.
Numbers and rates do not show underlying reasons or context. An obstetrician’s primary cesarean rate may be affected by the center’s patient profile, referred high-risk pregnancies, previous cesarean history, multiple pregnancies, maternal age, assisted reproductive technologies, and many other variables. The same rate can reflect entirely different clinical realities in two hospitals. However, the beauty of numbers is that they don’t tell stories. Because it’s much faster to look at a number than to understand stories, which are complex.
This is where science steps in and asks its question: Does this measurement really measure what we want to measure? In measurement and evaluation science, this is called validity. The primary cesarean rate, as its name suggests, measures the frequency of primary cesarean sections, not professional competence.
For this reason, in modern quality management, performance indicators are considered early-warning tools rather than decision-making tools. A rate that is higher or lower than expected signals a situation that requires investigation; it cannot, on its own, be proof of fault, negligence, or professional incompetence.
According to the principle known as Goodhart’s Law, first articulated by English economist Charles Goodhart and recognized for years in economics and public administration literature, “When a measure becomes a target, it ceases to be a good measure.” Donald T. Campbell went further, showing that the more a measure is used in decision-making, the more likely it is to distort the system it is intended to monitor. These two approaches, now considered fundamental in performance management, also apply to healthcare services. Both point to the same truth: indicators are created to monitor the system, identify problems, and improve quality. But when the same indicators become criteria for rewards, punishment, or disciplinary measures, people stop trying to achieve the real goal and focus on improving the indicator. Thus, the system does not truly improve; only the numbers change.
There is a similar principle in medical education: Evaluation shapes behavior. Students study for what is tested; doctors eventually modify their behavior according to the indicators by which they are measured and rewarded or punished.
In fact, this is true not only in medicine but in all professions. No one evaluates the scientific competence of a university faculty member solely on the number of published articles. The article count is one indicator, but without considering scientific quality, citation impact, originality, educational activities, and ethical conduct together, a decision on competence or incompetence cannot be made. Similarly, a judge cannot be evaluated solely on the rate of overturned decisions, a teacher on students’ exam averages, or a surgeon on the number of surgeries performed. Otherwise, statistics cease to be scientific data and become the basis for legal sanctions.
Numbers are important. But there is a limit to what numbers can say. Good medicine, good law, and good science base their decisions not only on numbers, but also on context and evidence.
Note for the curious: Two articles I wrote last year, examining the Ministry of Health’s approach to cesarean births and questioning the multifactorial structure of the issue: “Lost reason on the Cesarean and obesity scale” and “The Ministry of Health’s war against abnormal birth.” Mesude Demir from Diken is also worth following and is a keen follower of the issue. The Turkish Society of Gynecology and Obstetrics’ press release on this topic is available here.
To read the full story from the source: BirGün
