When doctors go on strike does the death rate go down?

January 4, 2008

Dear Cecil:

Hi, Cecil. I have come across a number of seemingly credible reports suggesting that every time doctors go on strike the overall death rate goes down, in some cases quite precipitously. Can you ascertain if this in fact is the case or if some other factors are at work here?

As we'll see below, Jacob, it's not really so surprising that mortality statistics sometimes show a drop during a doctors' strike. What's staggering is that a reasonable person could see such stats and for even an instant think: Holy crap, those doctors are killing us. Sure, there'll always be a few alternative-medicine fringe dwellers who genuinely see the medical establishment as some sinister cabal presiding over a high-density feedlot of human misery. But the way this "fact" about doctors' strikes gets passed around suggests that a lot more people are a little more nuts than you'd want to imagine.

No one's suggesting that changes in the availability of doctors wouldn't affect what happens to their patients in the short term - a study from last May, for instance, found that in both Australia and the U.S. birth rates decreased from 1 to 4 percent on days when OB/GYNs held their annual conferences. But looking over the data on doctors' strikes, it's hard to see where the MDs are saving many lives by staying out of the OR:

  • One example often cited is that of a monthlong strike by Los Angeles County physicians in 1976, during which the mortality rate for patients was seen to drop by 18 percent. But a 1979 study in the American Journal of Public Health showed that the overall area death rate remained unchanged, as enough personnel remained on duty to handle the real emergencies. Any seeming benefit to patients' health likely resulted from about 11,000 fewer operations (presumably elective) being performed that month than was typical, meaning that an estimated 50 to 150 patients who could have been expected to die didn't.
  • A four-month Israeli doctors' strike in 1983 was found to have some definable effects on public health - the percentage of cesarean sections increased somewhat, and one study suggested hypertension patients might have received worse treatment - but no observed impact on mortality. Nonetheless, the popular wisdom saw the work stoppage as a disaster: a detailed study of public perceptions afterward found that nearly one in four urgent-care patients (or their relatives) felt the strike had resulted in major health problems.
  • A 1984 doctors' strike in Varkaus, Finland, mainly meant fewer visits for colds and stomachaches; no significant harmful effects to the public were seen, researchers found, and the uptick in visits after the doctors returned to work suggested that patients were glad to have them back.
  • Another key example used to support the proposition that fewer doctors means fewer deaths comes from a June 2000 article in the British Medical Journal written during another Israeli strike; the author reported that in the three months after doctors walked out death rates fell significantly in affected cities. However, her data was by no means the result of a scientific study but consisted mostly of anecdotal reports from funeral home directors, who claimed they'd seen "the same thing in 1983." What is known is that, as in the LA strike, many thousands of elective surgeries were postponed but emergency rooms and chronic care departments remained open.
  • In 2003 a SARS outbreak closed four hospitals in Toronto, and all non-emergency services were suspended. Among other things, this led to the canceling of a quarter to a half of joint-replacement surgeries, 40 percent of cardiac surgeries, and as much as 93 percent of some outpatient procedures. The result? The greater Toronto area did see a slight dip in mortality rate relative to the prior two years, but so did the rest of Ontario, and the decrease wasn't statistically significant anyway.

So despite media suggestions to the contrary, doctors' going on strike doesn't seem to have much effect on the death rate one way or the other, and any reduction seen is probably the result of postponed or canceled nonemergency surgeries. And that figures: any surgery is risky, and some common procedures (like coronary bypass or aneurysm repair) have a death rate you just can't ignore. But leaving the tummy tucks out of it, most elective surgeries boast a pretty serious payoff, either in quality-of-life improvement right now or in medical trouble avoided down the line. If 600 people die each year as a result of hip-replacement surgery, does that mean the 200,000-plus patients that pulled through were fools to go under the knife? You're welcome to calculate the odds however you like, and in certain cases it may well make sense to question the value of surgery. As a general proposition, though, if my health is on the line, I'm glad to hear that the doctor is in.

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