Wednesday, October 13, 2010

"Top Doctors": Who are they -- and who are they not necessarily?

I have written about the US News and World Report ratings of “Best Medical Schools” (Rankings of Medical Schools: Do they tell us anything?, Sept 25, 2009; A New Way of Ranking Medical Schools: Social Mission, June 20, 2010). Another popular concept is identifying “Best Doctors”. Seems like every local magazine (“Your City’s Name Here!”) has a list of Top Doctors in various specialties. At another level, the airline magazines have full page ads ( where they list 6 or 7 “top doctors” in a given specialty (orthopedics, plastic surgery, cardiology…never primary care!), usually one in each of several major metropolitan areas. The idea here seems to be to attract the business of well-to-do people who are flying, and may need, say, a rotator cuff repair or a breast augmentation. In addition, if you put a doctor’s name into an internet search engine, most of the “hits” will not be links to her/his office, but rather listings – sometimes accompanied by ratings – on a variety of sites. So what does this mean? Are these listings reliable? Should you go to a “top doctor”?

Why not? We all want to go to a good doctor. And isn’t a “top doctor” even better? Of course, if we think about it, we might want to know the basis on which these top doctors are selected; that makes sense. After all, if a site lists the “best cars” and we discover the criteria is which ones are capable of the highest speeds, or hold the largest number of people or cargo, that’s great if what you are looking for is a fast or big car. But if you want, say, a high-mileage car, probably these cars are not the “best”.

Unfortunately, it is very difficult to find out what the criteria are. Even more difficult than finding out how US News ranks medical schools. Some of them are from patient surveys – you are randomly called, or more likely solicited to fill out a survey on what you thought of your doctor. There are problems with this method, although it is nice to know people like their doctors. First, it is not a scientific sample. Maybe people who are happy with their doctors are more likely to fill out such a form. Or (more likely) maybe those who are unhappy with her/him are. Second, people can only evaluate what they can evaluate, and that may or may not be what is important to you. If a doctor listens, shows caring, responds in a collaborative manner – a person can rate that, and maybe that is important to you too (it should be). But maybe you are not interested in collaboration; maybe you just want a doctor who will tell you what to do (probably not if you are reading this site, or reading “top doctor” surveys, but many people are).

Most determinants of physician quality, other than interpersonal skills (and these are very important!) are beyond the ability of patients to assess. Because people really have no way of knowing about many components of the quality of care that they get, much of what they evaluate hospitals (and to a lesser extent, physicians) on is their “hotel services” – are the rooms big? Clean? Well-furnished? Is the food good? More relevant to quality among things people can evaluate are “how are you treated”? Are people attentive? Do they explain things to you? Are your questions answered? (This is, of course, not the same thing as getting whatever you want; receiving medical care is not shopping in a convenience store!) Finally, while a patient can know if they had a good outcome or not, they have no way of knowing if it might have been better – or worse – with a different doctor, or hospital.

If you are, say, having surgery, it might be nice to know how satisfied people are with the surgical results. Or how often people die. It is very hard to get this data, and harder still to control for important causes of variation (we call them “confounders” in research; things that might be associated with both the condition and the outcome). For example, one surgeon might have a very much higher mortality rate than another – until you find out that s/he is operating on the sickest people, the ones who were at highest risk for death, the ones the other surgeons wouldn’t dare to operate on – and that is why a higher percent of his/her patients die; if someone else were operating on the same population, their mortality rates would in all likelihood be much higher.

So what do these ratings mean? Usually not much. One thing that most of the “top doctors”, especially the ones in the airplane magazines, seem to have in common is fancy addresses: Rodeo Drive, Fifth Avenue, North Michigan Avenue. They have their practices in rich neighborhoods and take care of rich people. This may make them the most famous, especially among the folks who the people who write these articles talk to. And, likely, they are among the most financially successful, and thus able to pay to get their names on some of these lists. What it most certainly does not mean is that they are the best doctors, in any of the ways that you might mean it (nicest, best surgical outcomes, best listener, wisest, most highly respected by his/her colleagues, you pick it!). It also doesn’t mean they are not good – or maybe even among the best doctors -- but it is scarcely a guarantee. What they are is doctors who have, for a variety of reasons, chosen to take care of rich people in fancy neighborhoods. The reasons may be ego, a desire for status, a desire for bigger incomes (really a common one) or even a prejudice against or revulsion for poor people.

They are presumed to be the best because they are the ones who take care of rich people, and rich people get the best, right? They have the best cars, and houses, and jewelry, and yachts, and everything else, so they must have the best doctors, right? Wrong. What they have is the doctors who want to take care of rich people. Any medical school has some students who are looking toward such a career, as a prominent rich-people’s doctor, just as others are planning to work in middle class, working class, or poor communities. Or in rural areas. Or in third-world countries. I’ve got news for you – the students in the latter groups are not less smart or less skilled than those in the former group. They probably are more committed and have more developed social values. The densest kid in the class could be on Park Avenue and the smartest practicing in the ghetto, the country, or in Africa.

I don’t know the association of skill as a physician or surgeon and the socioeconomic groups that they care for. I know of both good and not-so-good doctors in all groups. Certainly, every time a celebrity dies of an overdose, we hear of some “Dr. Feelgood” who supplied them with dope, a doctor who was – at least before this adverse publicity – a “top doctor”, a “doctor to the stars” – but not my any measure a good, not to mention “best”, doctor. While elite offices can offer you nicer furniture, less crowded conditions, and more people who look like you (if you are rich), if you are really looking for the “best doctor”, it’s a crapshoot. S/he may be working in the free clinic across town.

So what do you do? Pretty much what you do now. Take recommendations from friends – provided that you think that the friend values the same things as you do in a physician. One who listens. One who is old. One who is young. One who has a nice office or office staff. Maybe one who has – if your friend can tell – helped them to improve their health. Now that would be a good one!


Josh Freeman said...

Posted for Martin Donohoe, MD

Josh: You have analyzed this situation very well. I read some of these surveys and have known some of the doctors selected. They range from skilled clinicians to those whose medical knowledge base is sketchy at best, but all tend to be popular among their peers, their patients, or have a significant presence in local media (being often interviewed for newspaper stories, on TV, etc.). My current hospital has emailed its clinicians weekly to get us (and presumably friends and family) to vote our colleagues (and maybe ourselves too) into the city's "best doctors" list which will come out soon. Having a number of staff on the list makes for nice publicity for any institution, and I know mine is not the only one to engage in "get out the vote drives."

Even academic rank bears only a weak relationship to quality of care. I remember my days as a resident at a top-tier Ivy League institution. The residency was so good because of my fellow trainees, the nursing staff, and the sense that everyone was striving to do his/her best to maintain the hospital's well-deserved reputation. However, some of my best teachers had been at the instructor level for almost a decade, because they did little to no research. Believe me, though, they were superior clinicians and dedicated teachers, and if I was sick, I would have wanted them to care for me in a heartbeat.

Martin Donohoe, MD, FACP

Dr. Caryl Heaton said...

its a new phenomenon but I too have been lobbied to "vote" for doctors in my local hospital as "top doctors" and to vote for the hospital as "best hospital". This is also born out by the fact that when you look at these lists they are sometimes heavily weighted to one hospital or geographic area in our state. Hmmm.... I think we should have the medical students and residents vote - they actually know.

Cauê F Monaco, MD said...

In Brazil, where I live, it is pretty much the same, but in Brazil medical advertising is not allowed to be that explicit. One can not openly allege himself to be better than others or show pictures on advertisements, for example (I was shocked when I saw those on the plane in the US). But the doctors who have BMW's and offices in fancy addresses, work in hospitals that provide patients with L'occitane shampoo and charge a lot to care of the rich people are seen as the best ones.
The biggest problem I see, like you, is that all this system is not based on quality of care, but mostly on payment for unnecessary procedures. And medical schools incorporate that with almost no critical appraisal at all.

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