Top doctors may not always be the best physicians

I’m sure you’ve read through top doctor rankings and online physician ratings. It is only human to seek perceived leaders. But as sometimes seen in politics, those who have reached the pinnacles are often motivated by ambition, charisma, and gamesmanship instead of altruism, sincerity, and merit.

Beware the top doctors issues found in magazines and newspapers.

Some of these doctors are excellent, but many are simply “notable.” They may be well-connected, in leadership positions, or presidents of this or that society. Many are excellent self-promoters, branding themselves through the name brand institutions they work for and the billboards that increasingly advertise their faces. Many are simply well-known or popular among their peers.

But many are unavailable, aloof, or consumed with administrative duties for the institutions through which they’ve risen in the ranks. Others stand apart from the rest due to their strong entrepreneurial efforts. I know of a “Top Doc” who prescribes dangerous medicines for conditions I’ve never heard of. Many of the medications cause weight loss as a convenient side effect. He’s considered “cutting edge” or “popular among patients” simply because he fills a niche that’s in demand. Last I heard, he’s being investigated, but still graces the “top docs” magazine.

Be cautious about your own feelings about a doctor’s competence. A good bedside manner and a kind heart are important, and thinking of your doctor as a friend may lessen anxiety. But a certain distance is needed for objectivity, clear thinking, and a person’s best interest. For example, consider the doctor who pleases all his patients by agreeing to prescribe whatever medications requested. Before long the medication list bores a hole into some Wonderland, with pain pills, sleeping pills, anxiety pills, and weight loss pills whirling together in a mind-altering, life-threatening existence.

Consider the doctor who agrees to order every test you can think of, including full body CT scans that find little-nothings in your spleen, liver, lungs, and bowel that now require monitoring with more CT scans, soaking your body with cancer causing radiation and worry. You want a doctor who is not your best friend, who shoulders the uncomfortable task of telling you “no” when he believes it is in your best interest.

Beware the insurance company rankings of doctors based on quality measures. I just received a survey from a big insurance company. They picked one single patient from my practice and asked me if that patient had received colon cancer screening in the past ten years. I pulled the chart and looked over our notes from the past ten years. We had reminded, cajoled, educated, and tried to convince the patient of the benefits of colon cancer screening over twenty times, yet he refused or declined each time.

But to the insurance company quality rankings, this means I have failed, and I will be penalized both in terms of my “quality” as a doctor and most likely my diminished compensation from that insurance company. Shall physicians also be ranked based upon how many of their patients ride motorcycles, drink soda, or eat Baconaise? Other quality measures include stratifying doctors based upon how many of their diabetic patients’ blood sugar readings fall below a certain goal. Yet there is overwhelming evidence that excessively tight glucose control does more to harm patients than help. In this case, the best numerical results for quality only correlate with higher mortality for patients.

Beware the websites upon which patients can submit reviews and rate different doctors. Just because a doctor is well-received does not make him a good doctor. As I’ve written in the preceding paragraph, pleasing people is easy. Disappointing them out of a sense of beneficence is actually quite hard. A perceived bad experience by a patient may provoke a negative review online, but improving people’s health and satisfying their needs and wishes don’t necessarily overlap. A doctor could see thousands of patients and do a good job with them all, but never be rated by anyone except the three disgruntled patients she did not please. And staying on time is every doctor’s goal, but sometimes a 92 year-old woman with multiple needs shouldn’t be dispatched of in 20 minutes, and patience is a community responsibility.

I understand the need to measure quality in any system as a means to figure out how things can be done better. But the crowning of top doctors, the bureaucratic measuring of imperfect health quality markers, and the compulsive clicking of online reviews are not the solution.

Unfortunately I don’t have the answers. Perhaps we as patients should be ranked, too? I already see signs that insurance companies are doing this in subtle ways.

Plastics? Robots? Nanotubes? Some combination of cold fusion and artificial intelligence? Or just old-fashioned word of mouth.

Dr. Charles is a family physician who blogs at The Examining Room of Dr. Charles.

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