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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  • Ron Hekier, MD

    There is a maxim that one should never have surgery performed by a department chair at an academic institution because they are more likely to be attending meetings and conferences rather than operating each day. It is not an absolute truth, but something to think about

  • Evan Falchuk

    Thanks for the post, Dr. Charles.

    I think you make excellent points, and this is coming from me, the President of a company called Best Doctors. We’re responsible for creating some of these lists.

    In medicine, in which thoughtful judgment is the key to success, I think a doctor’s reputation among his peers is the best way to get an idea of how good they are. And so that’s how we do our surveys.

    Still, the issue in medical care isn’t your doctor’s reputation. Instead, it’s the extent to which he or she is able to spend time with you, think about your problems, and render good advice.

    Very few people working in public or private insurers seem to understand this. It’s why you see these deeply misguided attempts to measure doctor quality like the ones you describe.

    But I believe these attitudes are changing, and it’s because patients are getting fed up with a system that doesn’t let them really get what they want from their doctors. In this sense, think of popularity of these “top docs” issues as an expression of this growing consumer frustration.

    Once there was a time when your doctor could truly be your guide through the health care system. Progress in the quality and cost of medical care will come from getting back to the fundamentals of medicine, not by trying to turn doctors into ciphers.


    Evan Falchuk
    Best Doctors, Inc.

  • ninguem

    A nearby hospital has a large stable of salaried doctors. Their management likes to “own” the doctors. They’ve also received some heavy fines for various acts of malfeasance in their administration, that’s another matter.

    They go around to the doctors they own, and urge them to send in those ballots for best doc in our city magazine. They supply a list of suggested best docs, all on their staff, of course. They like to make sure the ballot box is well-stuffed.

    Given that their employed docs will not remain employed for very long if they referred outside the institution, they probably don’t know that many outside docs anyway. And when no longer employed, their noncompete makes them a nonperson in the best Soviet tradition. They won’t practice anywhere near that place.

  • jsmith

    Over the years, I have found no correlation between these rankings and quality of care in private practice. Perhaps this stuff is more reliable for academic subspecialists or in the big cities, but I really don’t know. In my medical world, word of mouth from other doctors, patients, and, especially, hospital nurses, is the best guide, but that too is not completely reliable.
    Anecdote: We have two partner urologists in my town, one of whom is a very nice guy who will give reasonable advice over the phone. His partner is, to put it mildly, a jerk. I was surprised to hear just the other day from two of the hospital nurses that the jerk is a superb surgeon and the nice guy is not someone they’d let operate on them. I suspect the nice guy would have higher ratings.

  • Martin Young

    While the bulk of your argument is correct, I think you oversimplify the issue. What you describe as being ‘nice’ to patients is really being a ‘pushover’ and serves nobody’s interests. I don’t think most patients are so dumb that they don’t know the difference, and those that do know the difference and still see doctors like that do so to serve their own purposes!

    In my opinion, being aloof and detached may be appropriate for a radiologist or a pathologist, but is not suited to a PCP or paediatrician. Or just about any other field where you deal with people.

    On the other hand, I couldn’t care less what my cardiac surgeon’s personality is like as long as he or she is technically good, and I would count on my colleagues to tell me that!

    What happened to good communication skills, being firm, but empathetic, explaining why another script for a narcotic analgesic is not a good thing? You don’t have to be distant and detached to do that!

    One cannot overemphasize the importance of these communication skills! It may be just poor attention by doctors to these ‘touchy feely’ issues that have led patients in their hundreds of thousands to seek alternative forms of medical care!

    • Stephen Paskoff

      We call the skills you refer to often as “soft” skills which suggests they are collateral to core competencies. Ironically, I wrote a piece yesterday which I will publish on my blog next week entitled Banish Soft Skills at Work –the term not the concept. Soft skills affect quality and safety of patient treatment and outcomes in healthcare; they need [and are getting per JCAHO accrediting standards] greater rather than less systemic attention

  • Leon

    “In medicine, in which thoughtful judgment is the key to success, I think a doctor’s reputation among his peers is the best way to get an idea of how good they are.”

    I live in a large city and those surveys are fillied with doctors from large corporate medical centers. Surveys go out to doctors who recommend doctors in their own medical center. A doctor is a small practice doesn’t have a chance-he doesn’t have the corporation around him.

    One of these medical centers extensively uses physician assistants for care. So even if your doctor is top rated, chances are an appointment will be with his PA.

  • The Happy Hospitalist

    Wait a minute. I thought spending several thousand dollars to be board certified gave me the golden ticket to the excellent doctor list.

    You mean it doesn’t? Why am I paying then to take the test. What’s the purpose.

    I suppose it won’t be long before I can pay an extra thousand dollars to get the super duper board certified certificate.

  • thejobbingdoctor

    Thank you for an excellent post.

    Doctors’ rating sites are being trialled here in the UK, and have (fortunately so far) been a resounding failure.

    I have taken issue with this over the last 2 years in my blog for these reasons, and I am pleased that Dr Charles sees things similarly to me.

    The Jobbing Doctor (UK Primary Care)

  • Primary Care Internist

    Happy, great comment.

    Why the f— is the ABIM (and other specialty boards) not endorsing their board-certified doctors, who support such organizations about every 10 yrs, with their OWN “best doctors” lists, based on maintaining board certification status and perhaps not using mid-levels in their practice?

    The recent episode of Nurse Jackie is telling – if a first year resident can pay a publicist to be included in New York magazine’s “best doctors” then what the hell is it worth? I don’t think this is that far off from the truth. Where I live (northern NY suburbs), Westchester Magazine publishes a list every year of “best doctors” which is notoriously filled with docs from one particular hospital along with tons of dentists and chiropractors (???).

  • Anne Marie

    So, how is a patient with no inside medical connections really know if a doctor is “good”. My only source are friends or neighbors who base their judgment on things like if they validate parking.

    • jsmith

      Very tough to do, Anne Marie. If you know someone who knows a hospital nurse, they are generally pretty good resources.
      Also, look for board certification. Lack of it can indicate a problem. Also, I might get some heat from my doc colleagues about this, but beware of generalist doctors who practice alone and who don’t have hospital privileges. Having hospital privileges usually means passing some quality tests. General docs who practice alone are a bit of a risk, unless of course they’ve been around your town for a while and have a good reputation.
      My family gets our medical care from a 4-person family medicine group, who admit to the hospital and who are all board-certified.

  • Paul MD

    @ ninguem

    You don’t work near me in New England do you (sic)?

  • Lisa Stockwell

    I’m with Martin and rank good communications at the top of the list of what makes one doctor better than another. A great doctor to me is someone who takes the time to explain a condition or treatment and provides other resources or willingly recommends a second opinion when s/he is not 100% confident in a diagnosis. Communication skills do not take the place of competence, but when comparing two competent docs, the one with the better communication skills will develop the healthiest interaction with the patient. And often that will lead to getting better information from the patient and a more accurate diagnosis and treatment.

  • Toni Brayer, MD

    I’ve been a “Top Doctor” but I agree that you can’t count on that designation to really tell. Many of the physicians on the list are well known in academia but don’t really even see patients…the residents see them in clinic. Some magazine “top docs” can buy their way in by placing large ads.

    Patients love seeing their doctor’s name on the list but I don’t think it is always an indication of quality. I think time spent with the patient is the best indicator of quality outcome. Good care takes time…period.

    • Evan Falchuk

      “Good care takes time…period.”

      This is such a fundamental and fundamentally unappreciated fact. More people need to be saying this.

      FWIW, it’s true that some ‘top doctor’ lists work the way you say. Ours at Best Doctors is purely through peer voting – you can’t pay to get in under any circumstances. Moreover, you have to be in active clinical practice, not academics or administration, and be board certified.

      There’s more to it, and like I said above, I don’t think it is the end-all of the question of whether a doctor is good or not, but it is a highly valuable and credible resource.

  • ninguem

    Paul MD – @ ninguem – You don’t work near me in New England do you (sic)?

    No. If you find the story familiar, I guess it means it’s pretty universal.

    One exception, Massachusetts does not allow noncompetes in medical employment contracts. They are specifically prohibited by statute.

    Of course, Massachusetts has it’s own problems.

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