Beware the Top Docs

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.


21 thoughts on “Beware the Top Docs

  1. Pietr

    Perhaps return to the old adage about med school grades:

    Those that get A’s are the researchers
    Those that get B’s are the best doctors
    Those that get C’s make the most money
    Those that get D’s become [redacted specialty]

  2. bb

    Great post. I guess I am one of the few that have not read the online physician ratings. But I can share that when I do read ratings in other areas whether it’s for a product or for a service, I like to read both positive and negative ratings. Even within those ratings, I am screening what is being said — trying to weed out the “complainers” just because something didn’t go their way and those that “praise” just because they got their way. I tend to look at the rating more closely if a person describes what they were either happy with or not happy with, something objective such as unhappy with a service because of delivery problems. If it’s a one time objection, then I chalk it up to “stuff happens.” If many people are complaining about that, then I assume that I am also likely to experience delivery issues. If one person complains that customer service was a bad experience and no one else makes that complaint, I chalk it up to possibly that person was a crabby customer and difficult to deal with.

    I guess I want to know why a service or a product is positively or negatively rated. It’s not that I don’t care about a person’s feelings re their experience, but their feelings don’t help me in making a choice. I tend to skip those type of ratings as they are not very helpful to me.

    And lastly, I WANT a physician to feel free to tell me no. I didn’t go to medical school so I depend on his/her expertise (just like I depend on other people’s expertise when hiring a service such as an accountant or a vet). I also would want to know why the answer is no. I also want to know why he/she is prescribing a certain test or treatment and what they expect to learn. I can then make an informed choice as to whether or not I wish to submit to that treatment or test.

    I guess in the end, my favorite way to get an opinion is either through family or friends. I can chat with them why they feel a certain way. That’s how I found my most favorite vet in the world. He rocks!!!

  3. Cat

    “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.”

    It’s called “one visit, one complaint”. They do it in Norway. Everyone gets 15 minutes. If you have multiple issues, you book several appointments and pay several co-payments. You don’t get to go, “oh and while I’m here, I’ve been having this odd symptom…”

    The doctors were always on time.

  4. cathy

    I don’t put much stock in what others say about any doctor. I can remember when my grandmother was 89 years old and in a hospital dying. My entire family despised a certain doctor. My dad had 10 siblings so this was alot of people in agreement that they did not like this man. Years later, my own Dad would be lying in a hospital dying and who did they call in? Yep, the doc that everyone in the family disliked. Myself and all my siblings thought he was one of the best and most considerate doctors we ever seen. He could not have been better or treated my Dad (and us) any better than he did. He went out of his way to make sure my Dad was comfortable and got good care.

    I assume what happened was that one of my Dad’s siblings had a personality conflict with this Doc., made it known to all the other siblings, and in-laws, thus creating this unity of dislike for him.

  5. PatricParamedic

    Terrific article, and one that should be re-read more than once.

    I can’t tell you the best way to find a great doctor. However, I can definitely give you some of advice regarding those you might want to avoid.

    Be safe this Easter week, and never let a ‘lab coat’ trump your common sense.

  6. Kendra

    Great post, and intriguing subject. I wrote a post for Medscape, “Yelp I Need a Doctor,” (!comment=1) which touched on this same topic. I think that online review sites can potentially be great ways to read opinions on docs, but as you pointed out, there are many reasons why they just don’t always work. I think word of mouth will likely continue to be the best way to find great docs for the time being. Interesting to see if we’ll find a better tool in the future!

  7. Bruce

    Right on target. Our local survey depends on responses from a physician’s peers, so those physicians working in larger groups tend to list the people with whom they work regularly. Great people in private practice and small groups rarely get listed. Top Doctors asks for nominations of peers in other cities, therefore the people who attend national meetings, lead organizations, and present papers get listed despite the quality of their medical care.

  8. Celeste

    Those online ratings have no verification to make sure it’s an actual patient of the doctor giving a rating of an actual appointment. For all any of us know, the great ratings could be coming from the doctor or any of his supporters, staff, or family. The poor ratings could be coming from a competitor, an angry ex, or even a campaign by just one unhappy patient.

    I say we have to start with word of mouth for referrals and recommendations, roll the dice on an appointment, and make up our own minds…just like always.

  9. emmy

    My friend said “You should go to my doctor, I just love her.” and I loved her too. But my friend only goes for physicals once a year, and I need a doctor who can see me when I’m sick. The lovely doctor is a single mom and she needs a schedule that is somewhat managable. My needs and the doctors needs didn’t match. It didn’t mean that she wasn’t a good doctor, just not a good match. My other friend said “I love this practice, most of the doctors are great and they can see you at the drop of a hat.” I was only somewhat impressed with most of the doctors in that practice and there was one that I wouldn’t send the devil too. Guess which one was the only doctor available everytime I got sick. I went to the in network list and started looking up providers on the websites. Most of the information that is posted is useless. I only considered patient ratings if they said there was an issue getting sick appointments. I looked for things like how much does this doctor know about treating cancer survivors or patients with arrythmias and diabetes. That kind of information isn’t on those sites. Finally my cardiologist asked me why I was changing primary care doctors every six months. I told him what I’d been through trying to find a doctor who understood me and was available within a reasonable time frame (like within the week of my sick call). He said that it would be unethical for a doctor to suggest a primary care doctor. I don’t understand that because primary care doctors refer to specialists all the time, but I’ll take his word for it. However, as I was checking out the ladies behind the desk were having a discussion about an internal medicine doctor nearby that they all loved. Coincidence? It doesn’t matter, he’s been my PCP for two years now and I love him. The point I’m trying to make is that there just isn’t a good way to find a doctor when you are looking for one. I wish there was a website that just said “This doctor has a lot of knowledge in these areas” or “This doctor has limited scheduling and refers sick patients to urgent care.” It would make things a lot easier.

  10. cynthia bailey md

    Great post showing the complex mix of what makes a great doc. Practicing really good medicine is part art, part science and part something else I can’t put my finger on but I feel it every day when I see patients. Ratings are for quantifiable things, which is why it’s hard to rate docs. This is the computer/social media age and were stuck with ratings-but it’s great to keep open the discussion of why the ratings are flawed.
    Thanks for doing that,
    Cynthia Bailey MD

  11. micah

    “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.”

    Funny that this elicited such diverse responses. This was my second favorite part of this overall nice discussion on the medical hazards of social media (right after the suggestion that patients should be ranked!).

    In general, I feel that the community should have a little more patience regarding just about everything. I argue that the system should be fixed so that morally-appropriate accommodations for emergencies and little old ladies do not result in regular disruptions for people like Cat and yield more frequent open slots for people like Emmy. However, it sounds like the people in Norway were ready to pay in time and treasure for that convenience, unlike the demand for McDonald’s medicine here.

  12. Aurora

    As someone who is online all. the. time. I definitely have gotten into the habit of checking the rating and online reviews of pretty much every service that I use, from the restaurant down the street to the doctor that I visit.

    The rankings may not make so much difference to me, but if that means they are more likely to have reviews online, and that will make a difference. I’ll read negative and positive reviews happily (I’m with the previous responder who wanted both positive and negative reviews)… I just want to be able to learn all about them before I go in for my first visit.

    This may not be the best way to pick a doctor, but as Emmy said, there isn’t a great way to pick them out, so this one works for me.

  13. Molly, NYC

    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.

    I’ve been living on-and-off near Portland Oregon, which is terrific. The MDs I’ve met here all seem terrific too.

    However, I’ve never seen a place where abject quackery is so normalized. Acupuncturists, reikian therapists, homeopaths, a Hogwarts-like college of naturopathy, self-described practitioners of herbal therapies, aura readers, yadda yadda yadda on every street corner and mini-mall–supported by a huge chunk of the population who think these “natural healers” are just the greatest thing since Lydia Pinkham went out of business.

    Ask ’em why and (1) they’ll invariably tell you about how much nicer, kinder, more caring, sweet-as-sugar the naturopaths et al. are.

    Well, of course they are. What else do they really have to offer?
    (1) Once you get past the diatribe about how the MDs and DOs have all prostituted themselves and their arts to their corporate overlords in the insurance industry and Big Pharma.

  14. Nick

    Great points. I’ve got a post in me, somewhere… someday… about how we’ve got to move away from this “top doc” mentality. And I’m not just saying this because doctors in my specialty (emergency medicine) are rarely ranked.

    Think about it this way: No one ever says, “I’m booking my next flight, and got a really great pilot!” No magazines have issues featuring “the best pilots in your city.” People just assume pilots have passed their tests, logged their hours, and will get the job done. They should start to think the same way about doctors.

    There’s the additional argument about extraordinary cases, like the plane that went down in the Hudson. How many pilots could do what Capt. Sully did? But Sully makes the point himself, that situations like his have been rendered extremely rare due to a culture of safety in aviation that puts established protocols over pilot ego. This hasn’t happened in medicine.

  15. Online Patient Surveys

    Good post, we BTW use for keeping a tab on patient feedback. Works out well. Makes the staff also think twice about how they treat patients. Plus, all staff wears a name tag just to make sure they know patients can see who the person is.

    Our Doctors are also aware of the feedback and spend quite a bit of time going through end of the month meetings on patient care and overall satisfaction.


  16. 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.

  17. Greg P

    There is typically in most places an unspoken sense of who the best doctors are, but it’s contained because it’s the sense we get about our colleagues. It has its limitations, for example, I have no good sense of who the best gynecologists are since neurologists aren’t seeing common patients.
    But certainly, as we go over the thoroughness of another doc’s notes, hear feedback from their patients about how nice (or not so nice) they are, discuss various difficult patients with them, we clearly develop preferences. Even so, there is a disconnect here, since that doesn’t necessarily mean I will refer all my patients to those doctors or even that I would choose them for my own needs(!).
    Mr. Falchuk and others try to get at this information, but much of it is inaccessible and he knows it. Most surveys are designed more to get clear results, which isn’t the same thing as getting answers to the most important issues.
    The other aspect of this is that there aren’t so many, maybe it’s rare for a doctor in some field to be the best at everything they see. I know I have my blind spots, the areas of neurology I am less comfortable with, the areas I have little interest in and therefore intentionally don’t spend a lot of time keeping up in those segments.
    The important thing is to be aware of those areas so that you can either refuse such problems up front or refer them on to those who are more appropriate. Some of the best primary physicians I know have a great knack for knowing when they need help and when they don’t, so this is not something unique to specialists.

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