Wednesday, August 13, 2014

Best Doctors? Indeed How should one measure up?

Top Doctors? Indeed How should anyone measure up?

A recent post in the NY Times posit this very relevant id puzzling question. 

Indeed, how often is it that we've been asked to refer to the best doctor in this or that discipline? Just this morning, one of my long-time patients called and asked if I could refer her to the best orthopedic doctor in a nearby hospital nearer her home. I was instantly flabbergasted, as I've just read the post attached below, last evening... 

Indeed, for that matter, how should I or we as physicians, know? Would our so-called professors in the academic centres, our past mentors and teachers know any better? Does this mean that the more academically inclined or brilliant or up-to-date physician would be the better doctor for any discipline or surgery or special care? 

Perhaps, I would guess we do so based on or by virtue of our own biases, depending on our usual coterie of friends or kindred-spirited colleagues whom we've shared or co-referred patients. Otherwise, we might become aware through some sort of 'connection' via academic or shared interests groups...  Or even because of quid pro quo... because that colleague has treated you or another member of your family, and therefore, we are obliged to cross-refer back as a sort of a goodwill gesture, a thank you... 

But of course in our own little niche of practice and circumstance, we've become accustomed or knowledgeable about this or that doctor whom we think has been good, excellent or technically brilliant or kind, or whichever traits or skills that might fire up our more intimate or inner connection. 

But really I would think that this is indeed very arbitrary... is the physician with the most citations in research be a top doctor in his or her field? Is that media-savvy doctor being the most recognisable be the best? Is someone who's heading a medial society or discipline the best or top doc? Or is another fully dedicated physician totally immersed in teaching in academia the best?

Finally how do we personally measure up in the esteem and eyes of our colleagues, our peers, our patients?

Food for thought indeed. 

Top Doctors, Dead or Alive
NYTS AUGUST 11, 2014

The official letter is sitting on my desk, announcing that a relative of mine has just been named one of the world’s top physicians in his area of expertise. Once he confirms his biographical details, he is guaranteed inclusion in online and print directories of similarly honored peers (“not only a tribute to your success, but also a valuable resource for potential patients”).

I can clearly imagine his reaction had he opened the letter himself: a combination of amusement, dismay and just a small hint of pleasure. However, since he has been dead for 16 years, his widow passed the envelope over to me, and I got to experience all those emotions myself.

The amusement and dismay speak for themselves. The pleasure lay in this really superb demonstration that skepticism should attend all interactions with services promising to lead you through the thickets of subpar and merely average doctors directly to best of breed.

The methodology of these enterprises varies. Some, evidently, cull names and addresses from obsolete phone directories. Some poll doctors themselves for the biggest luminaries of their acquaintance. Some rely on patients’ reviews, operating under the premise that a doctor who delivers a five-star health experience for one will do so for all.

It is easy to dismiss them all as just so much advertisement and avarice, contributing yet more buzzy white noise to the already crazy-making din of health care. But a more nuanced and charitable view is also possible. These services may simply be trying, valiantly if clumsily, to remedy the single biggest mystery in all of health care: that we do not have a clue what makes a top doctor, let alone how to find one.

Is it nature (unusual intelligence, compassion, common sense)? Nurture (diplomas from prestigious and pricey institutions)? Self-sufficiency? (Patients say proudly, “My doctor never has to send me anywhere.”) A central location in a medical network? (“My doctor refers me to all the top people.”) Is it speed or deliberation, ability to follow rules or ability to break them? Exuberant personal charisma or a peaceful office that runs like a Swiss watch?

No one has the slightest idea. Even the terms of the question are undefined. Is a top doctor one who keeps you in top shape, hauling you up when you plunge down? Or is it one who encourages you to remain in whatever shape feels right to you, even if some of your habits might give pause to less enlightened observers?

A sedentary, seriously overweight patient I know cannot walk a block. She adores the doctor who cheerfully tells her: “Who needs to walk? You should ride!” To her, he is unquestionably a top doctor. To the rest of her family, not so much.

I contemplate various listings of top doctors, recognizing the occasional name or face, often residents I knew long ago. Many of them, I think, are probably quite good. But why should I think that? Do I really know what goes on when they are closeted with a patient who drives them nuts, or when they are running late and have theater tickets, or when they completely miss the diagnostic boat and land on an atoll somewhere in the sea of wrong assumptions, many leagues from where they should be? Do they acquit themselves in top-doctor style then?
In fact, nobody knows who the top doctors are, not even the top doctors themselves. It is safe to say that the very topmost doctors, confusingly, are probably not top doctors: They have become news media stars and household names through efforts that presumably leave them little time to hone those top-doctor skills. But otherwise, all is smoke and mirrors.

Can the average consumer glean any information at all from the top doc lists? Here is one tip: Pay attention to the source of the information. Traits that doctors prize in their colleagues may be different from the ones patients rank high. Consultants who will see any patient at the drop of a hat — referring doctors love that — may have jam-packed waiting rooms and move with the speed of greased pigs. The rock stars of modern medicine, experts who publish widely and lecture all over the globe, may spend most of their workweeks in flight, inaccessible for humbler purposes.

Otherwise, I suspect we are left with only a single unarguable definition of a top doctor: one who is not on the bottom. Top doctors are, for instance, not in jail. They have valid licenses. They are presumably enthusiastic about taking new patients (although you can never be sure how enthusiastic they’ll be about their insurance). I used to think that at least they were all living and breathing, but now I guess you can’t be sure of that, either.

© 2014 The New York Times Company

No comments: