The Best Doctors in the Universe

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What do nebulous "top doctor" rankings actually mean, and actually say?

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Finding a physician often involves a daunting array of choices. It can be a difficult proposition, and as patients have increasingly begun turning to ratings of physicians, a number of organizations and mainstream media threads have sprung up to address the demand. Some physicians are rated as "top" or "best," and others are not. Yet many of these nebulous ratings are not as reliable as readers may suppose. Even those of us who have received such designations harbor doubts about not only their accuracy, but the appropriateness of their existence.

Travelers who have thumbed through airline magazines over the years are undoubtedly familiar with the many advertisements for products and services ranging from matchmakers to steak houses to negotiation seminars that adorn their pages. Many of these ads purport to rank and highlight the best such products and services available. More recently, a new player has emerged on this stage and is assuming an increasingly prominent role -- ratings of "best doctors."

One such series of ads bears the imposing title, "These doctors are among the best in America." Occupying a full page, they generally feature a photograph of a well-groomed physician sporting a perfectly pressed, monogrammed white coat or tailored suit, and holding a pen, a medical chart, or even an anatomic model. Each photo conveys the impression that the doctor is about to make an important point, and each doctor's smile exudes a potent combination of amiability and confidence.

If magazines tell us what we want to hear -- namely, that we are the best -- most of us are disinclined to put up much of a fight.

In smaller font are explanatory notes, such as, "Each doctor has been peer-nominated and selected by the nation's leading providers of information on top doctors." Along the right side of the page are listed six or so top doctors, including contact information and the source for their "best" rating. These sources include locally-oriented publications such as Atlanta Magazine, Connecticut Magazine, and New York Magazine, as well as various ratings agencies, such as "Castle Connolly - America's Top Doctors."

A variety of medical disciplines are represented in these ads, including plastic surgery, facial plastic surgery, spine surgery, hair transplantation, and infertility treatment. Others include Lasik surgery, orthopedic surgery, sports medicine, hand surgery, and cardiology. Some best doctors are drawn from non-medical fields, such as cosmetic dentistry. The ads also provide evidence of peer review: "All best doctors are board certified."

The increasing prominence of these promotions raises a number of questions. Who produces such ads? What are they attempting to accomplish? On what basis do they include some practitioners while omitting others? And perhaps most importantly, what are ordinary readers to make of such promotions? The answers to these questions offer insights into the current state of the health professions in our society.

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There once was a time when advertising by doctors and other health professionals was severely frowned upon. For doctors to advertise their services in broadcast or print media was regarded as a breach of professional ethics, seemingly putting trusted, skilled health professionals on par with car salesmen and plumbers. Any physician who resorted to advertising risked professional ostracism and even censure by the county or state medical society.

But times have definitely changed. First to embrace advertising were professions such as law. Today it is nearly impossible to drive around a large city or watch late-night television without encountering images of attorneys urging financially distressed viewers to consider bankruptcy or asking potential clients, "Have you been injured in an accident?" Such ads often project a quite adversarial outlook, encouraging the distraught, injured, and aggrieved to "show them you mean business."

Although professions such as law have performed the lion share of the work in breaking down public resistance to such practices, the profession of medicine has been quick to appropriate them to itself. Medicine's rapid embrace of marketing was predictable, in part because physicians in many fields compete with one another for patients, and effective advertising can provide featured practitioners a leg up on their competitors.

It is notable that many of the specialties represented in such ads are procedurally based. Surgeons are especially prominent, as are internal medicine specialists who tend to devote a significant amount of time to endovascular and endoscopic procedures. Partly as a result, at least in our current system of health care financing, featured physicians tend to be practicing in high-income fields. I have yet to see such an ad for general pediatricians.

The fact that these ads provide little or no information about each doctors' array of services seems to suggest that they are not intended to generate demand for any particular healthcare service. This conclusion is buttressed by the omission of patient testimonials. They do, however, aim to elevate the name and face recognition of featured physicians, implying that patients who need such services should settle for nothing less than a best doctor.

But finally, I could only admit that she was right. Exactly what is the point?

Do doctors pay, directly or indirectly, to be featured in such promotions? For some years, I have been ranked as a top doctor in local and national listings, though I have yet to come across my face in an airline magazine. I have received repeated solicitations to "update my information" on various ratings websites, notes of congratulations on my selection, and offers to purchase expensive commemorative plaques and the like. I have never paid a penny, but other physicians may leap at these opportunities.

Yet business is not the whole story. These ads also make powerful appeals to ego and pride. To be featured in this way probably makes some physicians proud. Being singled out suggests that we provide high-quality care, and some patients may assume that we are superior to colleagues who are not mentioned. Even physicians who feel initially disinclined to participate may fear that by not submitting our information we would undermine our standing among patients and colleagues.

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Physicians who long to be counted among the best probably have something else in mind as well, whether we have ever admitted it to ourselves or not. Many physicians suffer from a need for recognition, feeling that we are chronically under-recognized and under-appreciated. Beholding our names on a best-doctors list provides at least temporary relief from nagging self-doubt, boosting self-confidence and professional pride.

If magazines tell us what we want to hear -- namely, that we are the best -- most of us are disinclined to put up much of a fight. If they choose to make such proclamations in forums frequented by patients and colleagues, so much the better. In a world where tycoons, sports figures, and beautiful people are routinely singled out as the best, who could blame hardworking doctors for wanting a piece of the action?

Interestingly, even the ratings services themselves seem to operate under the same reputational imperatives. Some "top doctor" ads feature ratings of the rating services themselves. One, for example, singles out Castle Connolly as "the nation's leading provider of information on top doctors." The top doctors and the ratings services appear to be entwined in a symbiotic relationship, each promoting the other's reputation and business prospects.

Yet how seriously do doctors themselves, who are best equipped to evaluate the level of their colleagues' excellence, take such ratings? In my own case and that of many colleagues with whom I have spoken, the answer, surprisingly, is not so much. For each physician featured in such advertisements, many of us can name at least three local colleagues whose expertise we regard at least as highly. Moreover, I am honestly not sure that I am one of America's best doctors.

Admittedly, I was well trained, I have been practicing medicine for some time, and I try to care for patients as I hope a colleague would care for one of my loved ones. Yet am I really among the very best, or merely someone whose professional dossier happens to score well with different ratings algorithms? Perhaps I have a few more publications or grants than some colleagues, but this does not establish that I would do a better job in caring for any particular patient.

Recently my wife and I were seated in tandem on a long plane flight. Having exhausted my reading material and finding no film or television program to my liking, I picked up the airline magazine and started thumbing through it. My eyes alighted on a "best doctors" ad, reminding me of something. I turned to my wife and proclaimed that just the day before, I had learned of my inclusion on another such list. How did she feel being married to one of America's best doctors?

Her jaw did not drop. She did not beam with pride. She did not even offer a word of congratulation. Instead, with a look one might direct at a small child just beginning to succeed at toilet training, she answered my declaration with a question, "And your point is?" I struggled for a full minute, attempting to formulate a witty comeback. But finally, I could only admit that she was right. Exactly what is the point?

The real point is this: the science on which medical practice is based and the actual work of caring for individual patients are simply too complex and multi-faceted to permit any simple rating of "best doctors." Health systems, hospitals, and even some physicians may embrace such ratings, but they oversimplify and distort at least as much as they clarify. Too many really fine physicians are not included, and some of those featured are there for the wrong reasons.

Patients sizing up a physician would be ill-advised to base their assessment on billboards, television commercials, and airline magazine advertisements. The truly best physicians are often not the ones whose visages grace these promotions. In many cases, such physicians are too unpretentious, too secure in their own professional capabilities, and too busy actually caring for their patients to devote the time and energy necessary to participate in marketing programs for "best doctors."

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Richard Gunderman, MD, PhD, is a correspondent for The Atlantic. He is a professor of radiology, pediatrics, medical education, philosophy, liberal arts, and philanthropy, and vice-chair of the Radiology Department, at Indiana University. Gunderman's most recent book is X-Ray Vision.

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