Beauty Contest or Cynical Marketing Scheme?

 

Beauty Contest or Cynical Marketing Plot?

Well this is the United States so it is a safe bet that the answer will be “cynical marketing plot”, but even then the beauty contest may not be an independent variable.  I just listened to a story on public radio today about how government contractors in Afghanistan basically had blank checks for the services they provided to American troops. We live in a land where the government basically stacks the deck in favor of corporations and there is no clearer example than the healthcare industry.

Today I received a letter in the mail that said

“Dear Dr. Dawson - we are pleased to include you among the Top Doctors to be featured as a Top Neurologist representing Circle Pines, MN.  We will be featuring you in our 2021 Top Doctor list which will appear both online in our nationally syndicated publications. Your expertise in Neurology and dedication to upholding the highest standards of patient care in the diagnosis and treatment of neurological disorders and diseases is something to be recognized. This four-color wall plaque is a beautiful addition to your wall of achievements. Signed, the Selection Committee”.

I was very skeptical of this letter from the outset for obvious reasons.  First, I am not a neurologist. Second, I do not live or work in Circle Pines, MN.  I considered reasons for the letter the most obvious one that it was simply an error. Sarcasm came to mind as I reflected on the many people over the years who told me I was too preoccupied with either neurology or medicine for a psychiatrist.  Was this a sarcastic joke based on that criticism?  Finally, I have encountered some people who think it is hilarious that you are assigned a job title in error. Was this an attempt to do that?  Finally - the marketing aspects.  I had received many solicitations to get listed in various Who's Who publications.  This was probably the medical version.  I have never been compelled to get a copy of Who's Who to find out who the prominent people are.  They are usually obvious - at least the ones that I am interested in.

I don’t know exactly when the “Top Doctors” lists started to appear. The past 15 years - I have received a mailing encouraging me to nominate certain doctors for this award. Lists are compiled by specialty and they don’t seem to change much every year. I glance at the list from time to time and agree with about 20% of the rankings. But in their defense, how should a “Top Doctor” be ranked? When I am personally looking for a “Top Doctor” for my own medical care or the care of my wife I am interested in what their results are. That applies to both medical and surgical care. That data is extremely hard if not impossible to find. Do the physicians doing the voting know these details? In some cases they might. I depend on my primary care physician and his experience with surgical referrals and the results that he sees from those referrals. In the case of nonsurgical care my speculation is that those results are more nebulous. In that case do the rankings have anything at all to do with outcomes or quality of care?

It reminds me of the type of rankings I got every year when I was an employee for a managed-care company. They could fluctuate 180 degrees from one year to the next because they were totally subjective.  One year I was ranked number one in documentation and coding according to subjective chart audits. The next year I was dead last even though nothing had changed in the interim. We also had an anonymous “360° evaluation” where other staff were encouraged to critique us and say just about anything they wanted whether it was relevant to work quality or not. The entire exercise lacked accountability and was demoralizing.  In my annual reviews I started to refer to it as “the beauty contest” reflecting its subjectivity and fickleness. My boss thought that I was joking - but I was not.

These political subjective ratings have a goal to elevate organizations that are run by business administrators while maintaining leverage over the physicians who work in them. There is no clearer example than driving through Anytown in the USA and noticing that they all have a top ranked hospital or medical clinic. There just are not that many top ranked hospitals and medical clinics in the country.   The “Top Doctors” list may be another one of these trends. Some of these lists tend to have many specialists from same clinic.

The beauty contest concept brings to mind Atul Gawande’s essay The Bell Curve from 2004.  He develops the premise that there is very little objective measurement of physician outcomes and even less disclosure. With that data it would be possible to construct a bell-shaped curve and find out where physicians are plotted against their peers. This would be an ideal route to find the Top Doctors list but he is more focused on what happens if you find out you are just average. In any statistical compilations people are bound to be average and even below average, but Gawande points out that settling for average is the problem and he even rolls in the idea of the beauty contest:

“And in certain matters - looks, money, tennis - we would do well to accept this.  But in your surgeon, your child’s pediatrician, your police department, your local high school? When the stakes are our lives and the lives of our children, we expect averageness to be resisted.”

Even though that essay was from 2004, the actual measurement of doctors remains elusive except for a very few instances. Gawande points out some of the reasons including what to measure, who is doing the measurement, what is all means, and what the implications are. He does not comment on the major extraneous factors that may shift the curve. In the last 30 years, the single largest factor is the business management of healthcare and the move away from substance – in particular quality – to advertising and fluff. There is probably no better example than my Top Doctors letter.

I want to be clear that the letter I got was all about signing up for a meaningless plaque to recognize me as the wrong doctor from the wrong specialty in order to get money. Are there other  doctors out there going along with this? Are there doctors who are purchasing meaningless plaques and putting their names on meaningless lists to enhance their resume? That is an investigation that I don’t have time for. This post is all about getting the message out that rankings and proclamations that doctors, hospitals, and clinics are “top rated” is not necessarily something you can hang your hat on.

Be very skeptical of ranking systems especially ones that are self-proclaimed - and try to get reliable information on what counts. With physicians that would include their outcomes, their thoroughness, and the relationship they are able to establish with their patients.  Gawande’s essay points out that relationship may not always be comfortable

Don’t get pulled into a beauty contest…..even though in today’s healthcare landscape they seem unavoidable.

 

George Dawson, MD, DFAPA

 

 

References:

Atul Gawande.  The Bell Curve.  The New Yorker.  November 28, 2004

Graphics Credit: 

Bathing Beauty Contest 1920.  National Photo Company Collection, Public domain, via Wikimedia Commons:  

https://upload.wikimedia.org/wikipedia/commons/0/01/11_women_and_a_little_girl_lined_up_for_bathing_beauty_contest_LCCN2001706323.jpg