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
