One of the most pressing challenges in any medical system, and certainly ours in the United States, is finding who does the best job for any particular medical challenge.

The need for help from the medical world can be described as splitting into two major categories:  the need for a trusting, effective relationship with a guide who can help across a wide variety of challenges, and the need for a person who can perform a procedure well and successfully.

The approach to finding the right person for a trusting, effective relationship that can deliver guidance across a very wide range of medical needs is very difficult to measure, and there are few reports on how people  compare in this realm of medical care.

When it comes to judging how procedures are performed, there are emerging a large number of rating reports.

This is not a trivial challenge.  Certainly for minor procedures the challenge is less important, but for major procedures there are often large differences in the chance of surviving without complication, what could be more important?

Perhaps the dominant rating report available to the public comes from a magazine, US News & World Report (USNWR).   USNWR is not a medical journal, but a curious alliance has sprung up across the country.   The alliance is amongst major medical centers, we the public, and USNWR. Three needs bring these three parties to alliance.  For medical centers, there is the need to announce they really are the best place for medical care, for we the public there is the need to find out who does a good job (or better yet, the best job), and for USNWR there is the need to sell magazines.  

So, if USNWR can report that a large number of medical centers are the “best,” at least in some way, then banners proclaiming they made the list of best is USNWR can appear on their streets.  This satisfies the need of medical centers to announce they should be the preferred place people go for care.   We the public see a banner on the medical center we use and are reassured we are at the best place.  And everyone looks to USNWR as the definitive judge of who is best, selling lots of magazines.

There are two major flaws with the USNWR reports.  One is that so many medical centers get at least some listing that there are precious few medical centers of any size that can’t sport a USNWR banner proclaiming they are the best.  As we all know, however, not everyone can be the best.

The second major flaw is that the ratings in USNWR are based on votes of peers.  This approach has its value, but ultimately, what I want to know when I have a serious disease, is outcome.  I want to know, will I have a better outcome at medical center A or medical center B.  USNWR uses four criteria to pick who is the best:  reputation, chance of survival, patient safety, other care-related indicators.  These are each important indicators of quality, but they avoid the most important, and always the most elusive indicator- not just will one live, but how will the overall outcome be?  Will one survive with excellent health, or impairments, for example.

Beyond that, however, lurks a more important problem with rating institutions.   I know of no serious medical condition that is really treated by an institution.  Yes, all manner of medical conditions are treated at institutions, and by teams at institutions, but in my experience, the real differences are seen by the level of expertise and success of outstanding individuals.  

I have seen, countless times, that there are very real differences in outcomes, especially for very complex challenges, that are entirely the result of exactly which doctor is doing the care.  The name of the medical center is nearly irrelevant to this consideration.

What this means is that in a particular instance, it turns out the best person to achieve success in a serious medical challenge is at a medical center that may not be #1 when it comes to institutional ratings.

Sadly, it turns out to be very, very hard to discover who really does excel in especially complex procedures.  The American medical system is unfortunately very secretive and misleading on this point.  Most medical centers promote their staff, and like to blur distinctions.  But recently, a new approach to finding particular and specific doctors of excellence, it has to do with families, not publications.   Families are beginning to report their actual experiences and outcomes in social media networks, and for the first time in American medical history, we are getting the first glimmerings of an understanding of who really excels, again in very complex medical challenges.

A word on that last point.   As a medical procedure gets simpler, the range of ability narrows, that is there is less and less difference between doctors.  At the simplest levels, it really doesn’t matter who does the procedure, nearly every doctor of basic competence does it about equally well, with outstanding outcomes for nearly everyone.   So, for example, placing tubes in the ears for ear infections is an extremely simple procedure, I know of no difference in outcome amongst a wide range of pediatric ENT surgeons for this simple procedure.

Thankfully, the vast, vast majority of procedures children may require fall into this category, and thus it makes little difference whether any of  the major medical centers in NE Ohio perform the procedure, the outcome will nearly always be excellent at all of them.

But, now and then, very rarely, a problem comes along that is very complex, and it may turn out only a handful, or even just one doctor in the country actually has the expertise and ability to deliver a successful outcome reliably.   This is where my concern with publication-based ratings of quality sits, since their methods cannot tell us who that doctor is.

We at Advanced Pediatrics have spent many years listening carefully to families, observing outcomes, speaking to experts around the country.  We have tried in each instance when a rare and complex condition presents, to keep our focus on the child.  And, to that end, look nationally to determine which doctor(s) can actually deliver the expertise and outcome that put them ahead of the rest.

A last comment on judging the quality of the relationship-based medical care.  How does one determine who can deliver, not specific procedures, but good guidance across a wide range of medical challenges, across many years?  Who will be there when you need them, who can be relied upon to give good, well-thought out advice on approaches to complex, and simple, challenges?

As noted above, I know of no methodology that can reliably report on such important distinctions amongst doctors who provide general medical care.

That leaves all of us, I would advise, to keeping our eyes open and judging for ourselves.  Does your doctor respond to your concerns, deliver good guidance across a wide range of issues?  At this point, each of our own experiences are the best guide for this search for high quality medical care.

I hope these comments are of interest, and better yet, of some help.

We wish everyone much health and happiness.

Dr. Lavin

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