In Search Of The Mythical

bull's eye

Photo: ogimogi

Mr. Sikes (not his real name) came to me complaining of swelling of his ankles (worse as the day wore on), shortness of breath climbing half a flight of stairs, and sudden awakening in the middle of the night from shortness of breath that resolved after several minutes of sitting upright.  I didn’t even need to examine him to know he’d developed congestive heart failure.  Later that week, an echocardiogram confirmed moderate systolic dysfunction.  Because 75% of all congestive heart failure is caused by coronary artery disease, I told him I wanted to send him to a cardiologist, who I expected would perform a cardiac catheterization to determine if and where he had coronary blockages.

He readily agreed.  “Who’s the best heart man you know?” he asked me.

I paused as I always do before answering that particular question, not because I’d failed to understand why he’d asked it (we were discussing his most precious asset—his health—and he wanted to place it in the hands of the single most outstanding doctor possible).  Rather, I paused because no such doctor existed.

HOW DO PEOPLE TRY TO FIND THE BEST?

People try to find the best mostly the same way my patient did, by relying on the opinions of others.  We tend to give far greater weight to the opinions of others than to our own, not just because others may have specialized knowledge or experience we lack, but because we have immediate knowledge of the imperfections that mar our own judgment and a willful ignorance of the imperfections that mar the judgment of others.  Unfortunately, this approach is flawed for several reasons:

  1. People mostly give advice based on their personal experience.  Which, by definition, is anecdotal and therefore a poor data set with which to predict good quality service in the future.  Maybe the doctor they’re recommending to you was having a particularly good day when they saw them, or just happened to know a lot about their particular problem, or found their diagnosis by chance.
  2. People often make recommendations based on the wrong criteria.  Many people, for example, recommend doctors (probably primary care doctors more than specialists) based on their bedside manner.  Not that this isn’t important, but what about diagnostic acumen?  Ability to reason well?  Organizational and follow-up skills?  Ability to explain things clearly?  Availability?  Knowledge of the medical literature and the most recent advances?

The problem in identifying quality is that objective measures of excellence are often unavailable or inadequate.  And in many areas, objective measures don’t apply.  How do you identify, for example, the “best” artist or writer?  Is it Rembrandt or Velazquez?  Hemingway or Tolstoy (or Lickerman)?  Areas in which quantitative outcomes are measurable may make it possible to identify the best—we know, for example, who the fastest sprinter is, the strongest weight lifter, and even perhaps the best chess player because we’ve seen them run faster, lift more weight, and beat everyone they’ve played—but in every day life when we want to find the best service, these kinds of measurable outcomes are rarely available.

WHAT DOES FINDING THE BEST GET YOU?

In almost all cases, the idea that we’ve found the best is a story we tell ourselves in order to become convinced we’ve literally done everything possible to get the help we need.  But even just believing we’ve found the best presents several risks:

  1. The “pedestal effect.” When we’re dealing with someone or something we think is the best, we often convince ourselves they can do no wrong and substitute their judgment entirely for ours.  Further, the temptation to hand over full responsibility for the outcome to them is overwhelming, often leading to our…
  2. …having unrealistic expectations for interactions, results, and outcomes.  Even if the “best” existed, finding him or her would guarantee nothing.  And that’s what we’re really seeking when we ask for the best:  a guarantee.  But guarantees are for Ginsu knives and children.
  3. Abstracting a person into a thing.  Mostly people abstract others in order to dehumanize them, as I discussed in an earlier post, The True Cause Of Cruelty.  But we can abstract someone into something positive when it suits us as well—something from which we then expect a flawless performance.  But the best isn’t perfect, no matter how much we want it to be.

Though we may want perfect when we ask for the best, what we really need is good enough.  Good enough to diagnose our shoulder pain.  Good enough to win our lawsuit.  Good enough to stimulate our child to learn and have fun while doing it.

HOW TO FIND GOOD ENOUGH

Though “good enough” may imply mediocre, it actually means great.  What else would you call service that exactly meets your needs?  Here then are several suggestions for evaluating someone or something for greatness:

  1. Investigate yourself.  Unfortunately, in many arenas, little objective information of the right kind exists for us to do this well.  You may be able to find how many quadruple bypass operations Dr. X performs per year (experience has been shown to correlate to outcomes) but not how long on average his bypass patients live or even his rate of complications.  And as to how many of Dr. Y’s diabetic patients are on dialysis?  Forget it.  At least for now.
  2. Poll large numbers of people.  Again, difficult to do depending on the question you’re asking.  And though the herd is often willing to follow its leader off a cliff (thus proving itself wholly unreliable), there is something in the concept of collective wisdom—or at least, collective experience.  Technology sometimes comes to our aid in this respect.  The internet has numerous sites designed to offer collective experience in all sorts of areas.  But if you don’t trust them…
  3. Poll a selective group of people who have the best view and judgment of the person or thing in question.  The painful truth about rating doctors?  Only other doctors are really qualified—and even they’re not.  I don’t observe other doctors interacting with patients, listening to them think out loud about cases, operating on gallbladders or hearts (even if I did, I’m not qualified even to know if they’re doing the operation in the right order, much less with enough finesse to minimize blood loss).  If I’d had a negative experience with a cardiologist that seemed to hide a real flaw—like laziness, incompetence, or indifference—that feedback would have had real value to Mr. Sikes.  But other than that, I’d only be relying on my anecdotal experience to make a recommendation (arguably better than his—but not by much).
  4. Trust your intuition.  Once you’ve taken objective data-gathering as far as you can, including in-person interviews if possible, listen to what your instinct tells you, especially if it contradicts someone else’s opinion.  Unless someone else really does have superior judgment in a particular area due to training or experience, never trust another’s judgment over your own.

What makes a doctor, lawyer, nanny, real estate broker, or daycare great?  We can probably figure that out if we spend the time and avoid trusting unreliable processes, criteria, and sources, but in the end all we have to gain is an increased likelihood that the service we’ll get will meet our needs.  This is immensely valuable, make no mistake.  But expecting anything more than an improved probability of a good outcome is just wishful thinking.

WHAT DOES BEING THE BEST GET YOU?

What about striving to be the best yourself?  While fixing such a goal firmly in your mind may sustain you through the difficulty of becoming a master in your chosen field (think of Olympic athletes), being dissatisfied with anything less will not serve you well.  Being the best (compared to being great) would seem to necessitate (though arguably not always) that you have as your goal that all others be inferior.  That particular goal comes from the Buddhist world of Anger, usually arising out of feelings of insecurity.  If you need to be considered the best in order to prop up your self-esteem, your self-esteem will remain in constant risk of collapse.  After all, who’s to say even if you could objectively measure and prove yourself the best today that you’ll remain the best tomorrow?

No matter how good a doctor you may be, some patients will leave you for someone they perceive to be better.  No matter how good a writer or artist you may be, some people will think your stuff is terrible.  Nothing and no one can be all things to all people.  Ever.

Striving to be the best risks constant personal dissatisfaction, arrogance, and difficult interpersonal relationships.  Though it may be hackneyed, it remains true:  striving to be your best—to compete only against your yesterday’s self—is a far better goal, a far more attainable goal.  Remember that perfect is indeed the enemy of good.

Next WeekHow To Decide What Risks Are Worth Taking

14 comments to In Search Of The Mythical Best

  • Lisa

    Thank you for reassuring those of us who need reassurance about how the “best” for/to you is not always the “best” for someone else. Thank you for reminding us to be our own “best friend” and do our homework. And as you said, we need to listen to and trust our own intuition.

    Lisa

  • Tony LaPorta

    Trust your intuition.

    I like to call it “gut instinct.” Listening to your gut. My best friend Geoff Gardner turned 50 on August 15, 2007. Shortly after his birthday he had a colonoscopy and prostate check. They told him at the clinic in Winona, Minnesota the polyps on his colon were cancerous. If he had come in before his 50th birthday, they would have found nothing. In October 2007 he had outpatient surgery. The polyps were removed…life is good.

    As they do here in Minnesota, his results were sent to the Mayo Clinic in Rochester, Minnesota. He was called in and after further testing it was recommended he have about a foot of colon removed as a precaution.

    Geoff was in decent shape, but very overweight. His wife, mother, brothers and sisters thought he should have the surgery. We talked extensively about it. He did not want to do it. He did not listen to his gut.

    Geoff had the surgery on December 4, 2007. On December 7, 2007 he died is his sleep. On January 15, 2008 a letter addressed to Geoff from his doctor at the Mayo Clinic was delivered to his home. Geoff’s widow Julie opened the letter. Geoff’s doctor was writing to see how his recovery was going. This is the “Mayo Clinic” sports fans. Even the supposed best get it wrong.

    Julie delivered the letter to her lawyer. There is still a lawsuit pending. Geoff left a wife and four young children. The baby is now in 4th grade.

    The point of my writing…TRUST YOUR GUT in ALL the decisions you make in your life, be they medical or not.

  • Patricia DiMartino

    My husband was diagnosed with esophageal cancer at the age of 47. Since we believed he was ultimately facing an esophagectomy, we opted to receive his chemo and radiation in Milwaukee rather than in Rhinelander, our closest town that offered such oncology services.

    The doc at Froederdt was supposedly “the best.” Turned out he was way too busy to ever establish a relationship with Dave, as was the radiologist. We always felt we were infringing on their time, and apparently we were. The doc told Dave over the phone that his cancer had metastasized and he couldn’t do anything for him so there was no need to return to Milwaukee. The news, and the way it was delivered, was devastating.

    Back in Rhinelander, Dr. Patel, Dave’s new oncologist, was compassionate and open to our questions and exploring our fears. Dave died a month after our first visit with this caring individual but it gave us peace of mind to know that although we might not have had “the best,” we had someone really good in all the ways that mattered.

    Patricia: Stories like this make me cringe. That a doctor would ever feel comfortable delivering the news he did to you and your husband over the phone simply exemplifies the worst our medical system has to offer. As I wrote in an earlier post, Delivering Bad News, the way families receive bad news stays with them the rest of their lives. My condolences on your loss.

    Alex

  • This is an invaluable post.

    Too often we rush through our day and don’t take time to listen to our inner voice. I posted a blog last summer about healing and intuition with respect to traditional aboriginal healers (Medicine man). I think the same principles apply when seeking treatment in both instance.

    Angelina: Thanks for the link to your post and the link within the link. Both were interesting.

    Alex

  • The danger of always striving towards our best is that it almost inherently induces feelings of dissatisfaction as to what has been accomplished thus far. One doesn’t want to strive towards the gutter, but that’s a tough balance.

  • Vasavi

    Alex,

    Very thought-provoking blog.

    In the area of seeking medical support I have found a couple of things that have worked for me: 1) telling myself that if the person I am reaching out to is not helping then I have the freedom to find someone else, rather than give up the quest, and 2) become an active participant in my journey of health, asking questions, educating myself and sincerely listening and following the doctor’s advice.

    As a result I have seen that each medical professional that I have gone to has guided me in the right direction and has been very supportive.

    And as you correctly pointed out, striving to become a better “me” is the best thing.

    thanks,
    Vasavi

  • Then again, did you not give him your “best” recommendation for treatment? Is it not a figure of speech, in a way?

    Josh: Good point. How many patients who want to make sure they’re being referred to the “best” are speaking figuratively I don’t actually know. In general, from the tone I personally tend to hear, most seem to mean it quite literally. I’m sure you’re right though that by “best” many people actually mean “really good.”

    Alex

  • winterborn

    The Nirvana fallacy. Excellent post.

  • Janet

    A great post. At first I wasn’t sure what I thought about: “Remember that perfect is indeed the enemy of good,” but I have to agree with it, especially given some friends of mine. The post reminded me of an interesting discussion I lately read on “The Ideal Relationship”: What Is The Ideal Relationship?

  • Thought provoking as usual. I agree that trying to be the best in relation to others isn’t an ideal goal. But trying to be the best that you can be is surely a worthwhile one? If you aim high you might fall short, but if you aim low you’re unlikely to overshoot.

    Julien: Well said.

    Alex

  • Julia

    That may be so, Alex, but I still think this is the best blog I’ve read. ;)
    Thanks.

    Julia: :)

    Alex

  • Glenn

    Alex,
    Although only a fairly recent subscriber, I have come to look forward to your posts. Thank you. And although I enjoyed and largely agree with this one, I hope you’ll allow me to quibble a bit about one statement, that is that “good enough…actually means great.” I think that for most people, the connotation of “good enough” really does suggest mediocrity. And to suggest that “good enough” means something else is to redefine the term in a non-standard way and that kind of practice just leads to confusion. If you’ll permit me to suggest a different approach, I offer that what we should be looking for in the context we just were grappling with is “right measurement,” that is, given that true perfection is probably unobtainable, we should strive to determine, in each circumstance, what the appropriate measure should be, i.e., something along a continuum from excellence to good enough. Said in a less dense way: although it’s true that perfect is the enemy of the good, it’s also true that good enough is the enemy of excellence. In that scheme of things, what’s “best” is situationally determined. We want an excellent pilot to land the plane at night in a snow storm; but if I’m weeding the garden and pressed for time, maybe quick-and-dirty is good enough. Which is kinda where you landed too, I think. Thanks for the opportunity to rant about “good enough.”

    Glenn: I think you’re right, that I redefined “good enough” sloppily enough to create confusion. I like the ideas you put forth here much more. Thanks for pointing out my thought error.

    Alex

  • Goodness in the blogosphere : What My World’s Like

    [...] In search of the mythical “best” [...]

  • Jane

    Great post. I would like to add: if you want a good physician, ask a good nurse her/his opinion.

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