In Search Of The Mythical \'Best\'

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.