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More Rambling in the Rankings: Hospitals
Blind Spots in US News & World Report's Hospital Rankings for 2023-24
One of my best friends gave me the following advice several years ago, when I was talking about buying some property in the Carpathian Mountains I thought would both be beautiful and was undervalued. He told me (and I’m paraphrasing here) that his grandfather had told him (this is thirdhand advice so you know it must be good) to only invest in a “sure thing” — only invest if you knew something nobody else did.
Given what I know of my friend and his family, I don’t think this was encouragement to do insider trading. I certainly didn’t take it that way. It meant, as I understood it, that before investing in an opportunity, one ought to weigh the variables one knows, assess the risks in detail, and then decide whether the value of the thing is fair or better before putting money into it.
I didn’t end up buying property in the West of Ukraine in 2018, though I wish I had (and would still like to when I have money to throw around — that’s the retirement dream). I did “know something,” but I didn’t have the money on hand to make anything of the information.
We’re looking at college rankings and rankings in general now because they’re newsworthy, but also, one’s time and benefits are an investment. Rankings propose to give people a free and easy means by which to evaluate a place to invest. As it turns out, we know that at least some of the rankings (the best colleges for veterans) are flawed. Well, what about the rankings of other institutions? What about USNWR’s hospital rankings?
Tomorrow, we’ll take a look at how the VA ranks its medical centers — which will depend in part on understanding more about how USNWR ranks hospitals, today’s focus. Read on!
THE BIG STORY
More Rambling through the Rankings: Hospitals
Blind Spots in US News & World Report's Hospital Rankings for 2023-2024
If you’ve spent any time in hospitals or VA Medical Centers — as a nurse, doctor, patient, or staff — you know it’s really difficult to get them right. There aren’t always enough people to provide the attention that badly wounded or distressed patients need to feel safe and cared for. Effectively and fairly evaluating hospitals — the buildings, the staff — is extremely hard, because it’s hard to separate out the emotions one feels around a particularly vulnerable moment in one’s life.
Modern hospitals are also usually sprawling things, difficult to navigate and logical only to the people who work in them year-round. Multiple elevators and levels, and parking isn’t where it should be, all mean ambulatory patients and the families of patients can spend 10 minutes wandering halls looking for the place they’re supposed to be.
My father was hurt earlier this year during a vacation in Portland, Maine. Getting hurt is never convenient, but it’s doubly inconvenient when you’re traveling. He was hospitalized, at the Maine Medical Center, and treated promptly and effectively. Three days later, we brought him back home.
Minus the part where my dad was injured, the experience at Maine Medical Center was exceptional. Care was good, the building was full of helpful staff, the nurses were accommodating, and the doctors, capable and professional. Many of the easy small things that can make an experience like that miserable were, instead, small sources of joy: valet parking was free. The commissary was extremely cheap, less than $2 for a coffee and tea. Food for dad was free. Parking was free. I needed a room for a meeting and one off the nurses put me into one that was open.
Maine Medical Center sees a lot of older out-of-town patients who get injured during vacations, so they have a protocol in place; the problems that might have been burdensome in another situation (insurance, most of all) were not problems there.
But this hospital, which is among the very best I’ve visited in the last 10 years (and I’ve visited many) is not considered among the best in the country. It is the top hospital in Portland — I believe, the only hospital in Portland — and the top hospital in Maine.

U.S. News and World Report rankings don’t always fully capture the full measure of a college — this is true of its rankings of hospitals, too. Photo by Adrian Bonenberger
Nurses and younger doctors often move around for their education and professional development, and can be a good source of useful information that depends on comparing different data points. So I spoke with some of the nurses, both to pass the time and also because I was so impressed with Maine Medical Center, I wanted to see if I was being objective about the place. Those that had worked in different hospitals agreed, this was a good place to work, they were happy here, and some of them were thinking about settling down in Portland, making lives in that small (population 68,000) New England city.
I have been in hospitals before, as a patient and as a communications worker on staff, and I can say without reservation that the camaraderie and energy I saw at Maine is rare — exceptional, even — in my experience.
That’s just one data point, and there are many other to consider, if one's developing a holistic vision of a hospital. How does US News and World Report rank hospitals? Well, it takes these rankings seriously, as they deal in reputations, and people make health care decisions partly due to what they think of a place (among other factors). So it is fairly transparent about what goes into them.
Nevertheless, when one looks at the overall methodology for hospital ranking, two massive blind spots emerge. First of all, the ratings depend a great deal on a hospital’s ability to perform a broad range of procedures well, which favors very large hospitals with big budgets. Secondly, the ratings depend on the opinion of “experts” (this is in the linked document) who are solicited formally for their esteem of various institutions.
Now, the way medical education works is this: medical schools are tied into teaching hospitals. And many (all?) of the top medical schools happen to depend on the highly ranked teaching hospitals and reputable VA Medical Centers to give M.D. students experience during their clinical rotations. One attends a top medical school, and spends significant time working at a hospital, first as an M.D., and then in a residency program, and later, often, in a fellowship. Finally, when one finishes one’s medical education and begins one’s practice, one is then asked for one’s opinion of the hospital in which one works, and the procedures that occur there, as well as others of which one thinks highly.
Consider: you’re a radiologist. Everyone who has ever graduated from your residency program thinks well of it; you write your M.D.s letters of recommendation to the best hospitals and fellowships, as your mentors did for you. They are likely to “rank” your specialty at your hospital — even if they work at another hospital. And the graduates of the top medical schools often go to work at top hospitals (or stay put at top hospitals, as those top hospitals are often the very places one has studied). And they end up disproportionately highly ranking their friends, mentors, and former classmates, giving the impression of a hospital that is a good place to receive treatment or a procedure even if that is not the case from the patient’s perspective.
When we say “rankings are subjective,” we often think “rankings reflect the preferences of individuals.” But subjectivity still assumes an essential good-faith assessment; one that may be influenced by privilege or prejudice, but which is sincerely given nevertheless.
What if college and hospital rankings ultimately reflect power and wealth — rather than quality? If that is the case, the rankings are not merely unuseful — they’re actively harmful, in the sense that they give students and patients a false impression of what to expect.
Portland is a five hour drive, but I’d consider making it if I had to undergo some serious procedure. I’ll take that a step further: I’d rather go to my Ukrainian dentist in Kyiv for serious dental procedures than any place here in the U.S. Ukraine is at war. It would mean planes, trains, and automobiles. If I needed a partial or full tooth reconstruction? Ukraine 100%, no question.
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