What Makes A Good Doctor?


Before you can achieve something, you have to know what it is that you are trying to achieve. Thats pretty easy when it comes to some things. For example, a good running back runs for a lot of yards and scores a lot of touchdowns. A good cook creates food that people like to eat. A good salesman produces the most profits for his company. But what is it that a good doctor does to be considered good?

My goal is to be a good doctor but I am not sure what this entails. I was once told that patients judge doctors on the 3 A's (in order of importance): Availability, Affability, and Ability. The emphasis here is that no matter how good you are, being nice and being there are what matter most. The alternative viewpoint is that results are what matter. A good doctor is a doctor that can cure you of whatever ails you. If he or she is nice, so much the better, but this certainly doesn't come into the equation of defining a doctor's quality. Both of these measures of a doctor's quality are from the patient standpoint. If you ask doctors who they consider to be good doctors, they will envariably point to a physician with impeccable credentials, the most publications, the best diagnostic skills, or someone who generates the most profit for the hospital. In short, physicians judge other physicians not on character or medical results but on criteria that are often not even available to the public. Do you know where your doctor went for medical school, residency, or fellowship? Do you know which journals he or she has published in? In a cynical moment, one of my attendings once quipped that "You go into academic medicine if you want to be thought highly of by your fellow physicians and you go into private practice if you want to be thought highly of by your patients. " Maybe there is some truth to that.

In Doctor, Edward Rosenbaum, himself a physican, writes about his experience as a patient. He ends the book by commenting on what he thinks makes a good doctor: Ability and Integrity. In Dr. Rosenbaum's mind, those are the only two things that matter when deciding if a doctor is good. It sounds simple enough but an entire book can be, and was, written on what those two terms entail.


While I try to figure out what being a good doctor entails, I try to follow the following rules that were passed down to me from one of my attendings. Maybe this isn't the key to being a good doctor, but I hope these rules will at least keep me from being a bad doctor:

1) Be honest. At first glance this just means don't lie to others. But, it also means be honest to yourself -- know your limitations and when to ask for help. And finally, being honest means being reliable. If you say you're going to get something done, make sure it gets done.

2) Treat every patient as if they were family. This doesn't mean get emotionally tied to their case so that you can't make clear decisions. What this means is, pay as much attention to detail on each of your patients as you would if they were your family member, and advocate for each of your patients as if they were your loved ones.

3) Have fun. You can't do a good job unless you enjoy what you are doing.

Sounds pretty simple. Be honest, be considerate, and have fun. If it is really that easy why don't we have more good doctors?

NO VACANCY

Imagine that you booked a hotel room for $150/night and when you arrived at your room you found out that you would be sharing it with a complete stranger. You would each have your own bed of course, and the room even comes with a nice thin yellow curtain that can be used to partition the room in half. Both of you would share the same bathroom with the bonus option of requesting a portable commode so that you could conduct your business right at the bedside. Unfortunately, that nice yellow curtain isn't thick enough to block out smells or noises.

Am I the only person who would find such a situation unacceptable? And yet, these are the exact same conditions we subject our patients to when they are admitted to the hospital.

A shared double room is the norm and patients requesting a single room are frequently charged extra. Sometimes patients get lucky and land a single room without having to pay extra but this is usually only happens when the double rooms are all booked.

What's the problem with sharing a hospital room? How about the increased risk of hospital acquired infections? Frequently, patients with communicable diseases aren't identified when they first hit the door. Only later is it discovered that the patient has C. Diff (diarrhea), MRSA (skin infections), or some other super-bug that is resistant to many antibiotics. Being in the same room, sharing a common bathroom, having hospital personnel move back and forth between you and your roommate increases the risk that these infections continue to pass throughout the hospital. This is why once patients are identified with certain infections they are moved into single rooms. However, these isolation measures are frequently only implemented once the patient has interacted with multiple hospital staff and his/her roommate. If we really cared about stomping out hospital acquired infections, we would start by requiring all patients to be in single rooms. Unfortunately, these changes probably won't occur until a patient is afflicted with a hospital acquired infection and sues the hospital because he was placed in a room with someone that was also infected.

The counter argument hospitals will make is that there just aren't enough beds to make such a change feasible. Interesting when you consider that there is enough money to continually build more research buildings and operating rooms. We have enough money to spend billions on research infrastructure but don't have the millions required to insure that the patients don't get harmed by the very hospitals to which they go for help. Of course, building more research buildings, opening more operating suites, and buying more MRI machines increases the revenue of a hospital. Ensuring each patient gets his/her own room only hurts the bottom line.

Pity is a horrible feeling to have

I am currently on the solid oncology service (think lung cancer, breast cancer, colon cancer, etc... basically, anything other than leukemia and lymphoma). I recently took care of a lady that taught me how much my own preconceived notions affect my medical decision making.

When I first met Ms. M, she was clad in hospital garb -- she was barely covered in a faded, wrinkled hospital gown. A large central venous catheter, the size of a number two pencil, was attached to a vein in her neck and held in place by gauze and tape that were covered with dried blood. Her scalp was covered in some places with short, stubbly hair and was completely bald in other places. She was lying in bed staring off into space while the nurse fiddled with the catheter in her neck.

When I walked into the room and introduced myself she gave me a weak smile. She looked like she was about 60 years old. In fact, she was 40 years old. Just a few years ago, Ms. M had been diagnosed with breast cancer. Originally, the cancer was localized to just one breast. She underwent surgery and lived worry free for one year before the cancer returned. The recurrence was confined to the same breast. However, this time she underwent bilateral breast removal. She also underwent chemotherapy and radiation treatment. The worry free period this time around lasted just a few months and then the cancer returned. It had spread to her liver and bones. She was started on a very aggressive chemotherapy regimen. Her body was unable to withstand the side-effects but the tumors kept growing. Currently she is on her third different regimen of drugs. Despite all this, she has continued to live independently and is active at work and in her community.

She had been admitted to the hospital on Sunday after noticing dark blood in her stool and vomiting bright red blood. In the emergency department she had a very low blood pressure and was admitted the intensive care unit. The GI experts were consulted and she underwent an emergent endoscopy of her esophagus and stomach. This study was done to look for a source of the bleed. However, no source was found. Her blood pressure improved and her blood counts remained stable. She was transferred to the regular medicine floor after spending three days in the intensive care unit. This is when I walked in. I described her to the rest of my colleagues the next day as "An older than stated age female with past medical history significant for widely metastatic breast cancer who presented with a presumed upper gastrointestinal bleed and hypotension (low blood pressure)." Based on just my few first words the rest of my team had already formed a picture of this person. They knew, despite anything more I would say, where I was going with this. Our team decided that she had a very poor prognosis. We declined further workup of her bleeding. We focused on making her comfortable and getting her home as soon as possible.

She was discharged from the hospital today. I was about to leave the hospital when I remembered that I had forgotten to give her one last piece of information. I walked into her room and halted. There were two people in the room sitting comfortably in chairs chatting about where they planned to go tonight. I thought I must have walked into the wrong patient's room. Both of these ladies were very well dressed and appeared to be in their 30s. They were both beautiful. Just as I was about to apologize and excuse myself out of the room, I realized that the lady on the left looked very familiar. It was Ms. M. She was dressed in her normal clothes. She was wearing makeup. She was wearing a wig that made her appear to have long brown hair. The faded, wrinkled hospital gown lay on the bed. The lady that sat before me was a completely different woman. I stammered out what I had come to say. We made small talk and then I left. As I walked away from the room I was gripped with doubt. This lady looked great. Maybe we should have kept her in the hospital and figured out why she was bleeding. We should have been more active in our search. She had told me she was active at home and at work but I hadn't really believed it until I saw her sitting there with her friend.

Did the fact that she could cover her head with a wig and make herself look young mean she had any better of a prognosis? Probably not. Did we do anything wrong? Hopefully not. But, would my workup have been different if I had seen the younger looking, well groomed, and seemingly healthier Ms. M the first day? Almost certainly. Ms. M will follow up with her primary oncologist next week. He is one of the better doctors at our hospital and knows her well. I hope I am not just passing the buck.

I can't help but feel guilty about this case even though I don't think we did anything wrong. Ms. M was presented with the options and she agreed with the team that most of the workup could be deferred or done as an outpatient. Why then do I feel that I short-shrifted her? I think I feel guilty because of my own initial feelings of pity. I presumed that his frail looking, sickly woman had little to look forward to. I couldn't have been further from the truth.

Patient Empowerment: A Case Study

Nirali Naik is a young girl with leukemia (ALL). ALL responds well to bone-marrow transplant but because she is Indian it was unlikely that she would find a matching donor in the national bone-marrow registry. Her parents became proactive and coordinated bone marrow screenings for Indian Americans across the US. They also set up a website that updated everyone on their daughter's condition. Take a look at their website and spend some time reading the section Updates about Nirali to get a better idea about what this family has gone through.

Donald Berwick, the president and CEO of the Institute for Healthcare Improvement and once called the third most important person in American healthcare, gave a speech in 2002 titled "Plenty." He emphasized the importance of focusing on the abundance of resources that patients and physicians have at their disposal, namely the patients and their families!

"Patients and families bring to us their expertise, their commitment to themselves, their love of each other, their houses, their gardens, their hobbies, and most of all their innate, natural capacities to heal. Nature has spent 3.8 billion year of R&D developing biological healing capacity, and it walks into our doors -- free, for nothing -- wanting to help get done what we are trying to get done -- survival, healing. The selfish gene wants to work for us."

I believe that the Naik family is what Dr. Berwick has in mind. If we can get patients and families to be as involved and educated about their health as this family has been, I believe we gain a tremendous ally in our fight to better healthcare. If you would like to read more by Dr. Donald Berwick, pick up his book Escape Fire: Designs for the Future of Health Care.

Are You Racist?

Project Implicit: http://implicit.harvard.edu

What biases do you have?

The July Phenomenon

Hippocrates implored physicians to "First do no harm," and yet in the process of learning how to practice medicine, I wonder how much harm I've already done.

Medical education is one of only a few instances in health care (the others being medical research and control of communicable diseases) when the interests of the individual are sometimes superseded by the interests of society. However, unlike with medical research where the risks and benefits are plainly laid out for patients, medical education leaves no room for full disclosure. The "See one, Do one, Teach one" mentality is common amongst physicians but I wonder how many patients know that such a system (however unofficial) exists.

The first issue is whether or not there is risk associated with having relative novices "practice" medicine on patients. New housestaff start their training in July and the bump in complications during July is euphemistically referred to as the July Phenomenon. Hypothetically, new trainees are more closely supervised to ensure that there is no harm to the patient. However, in my personal experience, this oversight is oftentimes shoddy and inadequate. A recent study examined how comfortable medicine trainees were with their own competence in performing various procedures. The results showed widespread discomfort with performing most of these procedures. More simply, ask yourself how good you were when you first did something that required even an iota of physical skill -- hitting a baseball, catching a Frisbee, painting a picture -- and then think about how your ability improved as you gained experience. Common sense tells us that the more experience we gain, the better we do.

If there is even a slight chance that patients are at higher risk by having new trainees perform procedures on them, shouldn't they have the right to know? However, most physicians argue that patients that come to a teaching hospital are aware that they will have trainees work on them. Unfortunately, this is far from the truth. Up to 60% of patients presenting to teaching hospitals were unaware that they could have procedures done on them by physicians that had never done the procedure before. Clearly, there is chance of increased risk with novices performing invasive procedures and this risk is not clearly explained to patients. Just as we do with experimental drugs and new procedures, I believe INFORMED consent has to be obtained whenever patients are exposed to physicians in training.

Wouldn't this proposal hurt our great medical education system? Who would want to be the guinea pig? I would like to believe that full disclosure would not hurt medical education. Just as we continue to lead the world in the development of new drugs and innovative procedures (that were all once tested on volunteers), I believe we will continue to have a great medical education system. How can I know this for sure? Consider the following two facts:
1) The same study which showed that up to 60% of patients were unaware that they would have trainees practice on them also found that about half of those very same patients would still undergo the procedure even if it was the first time the physician was performing the procedure.
2) Teaching hospitals as a whole usually have lower mortality and morbidity rates compared to non-teaching hospitals. This is usually attributable to the fact that these hospitals have higher patient volumes. In contrast to the individual rookie physician who might not be great at performing any given procedure, the combined expertise of a large teaching hospital provides a great safety net that results in very good patient outcomes. Also, as physicians in training start doing procedures they become competent very quickly. The key is to make sure that they don't hurt anyone in the time it takes them to become competent.

Going through medical school and currently being a resident makes me a pretty informed consumer on where to get my health care. As a patient, I have never had any qualms about going to teaching hospitals. However, I make this choice after knowing all the facts. I just wish my patients knew all the facts.

Economic Incentives and Weight Loss

We have several pills to control blood pressure, decrease cholesterol levels, and fight type II diabetes, but what about a pill that makes people take responsibility for their own health?

Two thirds of Americans are overweight and close to one third are obese ( Prevalence and trends in obesity among US adults, 1999-2000. JAMA 2002) . "For the first time in human history, the numbers of overweight and underweight individuals are about the same, at 2.1 billion each." To emphasize how uncontrollable the obesity epidemic has gotten, consider that there are starving people in Sub-Saharan Africa while in the US we have competitions (The Biggest Loser) about weight loss!

High blood pressure, high cholesterol levels, diabetes, several types of cancer, joint disorders, and complications after surgery have all been shown to be affected by weight. Simply put, the more you weigh, the more complicated your medical course, and subsequently the more your medical care costs to yourself and to society (Medicaid spending for obesity related health problems has soared over the last 20 years)! Obesity related health care costs have risen dramatically over the last 20-30 years and medicine's only response has been to encourage better eating and more exercise -- something that Dr. PD White emphasized in the 1950s! Obviously our emphasis on better lifestyle is falling on deaf ears! Not surprisingly, when we are competing against the marketing budgets of Coke and Pepsi, the explosion of all you can eat buffets, and the growing emphasis on fast food. Complicating this, healthy food (fresh fruit/vegetables) is increasingly more expensive. People eat unhealthy because the food tastes good and its cheap!

What happens if we make fast food more expensive and healthy food cheaper? You can offer individuals a break in insurance premium and tax benefits for losing weight or joining a gym (and demonstrating active membership). Small studies have shown that financial incentives to promote weight loss work in the short term (Effects of outcome-driven insurance reimbursement on short-term weight loss. International Journal of Obesity. 2003). My current insurance plan will pay half of my gym membership dues.

Another option would be to focus your efforts on the companies that are facilitating unhealthy eating habits. We can make fast food more expensive by taxing it and make healthy food cheaper by providing tax breaks to companies that supply healthy food. Studies have shown that as taxes for other unhealthy products (such as tobacco and alcohol) have increased, use of these products has decreased.

Of course, we would have to have a process to define unhealthy/healthy food. I think we can all agree that a Big Mac, large order of fries, and a large coke isn't the breakfast of champions.

Some of you will read this article and think that no matter how expensive we make unhealthy food, people will still eat it. I've seen Bradley, a friend of mine from high school, scarf down several Wendy burgers and milkshakes in one sitting and I doubt increasing the price will affect his desire to eat this food. Somehow he manages to retain his girlish figure despite his eating habits -- a testament to the importance of genes and exercise, but that is a topic for another day. My response: So what. Let them eat unhealthy. Let people be overweight. But at least this way they will be contributing to their own health-care costs. The taxes gotten from this program should go to fund local health-care infrastructure. Just as we tax tobacco we should tax unhealthy food and use this money to improve our health-care system.

Either this program works and the prevalence of obesity declines and health care costs decrease or this program doesn't work, obesity rates continue to increase, but we have a way to fund the increasing demand in health care. Either that or we get to work on a pill that makes people care about their health.

Fast Food Calorie Counter

PERFORMANCE

If you have some free time, read Autl Gawande's new book Better. Gawande's discussion of how to become a better doctor hits very close to home for me as both a patient and a physician.

Contrary to what most physicians would like to think, just graduating from medical school or even going through a well reputed residency/fellowship does not make a good doctor. In fact, medical outcomes for different physicians and hospitals vary widely (The Bell Curve). In one part of his book, Gawande discusses allowing patients to know how doctors perform on various performance criteria. For example, a few states keep public records on the complication rates of all cardiac surgeons. Also, the Cystic Fibrosis Foundation keeps very detailed records detailing how each cystic fibrosis center in the nation performs against the national average on several important criteria.

Many physicians fear that the creation of these criteria (that will be available for everyone to see) will create an incentive to direct care towards the criteria and not towards each individual patient. Physicians might order tests just to check off a box and get a better rating, instead of thinking about whether or not the patient really needs the test/intervention. In addition, physicians argue that no set of measures can truly gauge the competency of a physician. Diagnostic acumen, integrity, and compassion are all important traits in a physician that are hard (if not impossible) to measure. In summary, the main argument against performance measures is that they are incomplete and they force physicians to disregard individual variation.

However, this does not mean that this data is not useful. I'll be the first to acknowledge that medicine is complex enough that no single group of performance measure will truly capture a physician's full ability, or lack thereof. I know plenty of physicians/medical students that might do great on tests, know all the answers on rounds, and be able to spout the latest data from the most recent research, but that I wouldn't trust to treat me or my family. You want your doctor to be compassionate and have integrity. But you also want your doctor to be able to cure you of whatever is ailing you. None of these factors is easy to measure. So, how do we figure out if our doctor is good.

I believe that information about adherence to performance measures and mortality/morbidity data for each physician should be recorded and made public. The combination of both of these pieces of information will allow patients to make a more informed decision. For example, if a physician does not adhere to well established criteria and has below-average morbidity/mortality rates, I think his prospective patients have a right to know this information. Hopefully, as physicians see that they lag in both categories, they will be encouraged to make changes to improve their patient outcomes. This might mean adhering to established criteria or it might mean innovating and finding new ways to improve patient outcome. This database will allow identification of physicians that do not adhere to the performance measures but have great outcomes. The establishment of a database that combines both of these factors will allow both patients and physicians to see what these innovative physicians are doing and hopefully allow for innovation in patient care that is evidence based.

This data will make patients more informed consumers, but in the end patients will still have to judge based on individual experience whether or not the doctor they pick is the right doctor for them. You might go to the physician with the best record of adhering to performance measures and the best outcomes and find that he is a jerk. Or you may go to a physician with a great record and find that he only treats the rich and famous (his patients come to him healthy) and he isn't doing much for them. Currently, patients pick doctors based on word of mouth (either through what their family/friends recommend or what another doctor recommends/refers). Having some solid information to base important health decisions on can make patients more informed consumers and encourage better patient care.