Wednesday, November 21, 2012

Where can you find an excellent doctor?

Performance related pay?
People only talk about two types of doctor. The really bad ones, and the really good ones. I like to think there are a lot more of the really good ones around. Many of us have met doctors we really admire, either colleagues or patients. It can be hard to pin down, though, just what it is that makes a really good doctor, especially one who is consistently good. Is it just a matter of personal opinion? Or if you recommend a really excellent doctor to me, can I be confident that we'll agree?

Interestingly, a team in Toronto have done just this to try and find out more about what was considered excellence in doctors. They asked doctors in their academic medical centre who they considered to be excellent physicians, and then interviewed the people who were named the most. The interviews came up with three consistent themes that described excellent clinicians: Core philosophy; deliberate activities; and everyday practice.

1. Core Philosophy
This was the personal values and beliefs held by excellent clinicians. There ere two components to this. The first was an intrinsic motivation, described as "passion" and "drive" for clinical care. This was described as putting patients first, curiosity about all aspects of patient care, including intellectual curiosity, and relationships with patients and colleagues. This drive sustained excellent practice over time, too.
The second component of the core philopsophy of excellent physicians was humility. There was an open-mindedness and desire to learn from alternative perspectives. It also exhibited as reflection on ones own abilities and limitations, though not as false modesty! Humility contributed to strong people skills ("people who are truly good clinicians never make a family or a colleague feel that they are beneath them") but it also contributed to good diagnostic skills, helping to avoid some common diagnostic mistakes. Humility also saw these clinicians downplaying their role in achieveements, attributing their success to others and circumstances.

2. Deliberate activities
These were the activities sought out by clinicians to maintain their performance over time. There were 2 components to this. The first was reflective clinical practice, where excellent clinicians described self awareness, attention to ones performance and learning from ones mistakes. The second was scholarship. This included research, teaching and knowledge synthesis, dissemination and application - essentailly applying research findings into practice - "...we need to try and advance thinking about a topic." This wasn't some academic desire for research for increasing publication, either. This was all related back to improving patient care.

3. Everyday practice
There were four components to this, and all were viewed as necessary for excellence. These were clinical skills and cognitive ability, people skills, engagement (enthusiasm and commitment) and adaptability. These are fairly self explanatory.

I think this description is useful, without containing too many surprises. Though it looks at a small number of doctors in a particular type of practice in one city in Canada, theses characteristics look familiar enough for us to imagine (hope?) they are transferrable to other settings.

So, come with me now to another setting. This paper reminded me of a paper published over a year ago asking a different question in a different setting. What are the characteristics of doctors working for over five years in challenging settings in Australia? These settings included Aboriginal health, drug and al;cohol services and in prisons. They identified three behaviours from their interviews.

1. Respect for patients
These doctors had a huge amount of respect and admiration for their patients. They described it as a privelidge to work with them, and were very interested in their patients as people, in the biography of them as a person.

2. A sense of control
These doctors  had control over  their working life. They made active choices in their career, and made the most of opportunities. Most worked in portfolio careers, and had interests in other clinical fields, research, advocacy or teaching. (Interestingly, this would be borne out by the 2009 Workforce survey, describing the smaller numbers of hours on average worked per week by those in Aboriginal health.) This sense of control is probably the reason why organisational factors or poor pay rates did not come out as negatives!

3. Intellectual interest
These doctors all found their work intellectually stimulating, and reflected deeply on it.

Though the categorisation is different, these two lists strike me as being very similar. The core philosophy of excellent physicians, may well translate out as profound respect for their patients in those working in underserved areas. The second paper describes a common thread of social justice motivation in deciding to enter this field of work. The deliberate activities of reflection and scholarship would overlap well with the intellectual interest of those working in challenging areas. The control over their careers is the mechanism for allowing this to happen, but could be described as one of the deliberate activities undertaken by excellent physicians. The everyday practice activities combine the intellectual curiosity and respect for patients. Being adaptible is what allows people to thrive in challenging circumstances - celebrating small, incremental change and not being bogged down in difficult organisational environments. It would seem obvious that enthusiasm and commitment is required to stay long term in these fields, and both these shine through the quoted section of the interviews.

This isn't definitive, of course, though I do find it suggestive. There are many unanswered questions. Would patients agree with this classification of excellent doctors? Would they even agree that those chosen were excellent? Would it be possible to have these characteristics and not be excellent, or stick around long term?

However, if you find this at least plausible, as I do, then there are some consequences that flow.

If you are involved in medical education, then perhaps the excellent role models you need to seek out are those who have been working long term in the undesirable parts of medicine. That would often mean getting out of the teaching hospitals.

And if you're wanting to develop an excellent workforce for areas usually difficult to staff, then perhaps creating an environment where there is room for adaptability and scholarship will go some way to encouraging excellence in your recruits.

If you're a patient seeking out excellence, it may be that you'll find it in those doctors working away in the places no-one wants to go!

Perhaps I've got this horribly wrong - do let me know your thoughts!

P.S. For further reading, The BMJ had a whole issue devoted to good doctors. Start with the editorials and letters (if you can get past the paywall. Sorry.)

check out this from JAMA: A Physician = Emotion + Passion + Science - an opinion piece, but sounds familiar doesn't it.

And finally, if, as a doctor, you consider yourself a scientist, then you might want to define science in this rather wonderful way:  Science is formalised humility

Mahant S, Jovcevska V, & Wadhwa A (2012). The nature of excellent clinicians at an academic health science center: a qualitative study. Academic medicine : journal of the Association of American Medical Colleges, 87 (12), 1715-21 PMID: 23095919

Stevenson, A., Phillips, C., & Anderson, K. (2011). Resilience among doctors who work in challenging areas: a qualitative study British Journal of General Practice, 61 (588), 404-410 DOI: 10.3399/bjgp11X583182

Hurwitz, B. (2002). What's a good doctor, and how can you make one? BMJ, 325 (7366), 667-668 DOI: 10.1136/bmj.325.7366.667

Rizo, C. (2002). What's a good doctor and how do you make one? BMJ, 325 (7366), 711-711 DOI: 10.1136/bmj.325.7366.711 
(And the other letters with this one!)

Brook, R. (2010). A Physician = Emotion + Passion + Science JAMA: The Journal of the American Medical Association, 304 (22) DOI: 10.1001/jama.2010.1807