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

References
 
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

Fixing AHPRA's draft Social Media Policy

There has been a lot of comment among Australian health professionals on social media about the Australian Health Practicioner Regulation Agency's (which I'm going to call AHPRA from now on!) preliminary consultation document on social media policy. (The policy is available here.) For a flavour of the debate, have a look at the posts on Croakey and read the comments, too. The only positive comments I've seen are that AHPRA are venturing nto this area and inviting feedback. The preliminary consultation document itself reads like it was written by someone who's not used the internet for the last decade!


There seems to me to be an obvious way forward for them, though. It is a related to the Medical Board, but would be appropriate for all the other health practitioner boards, too I would imagine. Ironically, the whole policy could be written ina single tweet with room to spare!

Practitioners engaging with social media are reminded of their obligations under Good Medical Practice.

As doctors, we have already been given guidance in a document called "Good Medical Practice" (Opens PDF document). The principles in here would be good guidance for the way we engage with social media. Most of the document relates directly to patient care and would only be tangentially relevant, but the initial principles and some of the later sections are highly relevant, and would produce some very different recommendations.

To quote:

"Doctors have a responsibility to protect and promote the
health of individuals and the community."

  The way we use social media can be measured against this statement.

"Good medicine is Patient Centred"

It seems to me, it is impossible to be patient centred if we are not willing to listen to what our patients say, both as individuals and as groups. There are many people who would find it easier and more natural to comment on the services they recive through social media, rather than face to face. There are already websites dedicated to hearing patient views - Patient Opinion is probably doing this best, based on some good outcomes from the UK. I have had interesting discussions with mental health advocates from around Australia, and heard the opinions of many Aboriginal people about their experfiences, which is essential in my role as a GP working with Aboriginal people. Restricting who I might connect with or how I might engage in discussion would seem to be counter-intuiitive towards achieving patient centredness. The potential that social media has for hearing the perspective of our patients has enormous potential to improve our practice, and it would be a shame to miss out on this because of fear of making a wrong step. There are boundary issues, and the vast majority of health care providers are aware of these, and reflect all the time on how their social media activity impacts on this. I have seen very thoughtful online discussions about whether o follow patients or not, which have used both professional guidance and other people's perspectives. Patient advocates often contribute to these iscussions, which give them a richness often missing elsewhere. It's worth pointing out that the same boundary issues often come up for practitoiners working in a small rural town, and are certainly taught about in GP training.

"Professionalism embodies all the qualities described
here, and includes self-awareness and self-reflection.
Doctors are expected to reflect regularly on whether they
are practising effectively, on what is happening in their
relationships with patients and colleagues, and on their
own health and wellbeing. They have a duty to keep their
skills and knowledge up to date, refine and develop their
clinical judgment as they gain experience, and contribute
to their profession."

I would argue that our use of social media is entiely underpinned by professionalism, self awareness and self reflection, and that those practitioners who do this regularly in their professioanl life are also doing this for their social media use. Those who struggle  with this in their day to day practice are also likely to struggle in social media. However, I wouldn't be surprised of they also had practitioners and non-practitioners telling them clearly when they thought a boundary had been crossed. Our use of social medis reflects our personality after all. (And here is a good example of a medical student learning the hard way! But this is a brave exmple of reflective practice after a mistake.)

"For the doctors
who undertake roles that have little or no patient contact,
not all of this code may be relevant, but the principles
underpinning it will still apply."

And his would be the same for social media use.

"Doctors have a responsibility to contribute to the
effectiveness and efficiency of the health care system."

Social media has been a very effective platform for doing this, and disseminating messages about this. Again, social media is not the only way of doing this, but is one of the many tools. From the wording of this, it could be argued that doctors on social media should be encouraging this!

 "There are significant disparities in the health status of
different groups in the Australian community. These
disparities result from social, cultural, geographic, healthrelated
and other factors....Good medical practice involves using
your expertise and influence to protect and advance the
health and wellbeing of individual patients, communities
and populations."

This has been one of the main reasons I have been using social media. I work in Aboriginal health, and have used my social media presence to engage internationally, and advocate for improved services, as have many people all over the world. Again, the prionciples of Good Medical Practice would seem to indicate that an active social media presence to engage on issues like this would be part of our duties, rather than something to be discouraged.

 "Doctors have a responsibility to promote the health of
the community through disease prevention and control,
education and screening"

One of my most re-tweeted tweets was about the measles outbreak in South West Sydney. I encouraged people to ensure they were fully vaccinated. I would hope that many people saw this message, and that I was doing ym duty under Good Medical Practice.

"In professional life, doctors must display a standard
of behaviour that warrants the trust and respect of the
community. This includes observing and practising the
principles of ethical conduct."

This section, which includes a parts on professional boundaries and advertising, would be highly relevant for our use of social media - are we behaving in a way that warrants the trust of the community - I don't think this means having no opinions at all, but might go to how we express them. The principles behind these would be (and probably have been) useful starting points. There is an issue for clarity, though, about advertising in social media, where the interactive nature can blur the line between patient engagement and advertising - mainly because big corporations want to "engage" with their customers, and the wording and tools look the same, even if the intent is different.

"Conflicts of interest"

This hasn't been explored much, but would be relevant. It is being discussed a little in the journalism world, and in the medical world in the context of drug companies and publication in journals, but there would be room for declarations somewhere, I would imagine.

I am sure these are not the only sections of  Good Medical Practice that would be relevant, but this would seem to be the obvious place to start.

There is much discussion in the #hcsmanz community at the moment, so do please put your in your two-pennies here, at Croakey or on twitter.

Health Care and Social Media - Look in the rear view mirror occasionally

When I was learning to drive, I remember having it drilled into me to look in the rear view mirror regularly. If you were slowing down, look in the mirror, if you were changing lanes, look in the mirror, if you were reaching for your mobile phone while eating a pie, look in your mirror.

Now I'm relatively new to Twitter (and haven't quite got the hang of Facebook, don't use Linked In to its full potential, haven't even got a Pinterest account and love Citeulike...etc...etc) but some of the most interesting conversations that I've been following have been about HCSM and HCSMANZ - health care and social media.

There's a real sense that something new is about to happen, that social media has the potential to revolutionise communication and engagement in health care, across services, between different professionals and, most importantly for patient engagement in their health care and health services. Increasing effective engagement and enablement of patients could really improve health outcomes. That, I think, is really worth working towards, and social media could really help this to happen.

And now comes my but. But.

I'm writing this watching multiple tweets fly across my timeline. Twitter is such an active medium, there is so much going on, that it can seem like that's all the activity there is. But I'm thinking of some recent people I've met and onversation I's had.

A elderly neighbour is writing a history of doctors in our local area and has asked me to look at the manuscript. It's printed out on paper from an old word processor, with a hand-written cover note.

A tech-savvy senior health care manager isn't sure how o operate twitter.

Many of my patients have no computer at home, don't have a smart phone, and struggle to operate the phone they do have. Difficulty paying bills means phones often change numbers, or are cut off or not used for a time.

My local library has a sign up saying their computers are not to be used for Facebook or Twitter.

These experiences are summed up in two really important bits of research looking at the digital divide, or who doesn't have good access to computers and smart phones. In essence, it's not surprising that those on lowest incomes have least access. But the important thing about this is that those on lowest incomes also have the highest health care needs.

So, think of the elderly, with a range of co-morbidities, really needing to be engaged in high quality health care, who might, like I heard someone say this week, just say "Facebook is stupid".

Think of many Aboriginal and Torres Strait Islander people, who through reasons of geography, money, literacy or health problems may find engaging online very difficult.

Think of those with health problems or disabilities - who, by definition need health services - who may have difficulty using the technology simply becuase of their health (my elderly neighbour mentioned above has quite severe rheumatoid arthritis).

My plea, then, is to make sure, when moving forward into the bright, engaging future of using social media in health care, that we check the rear view mirror every so often to see who we might be leaving behind. We won't find them on twitter. We might not even find them in our clinics. But they are definitely out there, and need to be enaged just as much to get good health care.

P.S. Thanks to these tweeps for a conversation on this topic, too: @LeonoraOT  @lygidakis @Dr_J_Lowinger @yusunbin and @PracticalWisdom 

Low pay for health staff in poorer areas?

So, Andrew Lansley, the UK Health Secretary, is supporting proposals to pay health care workers in poorer areas of the country less. It's as if, after pushing through an NHS Bill that almost no-one in the NHS supported, which allows, some-one stood up and asked "No, I'm still not sure these changes will make care worse for those on low incomes," and so Lansley says, "OK then, how about cutting pay for hose working in the areas that are hardest to staff and hardest to work in. Will that convince you?"

Some background: In 1971 - that's 1971, whern Andrew Lansley was aboout 15 - Julian Tudor Hart published a paper which has become rightly famous. The title has passed into the health lexicon - The Inverse Care Law. It is worth quoting the abstract in full.

"The availability of good medical care tends to vary inversely with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced. The market distribution of medical care is a primitive and historically outdated social form, and any return to it would further exaggerate the maldistribution of medical resources."

Let me paraphrase that for the hard of understanding: Places that need health care the most, get the least.

I think there is a good argument that any public health system worth its salt should be thinking about how to tackle the inverse care law. It hasn't been solved yet, either in the UK or in Australia (or, indeed, on a global scale). Andrew Lansley's plan just walks straight in the opposite direction.

I was struck by this quote from the proposal quoted in the Guardian:

The introduction of more sensitive market-facing pay would therefore enable more efficient and effective use of NHS funds." (my emphasis)

I would have thought that effective use of NHS funds would be to improve the health of those with the worst health. And that more efficient use of funds would be to direct funding to these areas preferentially. Clearly, I am wrong. The most effective and efficient use of NHS funds must be to continually reduce pay for those who work in the areas where it is most needed, until no-one works there at all.

There are 2 reasons I care about this, and in a nese, this is my declaration on interest.

I am from the north of England and my work in the UK was in communities who had been devastated by the closure of coal mines and steel works - I was working there about 20 years after this happened, and the recovery was only just happening. So, friends who work in these places still certainly stand to lose out. And, worse, the communities will lose out as they find it harder to attract and retrain staff - especially as the staff will be graduating from universities  with bigger and bigger debts, and will need to work in higher paid areas to pay this off.

The second reason is that it also allows me to reflect on the Australian context. The Inverse Care Law is alive and well here - rural and remote areas really struggle to attract doctors (and to be fair, financial reasons are probably not the whole reason for this) as do the poorer outer suburbs of the cities. In my sector of Aboriginal health, pay rates are less than other areas of General Practice, but the need is greatest. There is evidence that seeing a large number of Aboriginal patients reduces billing rates (and so GP income) by 25% - it remains to be seen whether Practice Incentive Payments will make up this gap.

Note also that practices that have a higher number of Aboriginal patients, patients from non-English speaking backgrounds and older patients are those that are more likely to be teaching students and registrars. Anecdotally, most teaching practices feel that they lose income doing this.

I suspect things would not be that different in the UK, though fee for service in Oz certainly has the capacity to exacerbate these discrepancies. The knock on effects on inequalities and on teaching are obvious.

So, Health Secretaries of the World, if you're in the market for differential pay rates, try out this method: make health workers pay inversely proportional to the median income of the area where they work. The higher the population income, the lower the health worker's income.

Naive? Idealistic? Perhaps. But I'd rather be that than actively choosing to worsen inequalities in health.

Power to exclude people from the health service?

The title of this post is taken from this BMJ article by Allyson Pollock, David Price and Peter Roderick. These are not sellers of the socialist worker on street corners. Allyson Pollock is a respected health services academic. These words are some of the scariest I've read - and there is no shortage of very frightening predictions about the likely consequences of the NHS reforms in the UK.

There is no question in my mind - the NHS bill should be stopped. And it's not just me who says this. My College, the RCGP, has been at the forefront of health service workers who are against these plans, and that's because its members are against the reforms. The government somehow claims that doctors support the bill, but they've mistaken carrying on doing their best or their patients as support. I have never known such unified support against a health reform.

Why should I care? I work in Australia. There are a few reasons why I care.

1. All my family live in England. They range in age from well into their 90s down to very early childhood. They'll probably be OK because they are all bright eloquent people. They are not on the poverty line, but don't have enough cash around to visit us in Australia. So I want them to have a good health service.

2. I trained in the NHS. The values I have as a GP I got from working in an area of Sheffield which had been devastated or decades by the closure of mining and steel works in the area. The doctors, practice staff and hospital staff who trained me worked hard to provide the best possible care to people who were not sought out by commercial firms. There's a lot of thought put into improving this sort of service - for example see the GPs at the Deep End project.

3. I now see the effects in Australia of people being excluded from the health service - not deliberately, usually just thoughtlessly - and I am astonished that a service that is the envy of the world would seek to deliberately make themselves more like the worst services.

What does that mean in practice?

Just this week, I spent half an hour on the phone trying to find an ENT surgeon who would see someone without charging extra money. This was not for something minor, either, but a condition that needs surgery to be treated if it is not to eat away the bones in your head. Seriously. Clinical need wasn't the deciding factor, income was.

Someone once came to me in tears because the specialist had said to her "You must have $2000 tucked away somewhere" about her operation. She was upset and incredibly embarrassed.

Anecdotes, yes, but most GPs practicing in underserved parts of Australia will recognise these stories as being very common. (And the difficulty of getting GPs to work in underserved parts of Australia is another part of this story, of course). Just about none of my patients have private health insurance because they can't afford it - we regularly run out of food vouchers for people where I work. Paying for medical appointments and medications comes a long way behind paying for food and rent.

Australia has a "Universal" health care system, called Medicare. Medicare statistics show (p6) that Medicare expenditure for Aboriginal and Torres Strait Islander people is just over half that for other Australians. As you may know, Aboriginal and Torres Strait Islander people have the worse helath outcomes in Australia. There is a lot of work currently to "Close the Gap," and a lot of this is around improving access. It is incredible that a service like the NHS that get's this so much more right is moving in the exact opposit direction. An NHS bill that even allows the possibility of excluding people from the health service needs stopping. Having a service in the world that prides itself on excellent access for all is an inspriation to those of us elsewhere in the world. Yes, it's not perfect. But it does a lot better than anywhere else. Until the bill gets passed of course.

Pleasant surprise at being mistaken for somone who knows something

My introduction to how much fun Twitter can  be came with the ABC Classic FM Classic 100 countdown of 20th Century masterpieces. I enjoyed the cameraderie of conversation with unknown others, some of them professional musicians and music teachers. I am merely an enthusiastic amateur, a viola player, who's favourite private joke is to be thanked at church as "Thanks to the musicians... and Tim". So imagine my surpirse to discover that I've been quoted! A rather lovely blog post by Leonie Doyle ruminates on the Classic 100 and describes the thrill of being touched by a new piece of music (which also happened to be a piece of new music).

So it set me thinking. I actually think I belong in both groups she describes - I love most of the toe-tapping classics (with a few exceptions), and can't get enough of being immersed in a Mahler symphony. But I also love discovering new pieces - I still remember hearing the Rite of Spring for the first time (on a very old radio, Desert Island Discs. In the bathroom) and thinking "Wow. Music can do that!" The same happened when I first heard some Phillip Glass years later. And also John Adams at the Proms on the radio (with my headphones in at dinner, like any teenager!) These are orchestral pieces, because that' what I know best, but there is also a fair amount of non-classical music that I love too. It's hard not to share those experiences.


I don't mind it if people don't like the music I do - I like classical music and new music so it happens all the time. The world of music for me is like being in a big fairground. I'd like to try out all the different rides, as they'll all give different experiences. And some might make me feel sick. But I know that some people will stick to their one favourite ride. And that's fine. But I might feel they are missing out a bit.

I now need to find Black Angels by George Crumb...

A quick thought on smoking cessation

Two interesting tweets crossed my timeline this morning. The first was this one from Laura Newman pointing to this blog post about intimidating tactics used by public health campaigns to try to persuade people to stop smoking.
The second was this from Simon Chapman about a Croakey blog post on the medicalisation of smoking cessation.
Both these blog posts make really sensible points about the ways we often think about persuading people to stop smoking. And trying to do this by thinking of people as inadequate moral failures or as products of imbalanced brain chemistry misses part of the picture - the context.
Iona Health puts it brilliantly in The Mystery of General Practice:
"I believe that all my patients are now fully informed of the dangers of smoking. Sadly many continue to smoke because they lead lives that are so materially and emotionally constrained that cigarette smoking is one of pitifully few sources of pleasure and relief."
I recognise that picture in my own clinical work. Pretending that people just need a bit of medicine or a scary advert or counselling without any effort to create societies that value people and give them opportunities to "live the lives they choose to live" is choosing not to solve the problem.
In passing, I'll also just pause to note that the same issues arise with pokie reform in Australia (where the clubs believe in Counselling for individuals) and (perhaps slightly less so) in treatment for depression where drug companies focus on neurochemical problems (which need medication) as opposed to social justice problems (which don't)
I'm not arguing that we don't need medication or individual approaches, but that if we only use these approaches we don't allow health professionals to be effective.
Heath aptly quotes Shelley:
"The rich grind the poor into abjectness and then complain that they are abject"

About this Blog

This is a blog for all the stuff that needs more than 140 characters, but doesn't fit anywhere else. It's essentially a musings page, where I'll set down my thoughts.
You might find me writing about General Practice or medicine or music or theology or politics or social justice or... well, we'll see, won't we.
And the name? Well, my first (of not many) properly published articles in the British Journal of General Practice way back in 2004 had this as its title. (You can find it on p13 of this PDF) And a Tricorder in Start Trek was a single machine that might tell you all about everything in your surrounds. So this blog might function like that for my brain. Who knows?