There’s no such thing as minor illness – three scenarios

Where you'd rather be than the doctors... until...

Sometimes commentary about health systems seems to view the people who use them as a nuisance. “If only they wouldn’t come with their minor problems.” “Let’s charge them so they think twice about coming.” We are made to imagine a health systemclogged up with people who shouldn’t be there with all those self-limiting illnesses. Leave the room for those who are properly ill, thank you very much.

It may be surprising to learn that there is no such thing as minor illness. That’s not to say that there’s no such thing as self-limiting illness, but that by trying to keep people out of the health system, we lose opportunities to get them in. Here are three scenarios. 

Scenario 1 – People only walk out with minor illness.

One of the common set of symptoms that people come to the doctor with is things like a cough, sore throat, runny nose, perhaps fevers. It’s really only possible to say this is minor illness at the end of a consultation. These symptoms can be the early symptoms of conditions like meningitis, pneumonia or a septicaemia. Usually they are not, but the headlines make the front page of the newspaper when they are missed. These diseases progress very quickly.

Much of the pressure not to go to the doctor with these symptoms forgets that these are not just an isolated and independent collection of physical occurrences. They are accompanied by feelings – usually worry and anxiety. The decision to come to adoctor is rarely taken lightly. Most people discuss their symptoms with friends and family beforehand and ask for advice on what to do. Some people will consult Dr Google. The decision to see a doctor is driven by anxiety – anxiety for themselves, often anxiety for a child, sometimes anxiety for a partner. (The main exception to this is a request for a medical certificate for time off work – this won’t change while workplaces require certificates for minor illnesses.) People don’t really come in for an antibiotic. That might be the request, but people want their anxiety reduced. That’s why with good listening and careful explanations which get at the reason they are worried, almost everyone is happy not to have antibiotics if they are not required. This is also an opportunity to speak with people face to face about how they make the decision to seek further medical help - probably much more useful than providing written information,

Scenario 2 - …And another thing

About 40% of people bring more than one problem at a time to their GP. (PDF) The minor illness might be a ticket in through the door – the reason they can give the receptionist and their workmates, but there are often more profound concerns that people come with. These might be the chest pain they’ve been having that they’re worried might be serious. Or it might be symptoms of depression or anxiety, or the worry over episodes of hearing voices. Often this is the real problem people come with, but it won’t be raised unless the person feels they can relate to the doctor they are seeing. Sometimes it will come up in the same consultation. All GPs know those final moments in a consultation, with the door about to open, when…”there was just one other thing, doctor.” It doesn’t always happen like this. I am aware that I have had people try me out over something fairly trivial for two, three or more consultations before feeling that I can be trusted enough to tell me about the thing that is really worrying them. If I don’t develop a rapport, I’ll never even know there was something else.

Both scenario 1 and scenario 2 are opportunities for the preventive healthcare that often gets talked about. 85% of the Australian population see a GP each year, which is a lot of opportunity to make sure screening and preventive activities happen, without needing any health check policy. It’s one good reason why we have excellent guidelines about what preventive activities work. And why many of the conceptual models we work with in general practice talk about something akin to “The Doctor’s Agenda” recognising that there are things that the patient needs to be done in a consultation, and there are things the doctor would also like to achieve. 

Scenario 3 - The Perhaps scenario…

Often people do come in with what turns out to be, when they leave, a minor illness. Sometimes these are people who rarely see a doctor at all. They may be young men (who’s consultations are usually shorter, do less preventive activities and deal mainly with physical symptoms) or they may be people whose first language is not English, or they may be people unused to navigating complex health systems, and a bit intimidated by health professionals. Or they may be people who see a range of different doctors. It doesn’t really matter. Everyone at some point is at risk of succumbing to a serious physical or mental illness. If that time comes, people want to see someone they can trust. If, having seen a doctor who treated the person with compassion and respect, and didn’t make them feel like they were wasting their time for something minor, then that will be remembered. And if it is remembered a few months down the line when that breast lump appears, or those suicidal thoughts keep entering the mind unbidden, the question “Who can I turn to?” comes up. One option for the answer should always be “I remember that nice doctor I saw with my cough.”

The seeds are sown in those consultations for minor illness for tougher times ahead, the investment made in the trust that is required to tell of your most worrying, perhaps shameful, secrets when it is required. Most experienced GPs know this, and put time in during those minor illness consultations to develop the trust. General Practice is, after all, a specialty built on relationships over time with patients, rather than a series of one-off information gathering exercises.

There are obviously challenges in funding and workforce. But if we forget that in consultations for minor illness, we are doing so much more than just seeing a collection of trivia, then we are building a health care system which is impersonal, anonymous and foreboding.We don’t just stop people attending their GPs now. We stop them attending in the future, too, perhaps when it really matters.

I should emphasise that this applies particularly to GPs and Primary Care. Emergency Departments are not set up to provide this sort of care, where GPs are. I also include non-medical staff in this description of a GP’s work. Nurses would clearly be involved in developing relationships, too. I am most familiar with the way this plays out for GPs, and know that GPs have been researching and teaching this core part of their role for decades.

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Doctors and the health of asylum seekers

No way should we be treating asylum seekers like this

Like many people in Australia, I am deeply concerned about the way we are treating a vulnerable group of human beings who come to Australia because they are persecuted in their own country.

There are many others who can talk about ways of helping, or our international obligations. My field is health, and I wanted to put in one place what I know from news reports about the health of asylum seekers, and the response of doctors to this.

I want to do this because I am angry, and I think you should be too. Doctors are not known for their left-leaning sympathy, but doctors groups across the political spectrum have spoken out about what is happening already. That's because this is not a left-right political issue, though it's often portrayed as such. This is a human issue. Doctors see every day in their practice the consequences of treating people like this. We are the ones who see and deal, often inadequately, with the problems people have arising from violence in the home, from torture in refugees and from physical and emotional abuse as a child. That our government could be deliberately choosing to do this to people is beyond belief.

Apparently, the biggest single cause of death for detained asylum seekers is suicide. This fact alone should make us ask what we are doing to people. The reports of the effect on children - exhibiting signs of depression - would legally oblige doctors to report the carers for suspected child abuse in any other setting.

Back in December, the Immigration department sacked its Immigration Health Advisory Group, which got a bit of coverage in the press. At the time, we were told that this was because the group was too large, and because they needed advice quickly. Good work from the AAP under a Freedom of Information request shows that the real reason was that it was "difficult for some members to provide health advice independent of their other interests." The minute, written by the secretary of the Immigration Department, goes on to say that these conflicts of interest arose from "natural professional interests and obligations." So that's not conflicts of interest like having a partner who parts owns a lobbying company, or receiving money. That sound to me like the conflict of interest is that they have professional obligations to speak out, to do the right thing! The secretary notes that the policy approaches were contentious, and seems to say that "policy and operational activities are becoming increasingly problematic." (It's possible, though less likely on my reading, that he's actually saying it's the potential and actual conflicts of interest, or the present challenges that are getting more problematic.)

My reading of this is that the Department knew that what they were doing was cruel, and they knew that the professional obligation of the doctors on the health panel would be to speak out, so they sacked them. The former panel member interviewed by the Guardian indicates that the advice the group were giving didn't fit with government policy.

You can see that professional obligation in action in the doctors contracted to work in the facility writing 92 pages of their concerns about the treatment of asylum seekers, and the inadequate systems they were asked to work with to manage this.

You can see professional obligations in action when organisations like the Royal Australian College of Physicians, the Australian Medical Association and the RACGP all speak out against our current policies.

You can see professional obligations in action when Michael Gliksman writes a strongly worded opinion piece for the MJA calling what we are doing torture, and calling on all doctors to speak out against it.

I've come across numerous other doctors speaking out on Twitter and on their blogs about what we are doing.

Why would so many want to sepak out? Why not keep our heads down?

It's because the Immigration Department are right in thinking that doctors can't stay silent on behaviour that harms others. The World Medical Association Declaration of Tokyo is pretty clear on this.

"The physician shall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures.

The physician's fundamental role is to alleviate the distress of his or her fellow human beings, and no motive, whether personal, collective or political, shall prevail against this higher purpose."

And we can go back to that old Hippocratic maxim understood by doctors the world over, (and even quoted by Tony Abbott)

"Primum non nocere - Above all, do no harm."

If there is one thing we know about the current treatment of asylum seekers arriving by boat, it is that harm is being done. It's why doctors are speaking out both publically and privately.

What you can do

• Find out more about the issue
• Join doctors for refugees
• Write letters to your MP
• Write to newspapers

Do we need a Romantic movement in medicine? Involving patients in medical education

Why this picture? ...Read on...

I have had a very interesting conversation with Anya de Longh on Twitter and commenting over on the AMS Doctor blog. She wanted to know how patients can be more involved in medical education. There have also been helpful contributions to this discussion from David Chessor, Meerat Kaur and Clare Morris. And then Anya asked "What are the biggest obstacles for clinicians in accepting teaching from patients?"

I don't have an easy answer to this, and would love to hear other people's thoughts. I also don't think it's something I can do justice to in 140 characters, as I think the answers to this questions are tied up in what we call the Hidden Curriculum - those unstated values which get acted out by doctors and medical students.

Why is something so obvious so difficult?

It does seem obvious to me that patients (and for that matter carers) should be involved in teaching doctors (and, for that matter, all health care professionals). I don't think there are that many people who would argue against the idea. So why is it so difficult to do? I think there are some particular ways we have of thinking about medicine that lead us to discounting the patients' views. I'll suggest what I think these are here. I don't want to suggest that these ways of thinking are wrong - they have been beneficial in many ways - but there are other ways we need to think, too.

Medicine is thought of as a technical discipline

The way we conventionally teach and talk about medicine makes it look like it's a technical and scientific discipline.The study of medicine becomes the study of scientific facts about diseases. This exhibits itself in traditional physiology and pathology, as well as the monitoring requirements of diseases, such as diabetes. Eventually, all that you need to know about a disease is the numbers assocated with its monitoirng - so you assume that you know all about someone's diabetes if you know their HbA1c, their fingersprick sugars, their cholesterol and their blood pressure. The way we teach using cases which concentrate on disembodied signs and symptoms of disease, and the way we encourage "taking a history" as the extraction of facts related to a diagnosis, with any other information deemed (by the doctor) to be irrelevant - ideed, patients who concetrate too much on these "irrelevant" facts may even be deemed to be poor historians. In our teaching, we pose clinical problems that always have an answer (and usually only one answer). We seek an objectivity that means anyone can mark the assessments. We develop and use symptom scoring systems to reliably diagnose or calculate risk for a huge number of conditions now, and we can even use the fact that people use more emotion-laden terms for their breathlessness to diagnose their chronic lung disease.

Evidence based medicine, in its success at giving us confidence about which treatments and tests work, has resulted in an inadvertent limitation in the sort of questions it is legitimate to ask in medicine. We are encouraged to ask "In a man aged 65 do the benefits of aspirin outweight the risks for primary prevention of cardiovascular disease?" It's not even assumed that we might ask the man himself of course - it is posed as purely an informational question. There are other types of legitimate questions that patients ask which the evidence has no answer for.

• "Should I see my sister with lung cancer on the Central Coast next week?"
• "Why do I feel so guilty about allowing my mother to go into a nursing home?"
• "How can I make her love me again?"
• "Who can I talk to? I feel so lonely."

In seeking out objectivity, we have crowded out the need for the voice of the patient without even realising it. If all you need to know about a disease is its pathology and biochemical markers, there's no need for a patient voice. Yes, we teach patient centred medicine, but if they know what's good for them, they'll fall into line with our objective evidence. Ultimately, when medicine is scientific, technical, "objective" then it is owned by us doctors, and patients don't really need to be involved.

Solutions

I have deliberately painted an overly bleak picture. In reality, there are many doctors (including most GPs?) who practice and teach medicine entirely inclusive of the patient's voice. Helman, a GP and anthropologist, wrote in a classic 1981 paper about the questions that patients want answered when they see a doctor:

1. What has happened?
2. Why has it happened?
3. Why to me?
4. Why now?
5. What would happen if nothing was done about it?
6. What should I do about it.or whom should I consult for further help?

It's apparent that only question 5 (and perhaps 1) is readily answerable by evidence based medicine.Medical schools are using the humanities - usually novels and film - to teach about the experience of being ill. However, it's notable that these approaches can still both be taught entirely sepearately from actual real patients - again, we have the capacity to go to research libraries to learn.

I have come to this in realising that our traditional objective approach doesn't work in Aboriginal and Torres Strait Islander Health. Where doctors (and other health professionals) need to be assessed or taught on cultural competence, Aboriginal people need to be involved in this. In asking Aboriginal people what they want from their doctors, they do want them to know the clinical science, but they also want them to have an appreciation of their lived experience. And reading about it is OK, but just doesn't come close to actually working in a community.

But this is what my patients wanted in Sheffield in the UK, too. Being a doctor is not just an example of applying evidence to a blank canvas. The way we teach and disciss medicine can make it seem as if it is, though. We need to find a way of appreciating the subjective, and combining our learning of scientific skills with hearing of the experience and priorities of those living with the conditions we discuss.

I was reminded of Richard Holmes' book The Age of Wonder, about the influence of the Romantic movement on science through the 1800s. (And also Craig Shuftan's book Hey Nietzsche Leave those Kids Alone - possibly the best book title ever!) Romanticism is about the power of the subjective experience. I wonder (in both senses!) if we need to recapture a Romantic movement in medicine - alongside our objective disembodied knowledge, we need a sense of the subjective experience of illness.

There are examples of patients being involved at all levels of medical student education. It does take individual and institutional goodwill, though. Here are my thoughts on how we could do it right now.

If you are a patient

• Take every opportunity you feel able to, to politely teach the doctors, nurses and students what you feel they should know
• Give them and the service feedback
• Ask around and find teachers enthusiastic to include you at the clinic, in the hospital and at the university 

If you are a student

• Take every opportunity you can to learn from your patients
• Ask them what they think you need to know
• Tell your teachers how much you appreciated learning from the patients

If you are a doctor (or other health professional) involved in teaching

• Take every opportunity to involve your patients in teaching your students
• Ask what they'd like your students to know
• If they want, help get them involved further with other organisations

If you are responsible for medical curricula

• Think about how you could get patients involved in development, delivery and assessment of learners
• Find out which individuals and groups are interested in getting involved
• Think about how the hidden curriculum at your institution sidelines patient voices.

You will have other, better ideas. Or you might completely disagree. I'd be interested to hear your comments below. It's my feeling that only by involving patients in medical education, do we help students really understand what is meant by patient centred, patient empowerment and partnership. And we bring a little wonder and Romance back into medicine.

GPs, Obesity and the Law – an amateur speaks

Recently the medical press, and the mainstream press have reported a case where a man won $365,000 damages from his GP for failing to do enough about his obesity. Like many GPs, my first reaction is WTF... My second reaction is to assume that there must be more to the case than just what is reported, and the case is going to appeal. So we don’t know all the details, but it does raise questions about responsibility and how well doctors influence behaviour. I think this brings us on to broader questions, too, about the role we ask doctors to perform in society and who is responsible for a healthy society.

Obesity is a risk factor for many health conditions, and as such, often ends up being managed in GP consultations. Sometimes it’s raised by the patient themselves, sometimes by the doctor. There is no miracle cure, it’s hard to lose weight. It takes a sustained change in diet and a sustained change in activity levels, both of which can be hard to do. Many people don’t want to try, many people try, and get frustrated by failure. This is only made worse by the images of success in tabloid “news stories” (read “marketing”) about celebrities and miracle diets. There is recent evidence that surgery can be helpful in weight loss, including preventing the complications of this. Even the surgery, though, doesn’t stop the requirement for long term lifestyle changes.

Read that paragraph back again, and note the language I used. Words like “risk factor,” “health conditions,” “managed in GP consultations,” “cure,” None of those words is wrong, but this is a very medical model and thinking like this will always ultimately mean the search for weight loss medications, and ultimately surgical solutions. It looks to me like the court has used a medical model like this – obesity is a medical condition, medical conditions are diagnosed and then have the (single) correct treatment given by the doctor to the patient and the patient gets better. See how passive the patient is in this scenario. And all the responsibility is on the doctor. That would seem to me to be how the court can come to a conclusion like this. However, real life is not quite this simple. As well as the medical language, see how I used moral language too: “...don’t want to try,” “failure.” To some extent the court judgement is about apportioning blame – a moral judgement – on one of the parties. Shall we choose the patient? Shall we choose the doctor? I don’t find this a particularly helpful way of thinking about this situation. This way lies arguments about compliance, and the set of discussions that assumes the people who come to see their doctors are frustrating nuisances. Reality is all just a bit more complicated than that.

At the core of what GPs do is behaviour change. We can get frustrated at how difficult it is to change people’s behaviour, but we will attempt to get people to stop smoking, reduce alcohol consumption, increase physicalactivity and eat more healthily. You can even view the prescribing of medication as behaviour change – for example from not taking aspirin daily, to taking it. One of the most widely used models to guide the way we do this is called motivational interviewing, which uses a stages of change model. In this model, people have change their thoughts about whether they want to make changes, and by understanding this GPs can adapt their discussions accordingly. 

Some people are described as being in a pre-contemplative stage, where they don’t recognise any need for change. Often doing anything more than raising the issue at this point just gets people annoyed. It’s when people are ready to make changes that you can dive in and make really practical suggestions. The trick is moving people around from being pre-contemplators to contemplators. It’s also crucial to note that failing to maintain change is a normal part of the cycle, and therefore not failure! This approach takes time, more specifically many conversations over numerous consultations. It also usually involves much more than just weight. It is unusual that there would not be other pressing issues too – physical health issues, mental health problems and social problems. And all of these interact – if you manage your anxiety by eating chocolate bars (and many do) then you need to talk about anxiety, stress and alternative ways of handling it and ways of changing that. It’s why GPs put such store on the relationship they have with their patients. These conversations have no hope without it. As it is, the evidence that we are effective at this is short on the ground (though I suspect that trials take a slightly reductionist approach – it’s unlikely that a trial would randomise to “Take as much time to cover all the issues which you and the patient believe might be relevant over several years” versus “usual care.” (Because that probably compares like with like!) I find it difficult to believe that a single referral would have made the difference in this case.

But this is a bigger issue than just what I as a doctor might be able to do with a patient over a period of time.  What we have managed to do is is create societies that make people sick. We develop our towns and cities with little green space, few cycle paths and pavements, and keep widening roads for all our cars to sit on unmoving. Physical activity becomes a product to be bought, either by joining a gym or by buying a Wii. We allow people to tell us that we are too busy to cook, so we should eat highly processed foods instead. If they’re unhealthy, then it’s a treat that you deserve, but if you can be told it’s healthy based on the presence or absence of single ingredients, then that’s even better. But you’ve got to eat processed. Because you’re busy. And you deserve it.

When we point out that the reason people become unwell is because of the environment they live in, then we get to do a bit more victim blaming – it was their fault; they had a choice. (Yes, but they were so busy! And couldn’t afford the gym)

So, by some strange combination, we end up with a situation where we are trying to claim that the person is unwell because they made a series of choices, and that the doctor is responsible for them staying unwell because they didn’t persuade the patient to make a different series of choices. Eh? (Another WTF!) 

Perhaps it’s useful to change the toxin. 

Imagine, if you will, a village where someone is poisoning the water supply. People are getting sick. You would want your village doctors to treat those who are getting sick. And you might want whoever is poisoning the water supply to stop. Instead they are telling us the water is very delicious. You deserve this water. And look how shiny the bottle is! Yes, you could go to the next village and collect water that isn’t poisonous. But you are so very BUSY. And look how cheap our water is. Lovely shiny bottles, see. You might ask why the village elders don’t stop the poisoners. Well the poisoners do donate much needed funds to the elders. And the system of self regulation, whereby the poisoners commit to reducing the amount of poison in the water to slightly less poison in 10 years time (never mind that they have missed similar targets in the past). And people do have a choice about which water they drink. And it does generate quite a lot of money (see how rich those poisoners are!) that generates tax revenue to fund those doctors you need to see because for some reason your personal choices mean you are all being poisoned! 

It seems obvious to me that a society that tells its doctors they are responsible for patching up (somewhat resource intensively and a little ineffectively) problems that are caused by the society we make people live in has got its priorities a little wrong. I’m left with a strange fantasy world where in the court of appeal damages are paid to both the doctor and patient by processed food manufacturers, town planners and the leaders who allowed them to poison our metaphorical water supply.

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