Wednesday, January 04, 2006

What makes a good doctor?

All doctors are different and none of them are perfect, but there are characteristics that make some better than others.

First, the doctor must be able to hear. I was going to say listen, but there is that expression “ever listening but never hearing”. A doctor can get by appearing to be a good listener. One partnership I knew was very popular with the patients. Both the doctors (now long retired) were very good listeners. Unfortunately, they didn’t understand what they were listening to. Despite their incompetence, their patients got a very good service because almost everybody who went to see them was referred to a specialist – and this was in the days when specialists did home visits. Of course, they were often referred to the wrong specialist, but specialists were known to play Happy Families with the referrals. They would meet at a local cafĂ© and the cardiologist would bid two hernias for a chest pain and the surgeon would swap.

It is important to listen to the patient and hear what he or she is saying because patients tell you what is wrong with them. This is the advantage we have over veterinary surgeons, who just have to poke and guess. Television’s Dr House says that patients always lie. So they do, but they don’t mean to. They leave things out that are important and they try to interpret things so that they make a pattern. In order to make things fit with their erroneous diagnosis they create false memories. That is the skill in taking a history; you ask leading questions to discover what seems trivial to the patient but meaningful to you. Don’t be afraid to interrupt the flow. Students tend to write down verbatim what the patient tells them. The result is wordy and repetitive, and comes up with the patient’s own diagnosis. If the patient were able to diagnose he wouldn’t need a doctor, and this is especially true when the patient is a doctor. I know that when I am a patient I’m always jumping to the wrong diagnosis. The doctor needs to be objective, to listen dispassionately, and to hear what is being said. The patient needs to tell the truth in plain English, not medical jargon. When the doctor hears medical jargon he first has to translate it back into plain English and then back into his own medical jargon. Does the patient mean the same by ‘chronic’ as I do? Or does she just mean that the pain is very bad?

Second, the doctor needs to be able to see. That’s stupid; how many blind doctors do you know? Everybody sees. No, everybody looks but it’s often a case of “ever looking but never seeing”. Even a blind man sees better than that. Dr House is, of course, a play on “Dr Holmes”. Arthur Conan Doyle was said to have based his great detective on a famous Edinburgh doctor, so a doctor named House making use of Sherlockian observation is doubly amusing. I do not expect the doctor to look at the mud on a man’s boots and deduce that he was once a corporal in the 14th Lancers serving in India and that the enlarged spleen must therefore be an infection cause by bathing in some obscure tributary of the Ganges, but I do expect him to notice that the patient is frightened or nervous, or embarrassed or holding something back. I expect him to know how to look for pallor, and what pigmentation of the skin creases means, and to know that you must look at armpits before you feel them.

The old medical student story is of the teacher who tells the class that the most important skill in medicine is observation and the second is testing the urine. “Now watch me,” he says, and proceeds to dip his finger in a glass of yellow liquid and then suck it. The students hesitantly copy him, grimacing as they suck. The professor chides them, “You will remember that I told you that the most important skill was observation. Had you been observing carefully you would have noticed that I dipped my index finger in the urine and sucked my middle finger.”

Consultation by telephone or via the internet is dangerous because you can’t see the patient. Everybody who asks me for remote advice needs to remember this. You are asking a blind man to help you.

The doctor also needs to be able to see in order to read. I am amazed at how little doctors read. The incompetent partnership that I referred to earlier was castigated by a local surgeon. “One of them doesn’t read letters, he complained, “and the other one can’t!” Reading is the only way to keep up to date. When I qualified, a child with acute leukaemia survived for on average 10 weeks and an adult for 40 days. Things have changed so completely that we might be living on a different planet. I was dismayed when the improvement happened that physicians were still reluctant to offer patients chemotherapy as it “only made the dying more dreadful”. More than seven years after I introduced VH gene mutations as a prognostic factor in CLL many oncologists have never heard of them. Indeed, some oncologists don’t seem to have heard of Rai staging.

If you don’t read, you don’t know the limits of your own competence. No doctor can possibly know everything. But unless you know what you don’t know you are dangerous.

It goes without saying that a doctor must be skilful. But skills can be learned by almost anyone. The best at bone marrow trephines are the nurses at MD Anderson who do 60 a day. Practice makes perfect. Our Hickman lines are put in by a radiologist. He also does prostatic biopsies. A different radiologist is the most skilful colonoscopist I know.

My near namesake, Dr Hamlyn, was a missionary doctor in Ethiopia. A major problem he and his wife encountered was the leaky young woman. The African girls had their first baby at a very young age and traumatic births left them with vesico-vaginal fistulas. Their urine leaked from their vaginas. They were disowned by their husbands and kicked out of their villages because they were smelly. Dr Hamlyn set up a service repairing the fistulas. He and his wife dressed them in a brightly colored dress and sent them back to their villages, clean and dry, and they were mostly accepted. Some were not and found their way back to the Mission Hospital where they were put to work as cleaners and cooks and then as nursing or even operating theater assistants.

One young woman began assisting in the theater and eventually began to do the operation herself, first with the assistance of Dr Hamlyn and eventually alone. Now, still unqualified, she trains surgeons from all over Africa to do this one operation. Nobody is better at it than she.

The point is that the technical skill is not enough. Surgeons are revered by the community. What they do is very impressive. Not as impressive as driving a Formula One car around Monte Carlo, but then, they are not paid so much. When you get down to it, surgeons are basically plumbers (and these days they’re not paid as well as them, either). One surgeon told me, “It’s not knowing how to operate that matters; it’s knowing when.”

This is all a roundabout way of defining what the third requirement is for a good doctor. He or she must be a human being. I’ve known surgeons (and physicians – let’s not get partisan) who were really robots. Automatons, they go through the same procedure with every consultation. Every operation is carried out with meticulous skill, but the anesthesiologist manages their care. That’s what a good doctor must do: care.

The doctor must be interested in the patient; not as a case but as a person. He has to show it, too. Someone told me that during their time as a student at St Barts they were taught two things: always have shiny shoes and always get up from your desk and shake hands with the patient when he enters the room. There are worse things to learn; not as a ritual, but as a token of interest, of care. Doctors who take a history while staring at the notes are performing a chore, not showing an interest. It mustn’t be feigned; that always shows. Doctors who care are available. Doctors who care are truthful. Doctors who care call back, answer e-mails, look things up, hold your hand, offer comfort in distress, time in grief. Doctors who care do not stand on their dignity, are not too proud to listen to your views or refer you on; and they keep an open mind on new ideas.


John Wagner said...

Thank you for another terrific post from a VERY good doctor! Thank you for your compassion, caring and hearing. But most of all for the fine human being you obviously are. I read your posts faithfully and although I don't understand all the details of the very technical ones, I am learning. Once again, thank you!

LivingToLove said...

Sometimes I feel Drs. need a longer breather between patients. One can sometimes see that they are "hearing" but a portion of their brain is still with the last case or perhaps saving someones life at the hospital. The ability to focus on the person the Dr. is seeing and should be hearing may not always be a trainable area rather a part of being good Dr material. One of the smartest Drs I ever had and I loved my time spent with him was a man who had left his calling {research} and was practicing internal med..Many people did not like him because of his intent look when he was "hearing" them. When I had a question and I had a few he would say lets go into my office he would get several books out read something pertaining to my question then he would say we can do this several ways and then he would give me the down side of each procedure and say why he did not like this or that plan..then he would say how would you like to approach this? He always loved to say "I am your advisor but you should take an active role in this because after all it is your life that we are dealing with". When one of his patients was in the hospital he was like a Mother Hen {some of the nurses did not like him because he expected an excellence of care for his patients they were not use to.} Another of his sayings oh I hope this illness will not have to end up being in a hospital because the less we have to do ones body the better and who knows what some of them will do. He did not of course share his thinkings with everyone...We had a wonderful relationship and never never did he talk down to me. I guess he spoiled me for the kind of Drs who get all bent out of shape if one asks anything about their plan of treatment and or their choice of medicine. {An Open Mind is so important} Thank you for your wonderful post on what makes a good Dr. I do feel in todays world all Drs face an atsmophere that deems their practice of medicine to be oh so much more taxing to them. God Bless the Drs who practice with a love of humanity ...they face so many different personalities everyday some nice some not and after all Drs are human with feelings after all..

Bruce Hopkins said...

Terry's post on "What Makes a Good Doctor" reminded me of a classic, one of the finest pieces of short literature in the English language. It is

"A Doctor of the Old School" by Ian MacLaren with Illustrations by Frederick C Gordon
Published in 1896

For those who have not read it, the e-book is available in many places. A willingless to puzzle out a bit of brogue is required. One site is:

David Arenson said...

Thanks for an interesting post. To my mind, the main CLL-specific problem is that many doctors simply are not up on the latest ideas, tests, and treatments. They don't have the time or inclination to think these things through; they're more solution-oriented, and solution means remission -- in almost every other cancer -- but not always in CLL! So there is some reflexive thinking that may not be appropriate for our strange beast.

A second problem is the doctor-who thinks-he-is-a-god syndrome. Alas, there are still quite a few of those types out there. I suppose the best thing for a patient to do when encountering one is to run for the hills.

Terry, you are most definitely not that sort. Your willingness to share your insights with the patient community -- and to treat us as equals and as adults -- is as commendable as it is unusual for someone in your position.

Beth Havey said...

Dr. Hamblin:

I have written a novel (unpublished)about an arrogant physician, a neurosurgeon,but the guy does have a good heart that can sometimes be reached. He recalls the words of Jane Austin, the definition of a doctor: sort of wonderful, nondescript creature on two legs, something between a man and an angel.

Doctors are human and therefore have to work hard to be doctors. When John and I told our local oncologist that we had bad news about John's IGVH status, whether it was mutated or unmutated, I could tell that the doc thought the unmutated was the better of the two. My cousin, another oncologist, referred to CLL Topics as a chat room. Oh well, with people like you writing and speaking, things will have to change. Thanks for your words.
Beth Havey