As much as most of us complain, it is truly a privilege to be a physician in the United States. There have been tons of articles and posts about “what it’s like to be a doctor”, but this submission focuses on what it takes to be a good (or a bad) one. The truth is that though we’re talking about physicians here, this can be applied to ANY type of worker, from doctors to cashiers, to accountants, to flight attendants, etc…
After a while, as much we’re taught not to judge, anyone in any medical community develops a sense of who’s “good” and who’s “bad” at their job. It’s very interesting to see how this happens as invariably, it is completely subjective. His good is her bad and vice versa. Increasingly people are reaching for more formal resources as guidance, however, the criteria that are being used to pass judgment are inconsistent at best. From hard facts like readmission rate, LOS, and hospital-acquired infections to a number of years in practice, the prestige of medical school/residency program, and social status to hours the office is open, reviews of office staff, and office address. I was even once told by a patient that he chose his doctor because of the electronic health record that was being used in their practice*!! None-the-less, I take issue with all of these quality “metrics”- I say that none of them are as important as would seem at face value…
In my primary role, I feel very fortunate to be looking at hard data all day long. Much of this data is about physician performance and it often takes an experienced eye to look past all the noise, deep into the data set to really uncover the sometimes hidden truth. It is very troubling for me to see someone that I KNOW is a great doctor be labeled as marginal by (complex) data. Our organization’s Physician Status Reports are carefully presented as “point-in-time” assessments of physician performance because they are! Anyone can get better (or worse) at any given metric tomorrow. It’s a continual process of growth and a part of every doctor’s commitment to lifelong learning. Do you think in 2018 doctors have a varying commitment to lifelong learning? But again, all of this is trivial…
So What’s the Answer?
Allow me to explain using a clinical vignette. A 32-year-old female with a fever, no chills, body aches, rhinorrhea (runny nose), anorexia (poor appetite).
What’s the diagnosis? Even my 9-year old would say, “Papa, this is a clear case of viral syndrome- antibiotics are not indicated here. Consider supportive therapy.” We should all be proud of his clinical acumen, for he is right! The point is that virtually anyone (or nowadays any connected device) can take a set of objective facts and perform a Bayesian analysis of the probability of any given diagnosis given signs and symptoms, but is that what a doctor really is? I think we would all overwhelmingly agree- No. A “good” doctor is much more than the guts of a good AI-engine. But let’s be more specific about what we mean and maybe even come up with a single, overarching metric for determining quality… read on!!
Some say that a good doctor is actually a healer- one that actually heals the patient, i.e. makes them feel better. A good doctor evaluates much more than just the symptoms of the disease but is deeply concerned about the patient overall well-being. Fever and productive cough of rusty-colored sputum is likely pneumonia, but what about the mass in the lower abdomen that eventually suppressed the immune system enough to succumb to the streptococcus pneumonia (that we all have in our normal respiratory flora)? What about the distant history of STDs that exposed the patient to the virus that triggered cancer that led to the mass? Who would think that a patients sexual history would have anything to do with rusty-colored sputum? The answer is: a doctor that CARES about her patient enough to spend more than the 30 seconds it would take to make the current diagnosis (and miss the real underlying root cause of the presenting illness). The rest of these findings would take even the most astute clinician a lot more time to elucidate from the average patient- time that they simply don’t have in today’s health care system (12 minutes on average).
Well, We’re All in the Business of Providing Care, Right?
Care is a word that is thrown around all the time both in healthcare speak and in real life. Care in health care can mean any of the following (according to Google):
- noun. The provision of what is necessary for the health, welfare, maintenance, and protection of someone or something.
- noun. Serious attention or consideration applied to do something correctly or to avoid damage or risk.
- verb. Feel concern or interest; attach importance to something.
- verb. Look after and provide for the needs of.
We most often use the word Care as defined in #1. Apprehensively, I think we often assume that #2–4 are inherent in conversations, but I wonder sometimes if it really is- EVERY TIME. I mean, the majority of healthcare workers care most of the time, but I think there are only a few that care every. single. time. On every interaction, they #2-#4- for these physicians, #1 happens automatically… My friends, allow me to propose that it is these workers that are our BEST doctors, cashiers, accountants, and flight attendants. It’s the ones that #2-#4, every time. Conversely, those that only #1 and don’t actively assume #2-#4, are just having a bad day.
But is it really anyone’s fault? Don’t we, as a nation, measure our desired outcomes? I have yet to come across the “CARE” measure in any of our most recent national policies or guidelines. Is Patient Satisfaction a surrogate of Care? Perhaps, but our current patient satisfaction metrics are only accurate for HOSPITALS, not individual doctors. Do we need evidence-based research to know that #2-#4 leads to better outcomes, less opioid-related death, increased patient satisfaction, better patient safety, and less physician suicide? Some would say we do. Do they really #2-#4? Wouldn’t it be great to measure how much they really care?
For most patients, modern medicine has made it easy to diagnose the medical condition, irrespective of the root cause. What modern medicine is increasingly failing to do is: heal the patient. It is my experience that irrespective of what type of #1 you provide, #2–#4 play a HUGE part in the healing process. By definition, Artificial Intelligence will NEVER be human and therefore incapable of providing #2-#4 for the masses, unless the masses change their definition of human first! This is more likely…
Let’s Ask the Right Questions
It turns out that we’re all just off on our frame of reference- it’s about every definition of the word care, #1-#4. The good news about what is being proposed here is that if you agree, you’ll realize that even the idea of “bad” doctors should be impossible… When ANY type of worker stops caring, isn’t that when they should seek something new? Sadly, no physician would disagree that the Care metric has been on a downward trend in the past decade. If it existed, the Care metric could help us all anticipate burnout and engagement waaayyyyy better, but what is really exciting is the potential effect it might have on our process improvement efforts!! How would our care environments look when every single worker #2-#4ed for every single task they performed?
If we all can agree on this proposal, the questions change for every one of our innumerable health care debates. The new question becomes: how can we enable doctors and health care workers to #1-#4 for their patients? Isn’t this what we all want from our health care system? I think we would all gladly pay for this type of care.
*Actually, the best determinant of health care quality is ACCESS to information, so this patient was actually smarter than the average bear.