To Be A Doctor

About a month ago, senior medical students across the country were celebrating Match Day.   This is the day they discover the next step on their path to becoming a physician, when they are ‘matched’ with a residency program in their chosen specialty.  Many will feel relief, believing realization of their goal is now clear.  Complete the journey through their training and they will become the physician they set out to be when they first applied to medical school.  If it were only that easy.   As the college one attends does not determine someone’s intellectual ability, the residency program does not guarantee who will be an excellent doctor.  This led me to think about what actually does make a good physician?  What are the qualities needed, no matter the training or academic pedigree, to be an outstanding doctor in the twenty first century?  

Pride. A doctor, or any one for that matter, needs to have pride in what they do.  You have to believe what you are doing is important, that you are doing it well, and when looking back on your work that it is the best you could have done.  For a physician, that will mean it demonstrates thought, caring, and sound medical decision making.  It will mean that at the end of the day you can look back and say that you did everything you knew to do for your patients to the best of your ability. 

Humility. While pride is needed, it can become a negative quickly.  Early in my career I recall pride overwhelming me after a series of good patient outcomes I mistakenly attributed to myself.  It was right about the time I could feel myself walk a little taller, buttressed by my unique ‘doctoring’ genius, that I was confronted with a call about a patient of mine not doing well despite my best efforts.  It did not take but a few times for this lesson to quickly sink in, that medicine is a humbling practice.  We can do the right things, follow the correct protocols, consult the appropriate specialists, provide the correct interventions, and yet the patient will still not recover or survive.  It is essential to remember that as a doctor we are working in an unpredictable service, one with great feelings of joy, but with opportunity for great disappointment as most of the outcomes we seek are out of our control.  Humility also teaches us to ask for help, that we do not have all of the answers. The old training message that it is weak to ask for help is misguided.  It is strength that allows the physician to ask his colleagues for their assistance and expertise, and the physician who fails to do this will be also be failing their patients.

Perspective.  Many may use the term empathy, but I am not sure that empathy serves a physician.  That term implies too strong of a relationship with a patient’s suffering, and that is  a dangerous thing for a doctor as it could negatively impact their decision making.  I choose to think of perspective as a more appropriate characteristic.  We need to remind ourselves, every day, what it is like to be that patient we are seeing at 1015am while we have two pages to return, a drug rep waiting for a signature for samples, and dreading a 1030 phone call to dispute an insurance company’s refusal to allow a PET scan.  That 1015 patient is going to see you today because they need you, and they rescheduled work, or arranged childcare, or had their cousin miss work to drive them to your office, all for these fifteen minutes of your time.  They need your attention, your expertise, and your focus.  All too often we will fail at this, but we have to recall why we do what we do, and who we truly serve. 

Curiosity.  Physicians have to be intellectually curious.  We have to want to learn constantly, and that does not end when our training ends.  Medicine is in constant evolution, faster now than ever.  We have to keep up the best we can, and be curious about what we can do better, what treatments serve our patients better, and how to provide the best care possible.  (And this can be done without Maintenance of Certification activities, but that is the topic for another essay.  Don’t even get me started.)

Communication.  The ability to communicate is essential to an exceptional physician.  Talking to nurses, letting consultants know specifically what we need from them, asking the right questions of referring physicians.  Most of all we need to learn how to clearly speak with patients, to explain to them what is wrong and what we are going to do to help.  Or those tough times when we have nothing to help, but we need to let them know we are not giving up or have stopped caring. An often forgotten element of communication is listening, probably the most essential part of this exchange.  So much is learned from listening to the patient describe what is wrong, and this is the most essential component of their visit.  If we just let them speak and tell their story we can most often learn why they need us and how we can help.  If we listen to the ICU nurse who has spent the past ten hours with their patient we will gain more knowledge than staring at a screen of lab results and images.   If we listen to a family member we will learn what really has been going on at home that led them to needing our help.

Courage.  More than strength, physicians need courage.  Every decision we make is out in the open, exposed in the medical record for all to see.  Now more than ever, those decisions will be examined and criticized.  By the family member who disagrees due to what they read on the internet.  By the insurance company who disagrees with your choice of test, or medication, or procedure.  By another physician, who you have asked for help and may either internally or externally critique the care you have provided.  It takes courage to be able to do this every day, to expose your work to others and be able to stand behind your decisions and defend them to all who question. But this is needed, and what is truly the point of the training we endure.  This is what we are learning during those endless rounds, when we are postcall and exhausted and our consultant is drilling us on why this patient (the sixth one you admitted that night) is short of breath if their chest xray is normal.  This is what we learn when we are drilled with questions during our surgical conferences, being asked to defend every step we took to take the patient to the OR, and then every decision we made during their procedure.  This is what we learn in the ICU, hearing distraught and frustrated family members ask us why we are failing to save their loved one from the horrors of ARDS. 

But it also takes courage to examine our decisions and acknowledge when we could have done better.  This is an essential part of the practice of medicine.  We have to look back and know when different decisions could have been made in the service of our patients.  To learn what we would do next time, who we would ask for help, what test or procedure should have been done earlier.  Mistakes will be made in the care of our patients, and it is the courageous physician who will acknowledge those mistakes, learn from them, to better serve those who will put their trust in us.