The role of the doctor
BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39399.659144.47 (Published 15 November 2007) Cite this as: BMJ 2007;335:0
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
The need to redefine the role of a doctor is based on changing disease
patterns and our changing perceptions of health, pre-disease and disease
states .The biomechanic view of health which, at one point of time
addressed most of our health needs does not do so today.Indeed, the
fundamental causes and remedies of our health problems are quite outside
the domains of our day to day care.
The concepts and perceptions of health are undergoing constant
metamorphosis.
The doctor today is more than ever before required to adderess
health in its totality i.e. encompassing an integral oneness of body-mind-soul. The reality of subjective dimensions of health is being
increasingly acknowledged by studies of psychoneuroimmunology.
A heightened intellectuality or an intuitive spirituality will
provide us broad outlines as well as minutest details for redifining our
fundamentals of what we understand as disease and what we want our health
care and medical education system to come up to meet the demands for
which an ailing patient looks up to us.
We can provide health, but can we provide healing ?
We need a Consciousness based approach to health to shape our health care
services which will not negate the best of our science but fulfil the
patient's expectations completely.
Competing interests:
None declared
Competing interests: No competing interests
In your editorial you have laid out many of the features that make up
the doctors' role. In response to the cartoon "Do you want to see 'nice
but average doc?' or 'grumpy but good doc'?" the patient's answer would
always be "I want to see nice and good doc"!
To my mind the most important thing for a doctor to provide for
patients is the confidence that they will be given attention and the best
possible treatment, that they will be told the truth, however unpalatable,
but in a kind and sympathetic way and that their doctor will admit when
s/he doesn't know the answer, but will find out or make the appropriate
referral.
I went into Medicine because our family GP always made me feel
better. Being an anxious child, when I was unwell I expected the worst,
but his presence made me feel everything was now going to be all right.
This, I think, is a key role for a doctor and probably one of the few
things the robot or machine cannot replicate.
Competing interests:
None declared
Competing interests: No competing interests
It is unfortunate but opportune when the core role of the doctor is
being considered to have the recent report that inadequate care occurs in
half of A & E trauma cases together with the details arising from the
inquest into the death of Diana Princess of Wales. These, together with
the knowledge that a major source of serious complaint against doctors
relates to failures in diagnosis which in turn often arise from taking
inadequate histories (it will be a foolish doctor indeed who relies on a
central data bank as an alternative to taking an adequate history when
possible) leads to an inevitable conclusion, that the most appropriate
core skills of a doctor should be the ability make an accurate diagnosis
and follow this through with the procurement of the best forms of
treatment. Only a medical doctor, out of a whole plethora of health
professionals, has the best greatest potential for this skill based on
knowledge, training and experience..
Sadly the GMC guidelines and a trawl on the internet through the
various rather banal mission statements from medical establishments show
that an accurate or indeed any diagnosis is rarely seen as a priority
amongst desirable goals - although there is much on interpersonal
sensitivity and non-possessive warmth towards diverse conditions and and
ethnicities, which is fine but surely not of greater importance than
basic good medicine.
Competing interests:
None declared
Competing interests: No competing interests
The role of the Doctor is changing in the brave new world of the MMC
particularly for F1 doctors . Traditional values of compassion combined
with astute time consuming attention to detail, in order to make an
accurate diagnosis are being replaced by new more resilient ones which
are appropriate to the altered working environment they find themselves
in. Working in the NHS today, is similar to working on the production line
of a very large impersonal factory . The analogy being particularly
vivid in hospitals.
The F1 doctor’s role is like that of a shop floor factory worker.
He or she must be able to look at the patient simply as a product on
the conveyor belt of the NHS factory. All empathic sentiments must be left
with their coats when the workers clock in at 8.30 in the morning.Any
emotional feelings about the product (patient) or extra time spent talking
to it would only waste valuable factory time .The product must get
through the system in the specified time and the factory worker (F1
doctor) must commit all his or her energy to making sure that as many
products get onto the conveyor belt as quickly as possible. The new
factory worker emerging from the MMC needs to be cold and unfeeling.He or
she must also be reasonably efficient, athough cutting corners is
acceptable as long as the product has a label (diagnosis) on it. The
supervisors (consultants and registrars) do not usually check that all the
labels are correct as they are so busy themselves, usually in another part
of the factory . So even the correct label is not important, the only
thing that matters is that the labels are slapped on as quickly as
possible and that the products look as if they are finished.Unfortunately,
the products often break again after leaving the factory but that doesn’t
matter as long as the managers can tick the boxes on their clip boards
and count that the right number of products are delivered for the target
count at the end of the day.
New factory workers no longer need to adhere to the outdated
Hippocratic Oath.Their new oath states that their purpose in the factory
is ‘to keep to the targets set, whatever the human cost’. Workers must be
exemplary at filling in forms and excel at ticking boxes. To do this
really well, it is essential to become skilled at working with one hand
only, as the other hand will be needed to carry their own clip boards
which give evidence of the tasks they have completed.Luckily this is not a
major problem, as examining the product by touching it or with a
stethoscope has become virtually obsolete due to the fact that every
product is put through the scanner before being despatched.
Factory workers should preferably be loners who are self reliant as
it is thought to be more efficient if everyone in the factory works
independently since this helps the factory to keep to its European
Working Hours Directive (EWHD). The factory runs on a minimum of
available supervisors ( consultants and registrars) and most of whom are
tied up doing specialist tasks in offices ( clinics) or repairing products
in the workshops (Operating theatres).If the workers ( F1 doctors) on the
shop floor need help with an especially difficult product (patient) or the
conveyor belt goes wrong and starts to cause damage , they must not expect
to get help from their supervisors. The old way of working in teams (or
firms) which were responsible for different parts of the factory,is no
longer thought to be efficient and the newest factory workers are expected
to try and fix the conveyor belt themselves. One of the best survival
skills for new factory workers is to be overconfident and happy to blindly
guess how to deal with problems . A useful maxim for a factory worker
would be ‘Que sera’. No matter what happens today, it is best not to care
too much as there will be lots more products arriving tomorrow, so
having a laid back attitude to what one does today is essential for one’s
psychological wellbeing. A false sense of confidence is especially
important when working at night as the factory workers must be sure that
they can run the whole factory with only one or two other workers. Night
work requires an ability to relax despite dealing with a large amount of
uncertainty and often very little supervision.Finally the new factory
workers must be very happy, even eager to leave exactly on time at the
end of their shift and to be blasé about the many unfinished jobs on their
production line.If they don’t leave on time, they will be punished by the
EWHD whipping boys and will be unlikely to get a reference from their
supervisors.
The old style workers ( houseman) would not be effective in the new
NHS factory .If they were diligent and meticulous in finishing the
product carefully and worried about putting the right label (diagnosis) on
each one, it would take too much time and time is money for the factories
. It would take even more time if they were to try to examine the product
in the old fashioned way using stethoscopes and their hands, rather than
arranging the factory standard battery of tests .This would lead to a lack
of ticks in the boxes which would upset the whole system and may even
bring production to a halt .If God forbid, they were to try to find out
more about the product (talk to the patient) they would really start to
have problems in keeping to the EWHD. One solution would be to miss out on
breaks for meals and drinks.However, eventually this would lead to long-
term sickness and they would be no good to the factory. They might try to
overcome the limitations of the hours by staying on late and finishing
some of the products that they had not been able to complete properly,
earlier in the day. These workers would have to be careful and sneak about
the factory unseen, whispering quietly so as not to be rumbled by the EWHD
spies. They would only be able to save their jobs by falsifying their time
sheets.
If the old style workers were to start looking closely at the
products and begin to worry about the fact that they are sometimes not
packaged very safely, they would not be able to sleep at night and so
would be useless in the factory the next day. These types of concerns
might well make the traditional style workers so unhappy, that the job
would become untenable and they would vote with their feet.
The role of the new F1 doctor is to assist the NHS ‘factory’ in
reaching its ‘targets’ and this must be achieved whilst sticking rigidly
to the European Working Hours Directive. Attention to the individual
patient is not required and would indeed be a disadvantage due to the time
required. We need no longer look for applicants to Medical School with
altruistic tendencies who want to do Medicine because they ‘like helping
people’ as these qualities are actually a disadvantage in a target led
NHS.This system is rapidly squeezing out the traditional caring role of
the doctor . The new science of administration and management has created
a doctor who is prepared to swallow the powerful potion of reduced waiting
lists and targets mixed with a good dose of EWHD so instead of Dr Finlay
we will have Frankenstein’s F1.
Competing interests:
None declared
Competing interests: No competing interests
The role of the doctor is fourfold:
-- To preserve health
-- To manage disease: treat, mitigate or palliate
-- To act as patient advocate
-- To educate: self, colleagues, patients and the public at large
The nature of medicine is changing much faster than the practice of
medicine: we are human and as such the older we get, the less flexible,
the less malleable. The role of the doctor cannot be tied up in specifics
because life is complex, uncertain and--at the individual level--entirely probabilistic.
Competing interests:
None declared
Competing interests: No competing interests
THE ROLE OF THE DOCTOR – TOUGH LOVE
It may help to understand our core role if we first understand and
accept the responsibilities that come from being a member of a
“profession”. This is an old chestnut and one about which there are levels
of understanding. The definition and concept I relate to is expressed in
the article by John K Davies in the Journal of Applied Philosophy back in
1991.
He considers a professional’s duty is not primarily to please but to
do or advise the “right” thing. Usually this does please as well as
alleviate the problem but at times what is said or advised is not what the
patient wants to hear. The integrity of the doctor and what gives him or
her professional status is the willingness and ability to take a difficult
or even unpopular stance because he or she knows, in good faith and not
paternalistically, that this is the best advice, informed by up to date
knowledge and opinion.
Doctors are in a privileged position and the concept of
professionalism as described above is perhaps subconsciously recognised by
society in awarding that privilege. With that privilege comes a
responsibility to always act professionally by being well informed. and
being able and prepared to provide “tough love” if necessary. In my
opinion the reason we are prepared to do this is because we CARE.
The irreducible core value of a doctor is that he or she CARES for
the wellbeing of his patient/client/population.
It is a sad fact that in my opinion the profession has not understood
this fundamental reason why most of us become doctors. We want to learn
and apply some of the ways (offered by the whole medical spectrum) by
which we can play a role in caring.
The soul and indeed our purpose for practising medicine is in danger
of being lost if we are not allowed to undertake this role because of
management and professional practices which emphasise process and
productivity. If doctors become unable to satisfactorily care for their
patients then their reason to remain in and maintain the standards
required of the profession will be lost leading to disillusionment and
perhaps the loss of moral we see at present.
This perspective raises many issues regards selection, education and
practice that time precludes from addressing now.
Ref.
John K Davies. Professions, Trades and the Obligation to Inform. J of
Applied Philosophy, Vol 8 No 2 1991 p168.
Competing interests:
None declared
Competing interests: No competing interests
I enjoyed reading this week's journal and it made me think of what
patients might expect of their doctor- so here is a distillate of a few
years experience. I suspect at the end of the day the core values of
doctors will not have changed but they have been temporarily misplaced
because there is so much else going on around medicine. It's a good time
to bring these values to the forefront again.
I regard a doctor’s clinical roles as essentially simple in their
objectives- firstly to differentiate between the temporary unwell and the
ill with accuracy, secondly be decisive and confident in giving advice on
therapy in its broadest sense and then thirdly ensure each patient has
access to the skills and facilities required. In short sort out the
problem for the individual patient. Some would call this approach
paternalistic – but who would accuse their plumber of being so when they
respond to your call for help -so what is the difference?
All of the above can be handled in terms of opinion and advice and
not dictats and patients, if they choose, should be involved in the
decision making. What is frequently forgotten is that a significant
proportion of patients would prefer the doctor to act on their behalf and
are confused by being faced with important decisions at a time when they
are already stressed. As patients differ in personality and approach
doctors need to develop the skill of identifying these differences and
adapt their consulting manner accordingly. Always advise and never
dictate, only reassure when it can be justified and mix bad news with
positive advice on what can be done to help. Never overstep one’s remit-
no-one knows everything so be prepared to help patients seek second
opinions and don’t be surprised when they come back to you!
In short- honesty with patients, a degree of humility, be supportive
and give patients confidence but it has to be based on ability.
My professional life was spent amidst a growing tide of political
correctness and vociferous media coverage of social trends as they abut on
medicine. These have been important in drawing doctors’ attention to the
need to adapt and be more sensitive to patient needs. Nevertheless the
simplistic advice laid out above – you would expect that from a surgeon-
has determined how I think doctors should continue to manage the ‘one to
one’ relationship that is the essence of all consultations- used in its
broadest sense where any doctor contributes to a patient’s care.
Consultations are the basis of the patient/doctor relationship -
everything else follows from that – and if done well doctors will continue
to make their contribution to ensuring a high standard of healthcare.
External influences cannot be ignored but they should not cloud the core
responsibilities in patient care.
I do appreciate that it is easy to sit back and pontificate when out
of the front line and importantly I do realise that time restraints and
intensity of work are often the reason why doctors are not always perfect
in their approach to patients. This message needs to be got across to the
powers that be. Meanwhile I am enjoying my retirement where time
management is equally as important!
Competing interests:
None declared
Competing interests: No competing interests
Perhaps it's too obvious to need stating, but the role of a doctor is
to use expert knowledge of processes of health and disease to promote the
former and minimize the latter. The rest of what it takes to be an
effective doctor is secondary to this, the primary objective of medicine.
Competing interests:
None declared
Competing interests: No competing interests
There is only one role of the physician that cannot be replaced by a
computer or a robot; a compassionate guide for a patient through the
journey of an illness.
E. Fitzgerald
Competing interests:
None declared
Competing interests: No competing interests
First need to know what makes a doctor to know their role
To understand the role of a doctor, one must first take a step or two
back and understand what is and what makes a person to be a doctor, or for
the pedantic, a proper, true doctor in its outright, as the founders of
medicine said.
A doctor is supposed to belong to that community where there is some
common cause, common feelings and mutual solidarity. The implication is
the doctor is a member in a community where the same body of the
individual is crucial for its survival and development. The doctor has a
big say and great weight in influencing their "medical clients"/patients
and in righteously guiding their orientation. This may answer one
responders question partly the role of a GP.
There should be good qualities and noble characteristics which should
be observed in dealing with others, the foremost among people who should
enjoy such good qualities must be with greater reason doctors. That is
their role.
In addition, of such qualities are the following:
A. Mercy, tender-heartedness, gentleness and patience. Doctors should
stick to such characteristics because they deal with people inflicted with
illness which makes them psychologically stressed.
It is indisputable that such "medical clients"/patients are the
foremost among other people who should receive due care, mercy and
leniency, especially from doctors to whom they are entrusted if a doctor
loses such qualities, one then loses the most important characteristic in
one's profession.
B. Among the most important qualities which a doctor should observe
is honesty in the broadest sense. Honesty to themselves will inevitably
produce a clean, open, good, sincere loving heart, mind, body and soul.
The doctor should guide the "medical client"/patient to that which
will benefit him in absolute honesty and precision. He/she should not
divulge patient's secrets unless there is a necessity. He/she should exert
his utmost to make the "medical client"/patient comfortable and lead him
to recovery.
I concur with previous responders that education of the society is
paramount, and for that practise what you preach is also a necessity for
doctors to not befall the bad virtue of being a hypocrite.
Doctors need to read the Hippocrates oath every morning before work
and understand that their role is not just a career but their life, as is
a person who is ordained to be a priest. Act with the wisdom that the
ancient doctors had, that we lack and believe the knowledge today makes us
infallible to any criticism or our roles today.
Peace to you all! :)))
Competing interests:
None declared
Competing interests: No competing interests