What's a good doctor, and how can you make one?BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7366.667 (Published 28 September 2002) Cite this as: BMJ 2002;325:667
By marrying the applied scientist to the medical humanist
- Brian Hurwitz, professor of medicine and the arts.,
- Alex Vass, editorial registrar.
I remember the time Shipman gave to my Dad. He would come around at the drop of a hat. He was a marvellous GP apart from the fact that he killed my father. 1
Are you a good doctor? This question is increasingly being asked by patients, governments, third party healthcare payers, and newspaper, radio, and TV investigators. It also topped the list of suggestions for BMJ theme issues in a recent ballot of bmj.com users and BMA members. But why?
Claims and complaints against doctors are growing worldwide. In the United Kingdom, a series of inquiries has ushered in probably the most sustained investigation and collective appraisal of medical and healthcare institutions since the NHS began. The performance of individual clinicians, laboratory and clinical units, the frequency of medical mistakes, the unacceptability of organ retention practices, and the adequacy of death certification procedures are only a few of many medical activities now subject to intense scrutiny. 2–8 A debate has thereby been prompted about the sort of doctors society wants and expects, and the need for answers is heightened by expansion in spending on medical education and health services.
One approach to defining a good doctor equates the answer with the skills of an applied scientist: good doctors combine individual clinical expertise and best available external evidence; they are thoughtful, evidence based practitioners who use “intangible personal resources” in the care of their patients. 9 10 Another approach lies buried in the Socratic dictum “Know thyself,” an exhortation discernible in the importance the General Medical Council attaches to vocationalism in medicine and to the personal qualities required of its practitioners, including truthfulness and a reflective turn of mind open to audit and to learning from mistakes. Readers from 24 countries responding to a BMJ debate about what makes a good doctor allude to desirable personal qualities more prominently than proficiency in knowledge and technical skills (p 715).
The psychiatrist Jeremy Holmes, writing in this issue (p 722), renders Socrates' dictum in a more modern, psychological form by acknowledging that the inner life of most doctors necessitates grappling with contradictoriness and incoherence of thoughts and feelings. If this state of affairs is the norm, reflecting on good and disapproved of aspects of the self will help doctors to become “good enough” practitioners.
But the proliferation of formal medical assessment agencies signifies that conscience and reflectivity—could they be reliably discerned—no longer offer credible guarantees of goodness in doctors. Five years ago, Richard Smith spelled out a population based rationale for setting up monitoring systems premised on the view that all doctors could potentially become problem doctors: “Think how surprised we would be by a community of 130 000 (the number of doctors in Britain) where nobody committed serious crimes, went mad, misused drugs, slacked on the job, became corrupt, lost competence, or exploited their position.”11
Society and government now look towards a mix of healthcare process and outcome variables for evidence of clinical competence (p 704)and, where possible, to markers of compliance with standards, guidelines, and clinical service frameworks. Are such variables set to become surrogate measures of the goodness of practitioners?
Does the notion of goodness have anything to add to what we want from doctors once their competence and performance have been specified and verified? After all, when “good” (as an adjective) qualifies “doctor,” a great deal of its meaning is determined by what is meant by “doctor.”12 This, in turn, is set out in education and training curricula (p 718) and in the knowledge, competences, and values to be demonstrated in the process of gaining a primary medical qualification.13 When it comes to doctoring, the term “good” increasingly functions as a descriptive label that denotes having met certain tests of competency.
A poor doctor is generally credited with good intentions but inadequate knowledge or skills required for the job, and there seems little doubt that some poorly performing doctors will be picked out by performance monitoring procedures. But what about bad doctors? A bad doctor, however skilled, is one with bad intentions, undesirable values, suspect—occasionally evil—motives. Judging someone a bad doctor implies serious defects of moral agency, even though these may coexist with commendable aspects of medical practice, as the above statement from the son of one of Harold Shipman's victims makes plain. Although the death rate of Shipman's patient list turned out to be high when examined retrospectively, performance outcome measures cannot detect bad doctors in all possible circumstances.
The varieties of good, poor, and bad doctors are diverse and may sometimes coexist in the same individual. This does not make becoming a good doctor an unattainable ideal. Medical education today should be aiming to marry the skills and sensitivities of the applied scientist to the reflective capabilities of the medical humanist.
Conflict of interest None declared.