By Philip R. Alper,MD
Dr Alper is Clinical Professor of Medicine, University of California, San Fransisco, Visiting Scholar, Hoover Institution, Stanford University, and Practices of Internal Medicine in Burlingame, Calif.
I've been around the medical block for a long time, and the best advice I've heard on how to be a good doctor came long ago from a colleague I respected. It's so simple that it will never appear on any board exam or as a clinical guideline. And yet it's also so profound that it can be compared with playing Mozart, which has been described as too simple for beginners and too difficult for virtuosi.
We were chatting after consulting over a young hyperthyroid patient who was in thyroid storm and who would need an eventual thyroidectomy. "You know," my colleague said, "good doctors worry about their patients." It was an offhand comment, but it caught my attention, because it said so much in so few words.
Doctors who worry about their patients keep up-to-date, listen to their patients, and think about not only what they say but also what they haven't said. They second-guess their own impressions because they are aware of the potential for error (as I discussed in my September column). More than adherence to clinical guidelines or being paid for performance and recertification, the combination of good medical training and worrying about one's patients is likely to lead to the highest quality care.
Obviously, this flies in the face of the entire movement toward accountability and outcomes analysis, the underlying premise of which is that only measurable results count and not soft and fuzzy platitudes. I don't disagree, but it should be obvious that there isn't enough time or money to measure everything and that what is measured is a proxy for everything that isn't measured. We ultimately take it on faith that doing well in one thing—or two, or three, or whatever—is a reliable guide to how we treat everything else. It's convenient to think so, even as we have to acknowledge that it's very naïve.
The less-competent doctor worries most about himself or herself. Will I botch the case? Lose the patient? Get sued? Fear may be a motivator to perform (as malpractice lawyers never cease to remind us). Better yet is worrying about the patient. That puts the patient and not the doctor in first place. It's a different mindset, one that's likely to lead to a host of good behaviors, ranging from keeping up with the journals to avoiding snap and uncorroborated judgments and to consulting with colleagues in the face of uncertainty. In my opinion, it's the patient's greatest guarantee of safety. No matter that it will elicit big yawns from consumerists and the healthcare management industry.
Putting the patient first is really at risk these days, because while everybody pays lip service to it, it's harder and harder to implement in a managed care environment. Patient advocacy risks pitting the doctor against everyone else. This may even include other doctors, who have their own agendas to pursue—hospitalists, for example—as well as the usual suspects: insurers, the government, and their intermediaries. Our age of unbridled capitalism also cynically exploits and denigrates caring (which is very close to worrying). Witness the routine and meaningless, "We care about your call" that comes in an automatic phone response, usually as a prelude to an interminable wait on "hold."
Doctors aren't saints. We tend to reflect the times we live in. A thoughtful, middle-aged surgeon recently described his view of the ethos of the emerging generation of physicians as, "It's all about me." He told me that their interest in lifestyle and amenities may begin with restriction in training hours. Although well intended, it does interrupt continuity of care and learning first-hand about how diseases and treatments progress. "That gets in the way of commitment," he says.
But do new doctors really perform poorly as a result, I asked? I had trouble believing that. My surgeon friend thought hard and answered, "No, but I think it's because they're specializing in narrower and narrower areas. Keeping up, maintaining income, and preserving lifestyle all become easier that way."
Narrow focus may even facilitate putting the patient first—but only in the narrow domain of the specialist. "Doctoring"—in the broadest sense of the word—is not facilitated.
The odd thing about doctoring is how hard it is to accurately describe. It's probably as resistant to capsule description as defining "obscene" speech—an issue that has preoccupied the Supreme Court for half a century. And if I can be permitted a bit of literary license to further the analogy, Judge Potter Stewart's comment that, however hard obscenity is to define, "I know it when I see it" might equally well apply to good doctoring. In fact, good doctoring is easier to spot when you lose it than while you have it. Perhaps that is why it is so often taken for granted.
How Doctors Think
Of course, attitude and orientation can only do so much. Awareness of the sources of cognitive error can do a lot to make us better doctors. In my review (in September) of Dr Jerome Groopman's book, , I began to discuss cognitive errors, concentrating mainly on how we see what we expect to see rather than what is there. Patients who are familiar to us, and those who come prelabeled with a diagnosis, present the greatest risk of prejudgment and consequent mistaken diagnosis.
We also play the odds when we say that hoofbeats are more likely to suggest horses than zebras. But it is one thing to say that diagnosis A is more likely than diagnosis B and quite another to actively resist making the less likely diagnosis or at least keep it in mind. Instead, we seek diagnostic closure so we could move on. That leads us to be overly influenced by context—either what's "going around" or the mix of similar cases we've recently seen that then short shrift our examination of the present evidence. We risk fooling ourselves by prematurely concluding we've encountered more of the same.
I use the inclusive "we" and "us," because studies have shown a diagnostic error rate among internists of up to 15%, and I suspect that few, if any, among us haven't experienced what I've been talking about. Because most errors don't have serious consequences, they tend not to make a big impact on our psyches, are easily forgotten, and therefore leave us overconfident of our abilities.
Drug side effects pose a special problem. There are so many of them listed that it is easy to disregard all but the most common. "I doubt that the medication is causing that" is something I've heard myself say many times. And my resistance to acknowledging a drug's side effects that aren't "serious" goes up when we are treating a significant disease and don't have good alternative medications to use. Perhaps I'm reluctant to either condemn a drug when I'm not certain or tell the patient to "just live with it," because the benefits outweigh the discomfort. Here too, I doubt that I am alone in this dilemma.
And then there is technology and the use of the order pad in place of the physical examination. To illustrate: a California woman with lower abdominal pain showed an absent uterus on ultrasound. Her reported "hysterectomy" turned out to be a massive uterine prolapse. Nobody had examined the patient. Similarly, a Texas woman had an emergency surgical consultation for an "effusion" on ultrasound that turned out to be a breast implant. The pursuit of excellence begins with small things.