The Good Doctor

What Patients Want

Ron Paterson

• Publisher: Auckland University Press
• Year: 2013
• Print ISBN: 9781869405922
• eBook ISBN: 9781775581864
• Topic: Medicine
• Subtopic: Health Care Delivery

Drawing upon real accounts of negligence, incompetence, and distrust, this book seeks to identify the key competencies of a good doctor, the ways in which medical care fails, and the roadblocks to ensuring that every licensed doctor is capable. Arguing that it is possible to improve patient care—by lifting the veils of secrecy and better informing patients, by establishing more effective ways of checking doctors' competence, and by ensuring that medical watchdogs protect the public—this discussion offers an expert's perspective on health care.

1

THE GOOD DOCTOR
THE IDEAL

In this part of the book, I seek to describe the ideal situation, in which patient expectations of receiving care from a good doctor are routinely fulfilled. I explain what I mean by a good doctor, based on the views of patients and doctors themselves. I introduce the concept of the ‘good enough’ doctor, who may not be excellent but who fulfils our expectations, in contrast to the ‘problem doctor’, who does not reach this threshold. Finally, I explain how, in an ideal world, patients would be able to rest easy in the assurance that every licensed doctor is a good doctor.

What is a good doctor?

‘Patients need good doctors’, proclaims the General Medical Council (the statutory body that has regulated doctors in the United Kingdom since 1858) in the opening statement of its guidance for doctors, Good Medical Practice.1‘Everyone is entitled to a good doctor’, states Donald Irvine, paraphrasing William Osler, the acclaimed scholar and teacher who was said to epitomise a good doctor at the start of the twentieth century.2 ‘Most doctors are good doctors in the eyes of most patients’, writes health advocate Angela Coulter.3 The phrase is bandied about in the health policy and sociology literature about doctors, and in the media when individual doctors are praised for their community service, or defended by patients in the face of official sanctions for misdeeds.4

In his powerful novel The Good Doctor, author Damon Galgut contrasts the characters of two doctors, one deeply cynical yet realistic, the other naively optimistic and seeking to do good, in remote, rural post-apartheid South Africa.5 The reader is left to ponder whether either of these flawed men is a good doctor. The word ‘good’ when applied to doctors is ambiguous, speaking both to the motivation and character of the workers, but also to the quality of their work. This ambiguity is reflected in attempts to define the attributes of a good doctor, and to describe the characteristics of good medical practice. Invariably, the desired qualities relate to both motivation and performance. The duality is also seen in an influential seventeenth-century definition of a physician as vir bonus medicinae peritus, a good man expert in medicine.6

Governments, insurers and employers, as funders of medical care, are interested in what makes a good doctor. So, too, are the medical schools and colleges that train doctors, the medical professional organisations that seek to promote the interests of doctors, and the regulators charged with overseeing medical practice. The ultimate arbiter, of course, should be the patients on the receiving end of medical care.

Patients’ views

Individual patients form their own views about what to look for in a doctor, influenced by personal experience and the experience of friends and family. With the burgeoning literature about doctors and health, some patients may even be primed in how to get the best out of their doctor, and alert to pitfalls in medical practice.7

Patient associations represent patients’ views in advocating for the standards of care and practice they expect of doctors. Health researchers, health policy and advocacy organisations, medical associations, medical regulators, and funders periodically undertake surveys and debate what patients look for in doctors. In the discussion that follows I have drawn on published surveys and literature from such groups. My thinking is also influenced by my observations from reading hundreds of letters from patients about their doctor, in which they praise great care and lament failings.

Technical competence

Patients generally rate technical competence as the most important attribute in a doctor. By ‘technical’ competence I mean the knowledge, training and experience to provide an appropriate level of medical care and the practical skills to do so. Some researchers draw a distinction between ‘competence’ (knowing what to do) and ‘performance’ (doing it),8 but I doubt that the general public makes this distinction. People expect both in their doctor. Competence in communication is obviously an important aspect of broader clinical competence, but patients generally differentiate between ‘bedside manner’ and knowledge or ‘technical’ competence.

Patients understand that doctors are cogs in a complex health system, and that sometimes things go wrong in health care. Public reports and media coverage of ‘serious and sentinel events’ causing harm to hospital patients have become relatively routine.9 The public is also used to being told, in the wake of human tragedy in many settings, that the outcome was caused by a ‘systems’ problem. However, in my experience, people are sceptical about the claim that the vast majority of unintended harm to patients is caused by faulty systems, not incompetent individuals – at least when asked to apply that general proposition to a specific case. The public and the media look for an individual practitioner to be held accountable.

Even if we accept the key role of safe systems in delivering safe care, the technical competence of individual health practitioners, especially doctors (who are often in the driving seat), remains a crucial factor. As Nancy Berlinger writes: ‘Mistakes are made by individuals, even if these individuals are working within systems.’10 Patients expect their individual doctor to be skilled and competent, and are wary of experts who glibly invoke the ‘systems’ mantra in the aftermath of disaster.

Public surveys and submissions from patient advocacy groups confirm this expectation. In a 2009 survey of 289 customers of 10 pharmacies in Dunedin, competence was ranked as the number one professional attribute for a doctor.11 In a 2006 submission, the Federation of Women’s Health Councils Aotearoa New Zealand noted that patients expect a ‘[h]igh level of medical competence – good up-to-date medical knowledge and diagnostic skills, sound technique for medical procedures and awareness of limitations’.12 In a 2010 survey of 502 members of the New Zealand public, 97 per cent agreed with the statement that it is essential that doctors stay up to date with developments in medicine.13 (Hardly surprising – indeed it’s intriguing that 100 per cent didn’t agree with such a leading statement, and that 1 per cent ‘strongly disagreed’ with the proposition!)

Of course, most patients have no knowledge of a doctor’s training (at best they may notice a faded degree certificate on the surgery wall), experience, or current skills. Unless a doctor is obviously inept at history taking, examination and diagnosis, it is difficult for patients to judge their competence – though an expert patient may sense that something is amiss. In A Fortunate Man, a moving account of an English country doctor in the 1960s, John Berger writes: ‘You have to be a startlingly bad doctor and make many mistakes before the results tell against you. In the eyes of the layman the results always tend to favour the doctor.’14

As a general rule, in the words of Donald Irvine, ‘although patients can judge a doctor’s personal qualities, they have to take clinical competence on trust because they cannot assess it satisfactorily’.15 Patients assume that their doctor knows what to do, and can do the job competently. They appreciate that medicine is complex and that sometimes specialist advice is needed. They expect doctors to recognise the limits of their own professional competence and refer to another practitioner if they are out of their depth.

Putting patients first

Technical competence is only part of the equation. Patients also value other professional and personal qualities in a medical practitioner. If asked, members of the public list a wide range of desired nontechnical attributes. One key quality is whether the doctor makes the care of the patient his or her first concern. In a survey of 98 members of the public undertaken by the Picker Institute in England in 2006, this was rated as the most important duty of a doctor by 78 per cent of respondents.16

How are patients to judge whether a doctor places their best interests first? It is something that patients take for granted and are not well placed to assess. There may be glaring examples of a doctor being distracted and not focusing on the current patient – for example, interrupting the consultation to take a non-urgent cellphone call about a business matter.17 In the absence of obvious omissions to give primacy to their interests, patients will assume that they are the main focus of the doctor’s attention. They trust this to be the case.

Patients understand that there are competing demands on doctors’ time. They are generally tolerant of having to wait, but if the doctor says a referral letter will be sent, or test results will be reviewed and the patient contacted if there is anything untoward, naturally the patient assumes that this will happen. So, if a doctor is indifferent or lax in these areas of professional responsibility, the patient will feel let down; that their care has not, after all, been the doctor’s first concern.

Many instances of failing to give primacy to patients’ interests will be covert. If a doctor provides unconventional treatment in pursuance of his own research theory, without his patients’ knowledge or consent – as Dr Herbert Green did at National Women’s Hospital in the events uncovered in the Cartwright Inquiry18 – they will feel betrayed when they later learn the true situation, however good his intentions. Similarly, if a surgeon takes an unnecessary biopsy for research purposes, without the patient’s informed consent,19 performs unnecessary stent operations,20 or orders unwarranted tests for extraneous purposes (such as meeting a funder’s target), the patient is likely to feel aggrieved. Such behaviour is not consistent with good medical practice, and even if the doctor claims to be well motivated, any avowal to be a good doctor is undermined by their failure to make the care of the patient their first concern.

Integrity and trustworthiness

Patients expect integrity and trustworthiness in their doctor. In the Dunedin survey cited above, being trustworthy and honest with patients scored just below competence as the most highly valued professional attributes. Like competence and putting patients first, professional integrity is something that patients assume but cannot easily judge for themselves. When a doctor is revealed to have betrayed a patient’s trust, both the conduct and the character of the doctor are likely to be criticised.

One obvious type of dishonesty is financial exploitation: the doctor who overcharges, receives an undisclosed kickback from a specialist or private facility to whom they made a referral, or sees the patient for a fee in private without disclosing the option of a free consultation in the public system.21 A more common example of untrustworthy behaviour is disclosing only the doctor’s preferred treatment intervention, or failing to disclose that an injury or complication resulted from a medical mistake. Breach of confidentiality, such as the doctor who divulges the patient’s private confidences outside the consultation room as gossip, rather than for purposes of treatment, is also a breach of trust.

More extreme examples of dishonesty and violation of trust are the physician who undertakes unnecessary procedures to provide cover for prescribing restricted medicines to which the doctor is addicted; the sexual predator who undertakes unnecessary physical examinations for personal gratification or who sexually assaults the patient; and the murderous doctor who kills an unsuspecting patient under the guise of medical treatment.

All of the above examples, to varying degrees, involve a breach of trust in which the doctor’s personal interests are advanced at the patient’s expense. Doctors who behave in this way, and are caught out, almost invariably face disciplinary process and professional censure, and may incur criminal penalties. Their behaviour is unlawful and unethical, and calls into question their integrity and moral character.

There is some survey evidence that the public is tolerant of misdemeanours in the private lives of doctors, so long as this doesn’t spill over into their professional work. This is reflected in modern medical regulation, with statutes removing requirements that relate to the ‘good character’ of the doctor. However, criminal behaviour in a doctor’s personal life (such as domestic abuse or accessing child pornography) is likely to result in professional discipline, since such conduct reflects on whether the doctor is a ‘fit and proper person’ to practise medicine.

Communication skills

One aspect of clinical competence that matters highly to patients, and that they are well placed to judge, is whether the doctor is a good communicator. Right 5(1) of the New Zealand Code of Health and Disability Services Consumers’ Rights affirms the right ‘to effective communication in a form, language, and manner that enables the consumer to understand the information provided’.22 From my experience, it will often be an aspect of the doctor’s communication or manner, rather than a simple mistake, that will trigger a patient’s complaint. If a doctor ‘talks down’ to a patient, or fails to explain clinical terms or to attempt to answer a patient’s questions, miscommunication is all but guaranteed, and the stage set for a complaint if things go wrong. Research indicates a correlation between good doctor–patient communication and impro...

Table of contents

• Cover Page
• Title Page
• Dedication
• Contents
• Preface
• Part 1: The good doctor: the ideal
• Part 2: Problem doctors: part of the reality
• Part 3: The roadblocks: why is change so difficult?
• Part 4: Prescription for change: what can we improve?
• Epilogue
• Acknowledgements
• Notes
• Select Bibliography
• Index
• Copyright Page
• Backcover