by Amy Tuteur, MD
What makes a good doctor?
There are two important characteristics. The first is clinical skill: the ability to find a pattern in the patient’s signs and symptoms, the ability to identify the pattern, and the judicious use of medical tests to fill in the blanks of the pattern. The second characteristic is compassion: the ability to care about the patient and empathize with his or her situation.
Many doctors have one or the other. Some of the greatest clinicians have excellent clinical skills, and poor bedside manner. And some of the most popular doctors have terrible clinical skills, but are easily able to deceive patients because they are kind and compassionate.
Both characteristics, whether alone or in combination, depend on one variable: time. Even the most clinically skilled doctor needs adequate time to listen to the patient, to elicit and think about all the relevant details of a patient’s situation. In the textbooks, diseases have straightforward signs and symptoms, and typical courses. As any doctor can tell you, patients don’t read the book. In other words, their signs and symptoms can vary from “textbook” descriptions or can be modified by other diseases or conditions that the patient might also have. And it goes without saying that the most important requirement for compassion is also time, the time to listen, empathize and offer comfort.
Yet if there is one thing that contemporary American doctors lack, it is time. That’s because the people who “manage” healthcare are obsessed with efficiency. In their minds, being efficient means seeing the most amount of patients in the smallest amount of time, as if efficiency in medicine should be measured by the number of patients “processed.” That’s not what it means to be efficient in the practice of medicine, though.
In medicine, efficiency means the ability to successfully treat as many patients as possible using only the tests and procedures necessary, and leaving the patients happy with their care. In the ultimate irony, the pressure to make doctors more efficient has made them progressively less efficient. That’s because no doctor can be efficient without adequate time to do the job. Simply put, no doctor can do a good job without spending substantial amounts of time meeting with and thinking about patients. Yet over the past quarter century, doctors have been pressured to devote ever smaller amounts of time to each patient, making doctors less, not more, efficient.
How have doctors become less efficient? Evidence suggests that doctors make more mistakes, and order more unnecessary tests and procedures, without a concomitant rise in successful diagnoses or longer lifespan. Moreover, patients are increasingly dissatisfied with their care. Yes, patients are “processed” faster, but medical care has arguably gotten worse, not better.
The deterioration in the quality of medical care is directly linked to the reduced time that doctors spend with patients. Because a doctor has less time to talk with a patient, he or she is less likely to make the correct diagnosis. Because a doctor has less time to thoroughly examine a patient, he or she will order unnecessary medical tests to fill in the gaps. Because a doctor has less time to think about a patient, he or she is more likely to make an avoidable medical error. And, of course, when a doctor has less time to spend with a patient, he or she is more likely to be brusque and unsympathetic.
Good medical care takes time. Forcing doctors to see more patients in less time does not make them more efficient, because they can’t make diagnoses faster, examine patients faster, or think about them faster. They can only push them through the office faster.
And that’s not efficiency.
Amy Tuteur is an obstetrician-gynecologist who blogs at The Skeptical OB.
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I enjoy reading your pieces. You may want to change “patter” to “pattern” in the first paragraph.
Thanks.
Kevin
Excellent piece.
Of course, as defined above, an efficient physician is not necessarily a good physician. But, I take issue with your definition of a good physician. Is compassion really necessary? Physicians maintain and restore good health by definition. Compassion is nice but is it necessary? You can argue physician delivered compassion is integral to health but I think not. Emotional and spiritual care is best delivery by families. Do not misunderstand me, I prefer a compassionate physician but I do not demand one just as I do not demand a compassionate plumber. Physicians have been saddled with the notion of compassionate care by satisfaction surveyors not medical science. As you stated, we all know physicians that commit malpractice routinely on unknowing, highly satisfied patients while hiding behind compassionate smiles. Compassion alone won’t cure but it can kill. Unfortunately, physician time is tightly rationed and we may have been driven to a fork in the road; compassion versus clinical excellence. Compassion and clinical excellence are not mutually exclusive and not of equal value in medicine. Clinical excellence must be the road we take.
It is a commonly held belief that the physicians of today’s era actually see more patients than they did 30 years ago – but as a junk store junkie and bibliophile I have over the years acquired several ledgers from doctor’s offices spaced over the last 75 years. The amazing thing I have found when sampling these, mostly GP’s daily life in review is that the average day’s worth of patients is almost identical as what we see today! It is not the number of people we are ask to see each day, it is the complexity and mountain of paperwork we must deal with INSTEAD of spending 15 minutes gently listening to and examining our patients. We need simplification, and the ability to use our heads to make decisions. Paring away PBMs, prior authorizations, formularies, ICD9 and CPT coding, inane documentation guidelines, and other barriers will help us do more with less.
The last paragraph in the piece doesn’t seem to fit. Was it from another piece?
I was denied a diagnosis because of efficiency. As I told my story, the harried physicians stuffed me into a box that I did not belong. Even after a diagnosis was made, the urgent care doctors, too busy to read my chart and listen to what I had to say, misdiagnosed me again and again.
Not one MD helped me regain my quality of life-all they had time for is prescribing medication. I found my answers on the internet and with alternate providers.
While I would prefer a doctor with clinical excellence, I don’t see how you can provide excellent medical care if you don’t have the compassion to listen to your patient. Box anyone?
Thanks. This has been corrected.
Kevin
Our current doctor, who is wonderful, has both qualities. Nice as could be, and superb at diagnostics.
Our previous doctor was all but useless.
Compassion can be useful in laying the foundation for good communication; good communication may speed the way to a correct diagnosis, and therefore impact efficiency.
Have had the same PCP since the late 1980s. Never felt even marginally connected to him until a physical several years ago. His office had just gone “electronic” that very day, and it didn’t seem to be going smoothly. He tried to print a prescription for me from his PC, then realized he didn’t know where the printer was. He left the room and came back a few minutes later holding the printout, which had a big footprint on it.
“This is what improved technology looks like,” he said. “You get your scrips after we’ve walked all over them.”
Knew he was the right doctor for me when I saw he could laugh at himself and such circumstances. Don’t underestimate the impact it can have on patients to let them see you’re human.
Genuine compassion may not be necessary. But a physician lacking all ability to at least fake it is not likely to get my repeat business. Especially in primary care.
A lot of the doctors that I take issue with have plenty of time, but choose to spend it sitting around doing nothing rather than talking with the patient or doing an exam. The same doc that I’ve never seen lay hands on a patient/palpate an abdomen/listen to a heart is on the Internet reading about his hobbies. If all you’re going to do is order maximal tests anyway, why bother getting a good history/exam? Layzeeness is certainly a factor!
The doctor-patient relationship is one of the two constants in medicine that precedes biotechnology and supercedes it outcome for many conditions. The quality of that relationship profoundly influences not just patient satisfaction and compliance but also profoundly affects the patients of sense of overall well-being. It is as critical an element of healing as choosing the right drug–for some conditions, more critical. And is founded to a great degree on the patient’s sense that the doctor has compassion towards them.
As a patient, I would say – yes, compassion is necessary, taking time with patients is necessary. It was because of a compassionate doctor that I returned for follow up care, allowing a lymphoma diagnosis that defied blood work (it was normal – but other symptoms persisted and the physician who had known me my whole life believed me, did not dismiss me, and CALLED ME to ensure that I returned for additional testing). It is because of the hurried, efficient, compassionless environment of current primary care that I have become so disheartened that I no longer have a primary care physician (but, specialists aplenty) to call home.
I am certain that had I presented my symptoms (this was 20 years ago – I was 20) to any of the pcp’s I’ve auditioned in the past few years that after the blood work came back as normal that my other symptoms would have been dismissed, metaphorically patted on the head and told to run along now. I am fortunate to be in excellent health. My specialists joke that I only seem to get catastrophic illnesses. (I have had additional unrelated cancer dx in recent years). My BMI is 19, my BP 90/60, my cholesterol superb. I eat a varied mostly plant-based diet and exercise regularly.
The relationship between a physician and patient is an important component of care. To be sure, compassion and its resulting relationship are less important in short term interactions – surgery, for example – but in primary care it is my opinion that compassion is as important as clinical skill.
It doesn’t take much to forge a relationship with a patient. A few random questions, unrelated to health care, a brief conversation (doesn’t have to last long) can be all is required. Show your humanity.
I have no doubt that most of the doctors reading my post (if they even bothered to read past the “as a patient” part) will dismiss my comments as irrelevant, without foundation, reflecting an uneducated, ignorant individual with unrealistic expectations from her physicians.
There is a lot of commentary from physicians on this and other blogs that complain of the lack of respect the public has for doctors these days. I would argue that the lack of respect for patients by physicians is even more prevalent in the blogoshphere and, really, far more harmful to medicine.
“Compassion can be useful in laying the foundation for good communication; good communication may speed the way to a correct diagnosis, and therefore impact efficiency.”
I think W’s got it completely right. To me, a compassionate doctor is one who takes the time to listen to me and then acknoweldges in some way that he/she has listened to me. Maybe that second part (acknowledgement) isn’t strictly necessary for the doctor to make an accurate diagnosis, but it helps me to assess whether the doctor is really taking all information into account.
For instance, I remember talking to my gastroenterologist after my colonoscopy (vaguely, because i was still sedated), and he asked me whether the fiber pills were helping. I said i had not noticed any difference. He said, “Well, keep taking them,” and left. What was i to make of that? (Had i not been zonked out, i’d have thought to ask. Instead i switched to an acupuncturist.)
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