“What does it take to be good at something in which failure is so easy, so effortless?” asks Atul Gawande in his book, Better. For medical students who will soon have responsibility over people’s lives, it’s a daunting question. It draws out our fears of messing up and making mistakes. Of getting a lower grade than our peers on a Structure Function exam. Of answering a question incorrectly and embarrassing ourselves in front of an attending physician. Of eventually getting threatened with malpractice lawsuits throughout our careers as physicians.
But what about striving to excel and dedicating ourselves to become better at what we do? Much of the culture of medicine focuses more on the consequences of mistakes than the rewards of going above and beyond. We fear potential lawsuits more than we value a 100% satisfied patient. It is a culture that breeds complacency with the idea of simply “not screwing up.” But the lives of the people we serve are just too important to be treated with mediocrity. We need a new culture in medicine, one that will foster a cycle of excellence.
So what does it mean to excel as a physician? Well for many patients, it can be the difference between life and death. Gawande points out that in 1997, the life expectancy of a patient with cystic fibrosis was 36 years if treated at an average medical center in the United States. This life expectancy increased by ten years at top-rated medical centers. And newborns admitted to a neonatal intensive care unit have an average risk-adjusted mortality rate of 10%, but the value can range from 6 to 16% depending on the medical center. The distressing reality is that quality of care is in fact on a bell curve with most providers in the middle and too few on the right-hand tail providing excellent care. This time, no Z-scores are announced and no AOA honors are given. But lives are impacted.
While factors such as limited funding and availability of technology certainly affect the quality of care that physicians are able to offer, there are things every physician coming out of medical school can do to be simply “better.” Lives are saved every day by the dedicated physicians who ask the extra questions to arrive at the correct diagnosis or make the extra phone call to make sure their patients took their medications. Gawande offers three pieces of advice for being better physicians: be diligent, do right, and strive for ingenuity. Our commitment to incorporate these basic principles into our work will make significant impacts on the lives of our patients, regardless of any other factors. It is about spending the extra ten minutes to finish listening to a patient’s story at clinic even though we are tired and want to go home. It is a state of mind that we must embrace.
In an ideal world, all physicians will commit to this philosophy solely out of good will. Nevertheless, systemic changes are needed from medical education to physician reimbursement methods to create and maintain this cycle of excellence. We are indirectly trained early on in medical school, during our time in free clinics or from conversations with stressed out upperclassmen on their clerkships, to limit the amount of time and energy we should spend per patient. As long as we get the job done with the assurance that there won’t be the possibility of a lawsuit in the future, we move on to the next patient. And who could blame us? In a system where a physician who performs the bare minimum for an individual patient receives the exact same monetary compensation as one who spends extra time and energy to provide high quality care, there is little incentive to step up from mediocrity. In fact, the former will likely even get paid more under our current fee for service system.
Aside from the obscure physician rating websites scattered across the internet and the America’s Top Physicians lists I see in the American Airlines complimentary in-flight magazines, there are few existing methods to recognize and reward the physicians who are making the extra phone calls and asking the extra questions – those who go above and beyond to provide excellent care. Other industries have spent huge amounts of resources devising payment and bonus schemes to incentivize performance. While there has been talk of physician payment reform measures – for example, the creation of Accountable Care Organizations and bonuses for physicians – to create positive reinforcement for better performance, medicine still has a long way to go.
But I am an idealist. Regardless of whatever payment system encountered in our careers, we must always recognize that in our line of work, we are treating people – people like you and me, our brothers and sisters, our mothers and fathers. We all deserve better from each other. We owe it to ourselves, our profession, and everyone whose lives will be affected by our actions. As Nobel Peace Prize Recipient Desmond Tutu puts it, “I want you to be all that you can be. Because that is the only way I can be all that I can be.”
Ron Li is a medical student.
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