How to be a good doctor and ‘be good’

This is a presentation I gave to final year medical students at Guys and St Thomas’ hospital medical school on 27.02.2013

This blog is intended to start a debate, about what it means not merely to be a good doctor, but what it means to be a good doctor and a good person. Please feel free to comment, it’s intended to raise questions rather than provide answers. In part it is my response to the terrible treatment of patients at Mid Staffs.

The link to the prezi is here.

… but it is a basically a series of pictures, so the notes and references below will help you make sense of it. I would suggest opening the prezi in another window and taking your time … going too fast will be disorienting!

There are five themes:

1. Power and culture

2. Insight and self-awareness

3. Scepticism and scientific integrity

4. Advocacy

5. Kindness – it’s value and meaning in relation to health care.

Aspiration

Stairway. “Here you are at the beginning of your career, ever upwards and onwards ….”

Discussion: What do you think it means to be a good doctor and a good person? What kind of doctor do you aspire to be? Who has inspired you?

Can you be a good doctor and a bad person? Do personal morals matter?

Culture and Power

(Hospital) culture eats (moral) strategy for breakfast

The Circus. You are entering hospital culture, an extraordinary environment where you will work, eat, sleep, experience births and deaths, be moved to tears, perhaps fall ill or fall in or out of love. You will take on the robes and habits of the culture you inhabit. You will soon be acting your part – like a monkey in a circus.

The Gorilla. You will learn from day one that the culture is profoundly hierarchical and relationships of unequal power are everywhere. Deborah Lupton: Medicine as Culture

Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study: Conclusions: Our results highlight the importance of clear, challenging goals for high-quality care. Organisations need to put the patient at the centre of all they do, get smart intelligence, focus on improving organisational systems, and nurture caring cultures by ensuring that staff feel valued, respected, engaged and supported. Mary Dixon Woods et. al.

Discussion: French and Raven. What power will senior doctors, managers and other hospital workers have over you? What have you experienced as a medical student? What new powers will you have as a junior doctor? Over whom? See also, Doctors as Victims by John Launer and Medical Power

“My contention is that the imbalance of power between managers and doctors, which Griffiths set in train, is harming patients.” Prof Brian Jarman, Imperial College, When Managers Rule

How to fix the NHS’ crisis of moral leadership HSJ Mike Roddis

Time for truth and reconcilliation in the NHS. Dr Kim Holt, Patients First HSJ

Doctor bashing and confronting physicians in the media. Good piece arguing for more sophisticated methods than exposing bullies in the media by Kevin Pho, follow up to this piece, “The hierarchical culture that perpetuates bullying goes back as far as medical school, when as students, future doctors are trained in a pecking order not unlike the military. It’s no wonder that some carry that attitude into the workplace”

Surgical complications and their implications for surgeon’s wellbeing

Insight and Self Awareness

“There is, I assure you, a medical art for the soul. It is philosophy, whose aid need not be sought, as in bodily diseases, from outside ourselves. We must endeavour with all our resources and all our strength to become capable of doctoring ourselves.” Cicero

The Cellar. What if instead of leading up the staircase leads downwards? (metaphor for our ‘dark side’) Nicolas Spice: Up From the Cellar. London Review of Books. We all have a dark side, and sometimes discovering our new power reveals it. It is essential that we understand our capacity to do bad things, our dark potential. Doctors who lack this capacity, lack insight and a lack of insight is associated with poor professional performance.

Breaking Bad. If any of you are familiar with Breaking Bad … here is a Walter, a massively overqualified high-school chemist who found out he had lung cancer. Without sufficient health insurance to cover his treatment costs, and faced with leaving his family bankrupt, he turned to cooking meth(amphetamines) to pay for his medical bills,

Bruce Alexander, professor of addiction studies (12.50-13.30):

“our predominant addiction in the world today is not to drugs, but to …. money [and power]”

Leading to cooking more meth …

… making more money and finding justification -his new baby- to keep cooking more meth …

… leading eventually to the abandonment of all moral principles … i.e. ‘breaking bad’

Ordinary Men – ‘Breaking bad’ isn’t the behaviour of an imaginary TV star, but of ‘ordinary men’ – Extraordinary situations and make people do extraordinary things, the killers of the Jews were ordinary men and very often medical professionals. Given a choice, only about 20% refused to join in. See also Milgram experiment.

Doctors are ordinary men and women too, and hospitals are extraordinary places. Menzies Lyth showed that hospital culture was designed to protect nurses from the burden of psychological involvement with patients, by separating their duties into their constituent parts, temperatures, blood pressures etc. rather than care of the whole patient.

Michael Balint wrote about the ‘collusion of anonymity’ in which specialists took care of their organs of interest, but nobody took care of the patient.

Providing healthcare can be extremely stressful:

How stress and sleeplessness make doctors self-centered and insensitive. Excellent blog by Dr Phil Berry Precious: A legacy of under-staffing in healthcare

Why managing emotion is such a crucial task. Excellent brief review of the literature. why_managing_emotion_is_such_a_crucial_task

Physician understand thyself, and develop your resilience BMJ careers April 2013

Resilience among doctors who work in challenging areas: a qualitative study British Journal of General Practice July 2011

More than a broken leg: When patients and NHS staff really count as people. Guardian

Threats cannot make healthcare workers more compassionate. Paul Gilbert et. al.

When Doctors are Bullies, Patients Suffer. Excellent USA Today article with good links.

Providing care can be extremely stressful: For Traumatized Caregivers, Therapy Helps NY Times

Empathy decline and its reasons: a systematic review of studies with medical students and residents.  Academic Medicine 2011

A study of empathy decline in students from five health disciplines during their first year of training  International Journal of Medical Education 2011

Mid Staffs: Does this introduction help explain what happened at Mid Staffs? Bullying and the abuse of power, the failure to take responsibility for the whole patient? Does empathy decline during medical training and practice?

Did the government ignore criticisms of the NHS in the run up to the Mid Staffs scandal?

Francis Interview: What doctors must learn from my report. BMJ

“A consultant has a personal professional responsibility for the welfare of their patient, not just their liver and appendix or whatever, and if that consultant turns up [on the ward] and sees that the care being given to that patient is unsatisfactory then they have to do something about it. I suspect many do, but it’s a regrettable fact that some consultants at Stafford cannot have been doing that otherwise these things would have been spotted and stopped.”

“It’s vital that GPs remember that their responsibility to their patient doesn’t end when they go into hospital. They need to be more systematic about how they gather information because, after all, they are meant to advise patients on where is the best place to go for their treatment. The old fashioned way of phoning up their friend the consultant and having a word is just not good enough.”

Will prescriptions for cultural change improve the NHS? BMJ

Boston Hospital publishes regular newsletter called ‘Safety Matters’, detailing medical mistakes

The Whistlblower. Useful overview of how and when doctors should blow the whistle on dangerous care.

How mistakes can save lives: one man’s mission to revolutionise the NHS: After the death of his wife following a minor operation, airline pilot Martin Bromiley set out to change the way medicine is practised in the UK  – by using his knowledge of plane crashes. New Statesman June 4th 2014

Scepticism and Scientific Integrity

Do we question what we are told? Do we present evidence honestly to each other and our patients?

Lies, Damn Lies and Medical Evidence, The remarkable Dr John Ioannidis Atlantic Magazine Essay.

Five reasons why doctors don’t do right by you.

• We rarely use decision support aids. Patients’ preferences matter: stop the silent misdiagnosis – The King’s Fund, May 2012.
• Is anything less than fully informed consent abuse? Asks Richard Smith, concluding that we need to make far better use of patient decision aids.
• NHS patient decision aids online.
• We are poor at explaining the risks of medications and screening, in particular breast and prostate screening is very controversial and thousands of people are misdiagnosed as having cancer every year. See The Patient Paradox, book and Private Screens website that explains both the benefits and the risks of screening, both by GP, Dr Margaret McCartney
• We need to be able to appraise and explain medical research, as a minimum we need to be clear about the differences between efficacy, effectiveness and efficiency, between absolute risk reduction and relative risk reduction – also good explanation here and about numbers needed to treat.
• Why do we always end up here? Evidence based medicine’s conceptual cul-de-sacs and some off-road alternative routes.
• What Evidence Do We Need for Evidence Based Medicine?
• We need to realise that up to half of what we need to know about the effectiveness and safety of drugs is not reported BadPharma Rxisk
• We need to sign up to AllTrials and demand that the missing data is made available
• We need to be aware of the corruption of medical education: Questionable content of an industry-supported medical school lecture series: a case study. BMJ June 2013
• We must recognise financial incentives, they lead to perverse incentives in which doctors over investigate and over treat their patients to raise money for themselves and their hospitals. Overdiagnosed, Making People Sick in the Pursuit of Health, Competition in Healthcare: the risks, Winding back the harms of Too Much Medicine BMJ, A Call to Challenge the Selling of Sickness. BMJ
• The Political Economy of Healthcare,We should understand the Inverse Care Law which states: “The availability of good medical care tends to vary inversely with the need for it in the population served. This … operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.”
• The Cost Conundrum,
• The Bitter Pill, Why Medical Bills are Killing us
• “There are still plenty of honest doctors out there. But it’s getting harder all the time. Without actually intending it, we have created a medical system in which deception is not just tolerated, but actually rewarded” White Coat, Black Hat

Advocacy

I believe that ‘professionalism is the basis of medicine’s contract with society’. Our training and our wages are almost entirely paid for out of taxation and so we have a duty to ensure a healthy society. Rudolf Virchow was only 27 years of age when he studied the Typhus epidemic and he spent the rest of his life fighting for social reforms. He is best remembered for saying,

Medicine is a social science, and politics is nothing else but medicine on a large scale. Medicine, as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution: the politician, the practical anthropologist, must find the means for their actual solution… The physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.

The inspirational essay, To Isiah, by Donald Berwick is a call to doctors young and old to take on this role today,

And your voice—every one—can be loud, and forceful, and confident, and your voice will be trusted . . . please use it.

Can a Novel Med School Curriculum Improve Doctor-Patient Communication?

Promoting networks between evidence-based medicine and values-based medicine in continuing medical education

Patient Centered Care is greatly misunderstood. In practice it means listening carefully and seriously to what our patients are telling us, and working out, with them, what they mean. It is a skill that takes years of practice, immense patience, and reflection. Recently retired president of the Royal College of General Practitioners, Iona Heath has written beautifully about what it entails. See also, the End of the Disease Era

The importance of listening to patients cannot be overstated.

Narrative Medicine as a means of training medical students towards residency competencies.

Narrative Diagnosis. John Launer, postgraduate medical journal.

Kindness and Compassion

Exert from Do Doctors need to be Kind?

Iona Heath, in her review of Intelligent Kindness for the British Medical Journal writes,

… it is easy to forget the appalling nature of some of the jobs carried out by NHS staff day in, day out—the damage, the pain, the mess they encounter, the sheer stench of diseased human flesh and its waste products.” Of course, such forgetfulness is not at all easy for those actually doing this work, those struggling not to allow any hint of their physical revulsion to show, but these challenges seem hardly to register in the conscience or consciousness of those charged with the running of the NHS.

The NHS represents the last vestige of social inclusiveness and solidarity for frail, elderly people; for traumatised children; for people with intellectual disability, dementia, or severe mental health problems; and for people who repeatedly harm themselves, either directly, or persistently through the misuse of drugs and alcohol. And yet the staff who do the hard work of maintaining that solidarity are subject to a constant stream of criticism, efficiency savings, and instructions to do better. Exposed to precious little kindness themselves, they are nonetheless expected to provide it unstintingly. “There is a lack of understanding, a lack of thoughtful connection—a lack of kindness in the way the organisation as a whole is treated.”

After Mid-Staffs: the NHS must do more to care for the health of its staff. BMJ

“I found that healthcare workers were some 70% more likely to have developed work related stress, depression, or anxiety than was the general workforce” “NHS management seemed not to understand that it had a duty to protect its staff from the pressures under which they were working. This was a callous disregard for staff wellbeing.” “… the 2012 prevalence of work related mental health problems in health professionals was 110% higher than in the general workforce”

What can be done?

First of all we need to start talking about kindness. We need to talk about the value of kindness in healthcare and agree that it has been neglected and that we need to take action. Everyone involved in health leadership and policy should read Intelligent Kindness, in summing up her review of Iona Heath wrote, “If I ruled the world, I would arrange for everyone who wields any power in the NHS to be locked in a room until they had read it.”

Once we have agreed that it is important we need to do something to institutionalise kindness. We must focus on patients by improving continuity and a holistic approach to care. In order to be kind to patients, we must cultivate kindness between and towards ourselves. John Launer described an experiment at Indiana Medical school in which researchers recorded the positive narratives of students and staff, focusing on postive experiences and not the failures and critical incidents they were used to. They were then presented with the findings, “One participant is quoted as saying afterwards: “Now that I see how good we really are, I have to ask myself why we tolerate it when people aren’t as good as this. I can’t look on quietly any more when people are disrespectful or hurtful. It’s no longer okay to remain silent; this is too important.” Kindness improved quality of clinical care and was contageous, spreading and tranforming the organisation.

The relentless focus on efficiency and productivity in healthcare highlights the intrusion of market values into the NHS. There is an urgent need to to defend the values of social solidarity and rediscover an intellectual and emotional understanding that self-interest and the interests of others are bound together and acting upon that understanding. By committing ourselves to the values of kindness we may yet rescue the NHS.

Intelligent Kindness: Reforming the Culture of Healthcare. John Ballatt & Penelope Campling. RCPsych Publications.

Kindness in Healthcare, What goes around. Iona Heath review of Intelligent Kindness BMJ

Compassionate Care: The Theory and The Reality. J. Holistic Healthcare 2011

Compassion is the quality that should inform all healthcare

Medical students will be recruited on their compassion, says Health Education England Student BMJ (I’m very sceptical about this)

The last thing the NHS needs is a compassion pill. BMJ

The need for an NHS staff college. 

Final slide: The Circus

Medicine is a part of the culture we live in, one that is increasingly individualistic, self-interested, business-minded and in which we are all in too much of a rush to sit down and talk seriously with eachother and listen to eachother’s stories. We are all players in the circus of life.

But if we are to take something positive, it is perhaps that we are able to share our stories, our knowledge and insights in other ways. Thanks to social media, I have been inspired by a huge number of people from all around the world to think about what it means to be a good doctor and ‘be good’. It’s given me a lot to think about and some dizzying heights to aspire to.

I will add links and references as I discover them and keep the blog updated.

Other reading material:

‘A world of difference’: a qualitative study of medical students’ views on professionalism and the ‘good doctor’ BMC medical education. BMC Medical Education 2014, 14:77  “The ‘good’ doctor emerged as a complex and multifaceted construct; students provided long and articulate descriptions, and they often referred to the notions of ‘balance’ and ‘the art and science of medicine’ in their discussions. Three main themes emerged: competent doctor; good communicator; and good teacher.”