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?

“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.

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.

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.

19 responses to “How to be a good doctor and ‘be good’

  1. Thank you for this . It is excellent and thought provoking for those of us working to make the NHS a safer better place for patients and staff

  2. This is really impressive and I hope it goes well

  3. Simon Tricker (@tweetertricks)

    Thank you very much. As always, so much to think about as a GP and programme director. I hope your lecture goes well today – are you going to be recording it?

  4. This is a important conversation, thanks for sitting down from your rush and pulling this together. Hope it goes well today. Some thoughts:

    Making Space for kindness – How do we cut out some of the wall-to-wall nonsense – your recent post on the pointless metrics that GPs are asked to gather – to make space to do that. How do we guard that space?

    Connecting – care of all kinds involves a chain of interactions. It only takes one to break down for care to break down. If that happens often enough it is deeply damaging to whatever culture(s) of care exists. How do we work out what are the most important connections – patient-doctor is one – and improve those?

    Technology – how can we make better use of simple technology e.g. sms and phone calls to efficiently (sorry, can’t avoid some of that) maintain the more informal but massively valuable connecting? And how to deal with the inevitable legal reaction to doing this?

    This Economist article on the waste in US healthcare due to commercial cultures:

    US spends 17.9% of GDP on health care massive waste identified by econ.st/15NQ3IT

  5. I don’t think it will be recorded. It’ll be difficult I think because I’ll be asking the students to have discussions at intervals. It is an experiment! I hope to learn from it, adapt and evolve the session to be used again. Jonathon

  6. Heart warming and beautiful

  7. Yes, they are going to be very upset, there is something about how whats going on in your life affects how you are able to be ‘good’ here.

  8. This is very interesting stuff as an ex NHS manager and current psychotherapist, a lot of what you say resonates with me in different ways and I would love to see how your audience responds. Two things in particular struck me, firstly insight is crucial to any of us working with people. We all have a shadow (dark side) and it is at it’s most dangerous when it is ignored, denied or repressed. I wonder if the aura that surrounds doctors as “life savers” makes it harder to own the shadow side? Secondly, kindness; yes life is always better when we are kind to each other and I am lucky to have 50 minutes with my clients, rather than the rushed appointments I experience with the medical profession, (for the reasons you previously blogged). I am curious to know what your audience expectations are with regard to kindness to self and also peer support? Please post a follow up and let us know how it went and the responses that you got.

  9. Hi J

    If you can’t record the live presentation you should definitely try and find the time to record an online version. (Have you seen @ffolliet’s online lectures on slideshare? e.g. http://www.slideshare.net/ffolliet/on-tablets-of-stone ).

    I’ve been on at Iona Heath for ages about puttin gher talks on Youtube. Perhaps you could lead the way…

    Pete

    • I’m in awe of @ffoillet’s slideshares. My presentation wasn’t too slick, some IT issues to start, a perplexed audience, and then a confession that sceptical thinking wasn’t something they’d been encouraged to pursue, and a bit of a gallop (on my part) to finish, gave me quite a bit to think about in terms of how to better address the concerns and learning needs of my audience. I’ll be changing the Prezi and the references in the next few days to adapt for another go with a live audience. Prezi does have an audio option, so I might try if i get a spare night (I do this stuff when I ought to be asleep …) JT

  10. A very intelligent and mind opener lecture- a survival guide for junior doctors!
    Pastry

  11. Very interesting, very challenging very necessary.
    Conversations about kindness, goodness, and compassion are difficult to have when the staircase is taking us into the cellar. The soft social art/science of medicine is sometimes can be lost in our quest for the grail of evidence based medicine. Heroes are hard to find. Well the right sort of heroes perhaps. I think that stories telling can sometimes help take us out of the cellar. And the gift of being able to laugh at ourselves is one key to achieving insight with kindness. I try to do this in a small way with my stories about the work, life and loves about a family doctor. Poetry can also be part of the Rx.

  12. Meant to say here that I thought this was great – as per my tweets I think it would make a great little module, perhaps an optional study module – you could entice students with the title to come and think and discuss about how to be a good doctor and a good person.

    Some friends tried to get something like that off the ground here in Birmingham, but don’t think it came to anything. Perhaps it is time to join up thinking and try again…?

  13. L’ha ribloggato su Carlo Favarettie ha commentato:
    Add your thoughts here… (optional)

  14. Your writing is like a hip flask for survival in practice
    Always feel better and more positive after reading your stuff
    Thank you for doing it and being so generous with distributing it

    Let’s discuss the “exasperated confessional students” next week

  15. What a superb post. I shall keep returning to it. I will e-mail you a poem from yester-year called ‘The Clinical Examination’ as the words of Robert Francis reminded me of it. Aye Peter

  16. Thank you for sharing this

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s