What Makes an Ideal Doctor?

12th Induction Lecture for the Newly Qualified Medical Doctors of the College of Health Sciences, Ladoke Akintola University of Technology, Osogbo on 16th Dec. 2015 by Prof OLUWADIYA Kehinde Sunday.

II greet all of you seated Induction Posterhere. This is a most important day to every one seated here. To the inductees, it is the glorious culmination of a journey that inauspiciously started some eighteen years ago. Some have spent more, and a few had spent less, but for the vast majority, it is 18 years of toils, tears and triumphs. It is 18 years of chasing a vision and I congratulate you for making the milestone. You are welcome to the start of another journey that will expand your usefulness to yourself, your family and your community. Welcome to the world of medicine. To the parents, the guardians and the family, it is a most important event because it marks the point when that little, fragile bundle of joy that you brought forth some years ago has attained what every parent wants for their children: making the dream they dream for their children a reality.  On behalf of your wards, I salute your vision for them, I appreciate you for doing what it takes to achieve the visions and as you are witnessing today, I pray that it will be the first of many triumphs you will be witnessing in their lives. To the teachers, it is a most important event because it is another evidence of their importance to the society, for today, they have produced another set of professional children who will take over the mantle from them. It is a form of professional immortality. To the students who have come to celebrate with their older colleagues who have crossed to the other side, it is a most important day, because it is a day that doubts are set aside, and they reinvigorate their determination to have a day like this. Just as it is happening today, that day too will come for you. And to me, it is Class of 89 UCHan important day because, some 26 years ago, as  I was sitting down, listening to a lecture like this, along with my fellow inductees in the College Auditorium of the University College Hospital, Ibadan; I never new that one day, I would have the singular honour of giving the induction lecture to a future set of newly minted medical doctors. I thank you for the honour, and my prayer is that in a not too distant a future, some of you too, will be doing just that. Wow! 

The title of my induction lecture to the 2015 class of the MBBS program of the Ladoke Akintola University College of Health Sciences is "What Makes an Ideal Doctor?". Come along with me as we explore this concept:

The most important aspect of medical practice is the instance when, in the closeness of the consulting room, or the hospital ward, a person who is unwell, or believes him- or herself to be ill, seeks the advice of a doctor whom he or she trusts. This is the beginning of the doctor-patient relationship. It is a frequent and regular occurrence, which all of us here have experienced either as the patient, the physician or both. It happens every minute of every hour of every day, the world over. It runs to millions of consultations every single day of every single month of the year. But just because it is so common does not mean that doctors and indeed, all healthcare professionals should take for granted the enormous courage and conviction it takes for an individual to go into consultation with a physician surrendering his privacy, granting the doctor access to the most intimate areas of his or her physical, emotional and personal life. When he finally picks up the courage to go and consult a doctor, he hopes to see a good doctor. An ideal doctor who will solve his medical problems in a satisfactory way.

What then constitutes a good doctor? Who is the ideal doctor?  Is technical proficiency sufficient to be a good doctor? Clearly, a physician cannot lack necessary technical knowledge and skills and still be a good doctor. Less clear is whether a technically proficient physician can lack interpersonal skills necessary to relate well to patients and still be a good doctor. The answer to this question must incorporate the views of patients, who are the users of health care services.

The Concept

AmielWho is the ideal doctor? Back in 1873, M. Henri-Frederic Amiel wrote as follows in his journal "To me the ideal doctor would be a man endowed with profound knowledge of life and of the soul, intuitively divining any suffering or disorder of whatever kind, and restoring peace by his mere presence".1  The person described here is not a doctor. He is a miracle worker, and such a person is not practicing in any of our hospitals. Doctors are only human. They are expected to apply a high level of skill and knowledge to solving the patient's medical problems. But since they neither have any magic wand to wave nor incantations to conjure, they have to do this by investigating the circumstances of the illness. In an ideal world, they must do this in a way that conforms to the patient's expectations. And herein lies the conundrum. Each patient is unique. As the esteem Monseur Amiel elegantly put it "Every illness is a factor simple or complex, which is multiplied by another factor, invariably complex, the individual, that is to say, who is suffering from it, so that the result is a special problem, demanding a special solution, the more so the greater the remoteness of the patient from childhood or from country life. The principal grievance which I have against the doctors is that they neglect the real problem, which is to seize the unity of the individual who claims their care. A doctor who does not read you to the bottom is ignorant of essentials." This is a utopian concept. Unfortunately, we live in a very real world. No society in the world have the resources to give this kind of medical treatment to its members.

Since this utopian concept of the ideal medical doctor is neither affordable nor practicable, more realistic models have been suggested throughout the ages.

One of the very first models was suggested by the man who was widely regarded as the father of medicine. Hippocrates was born on the Greek island of Cos about four hundred-sixty years before the birth of Christ. It is believed that his father was a physician, as were a number of his ancestors.
Hippocrates's requirements for a physician was probably written after his death, but it represents his teachings on the subject. It prescribed how the physician should behave within his community in order to earn the respect of his fellow citizens and elevate his status. Its dictates are as relevant today as they were two thousand years ago: 2

"The position of a doctor must make him careful to keep his complexion and weight at their correct natural standard. For most people think that those who fail to take care of their own physical condition are not really fit to take care of that of others."

"Secondly, he must have a clean appearance, and wear good clothes, using a sweet-smelling scent, which should be a totally unsuspicious perfume. This is pleasant when visiting the sick."

"Also he must observe rules about his non-physical effect, not only in being quiet but also in being self-controlled in all aspects of life, for this has the best result on his reputation."

"His character must be that of a gentleman, and, as such, honourable and kindly towards all. For people dislike forwardness and interference, even if these qualities sometimes prove useful."

"He must also pay attention to his technical ability, for people like the same medicine in small doses."

"In facial expression he should be controlled but not grim. For grimness seems to indicate harshness and a hatred of mankind, while a man who bursts into guffaws and is too cheerful is considered vulgar. This must especially be avoided."

"He must be just in every social intercourse, and a sense of fairness ought to help him in every dealing."

"The relationship between doctor and patient is a close one. Patients submit themselves to doctors, who are always likely to be meeting women and girls, and entering houses with valuable possessions. Towards all these, therefore, he must keep himself under strict self-control."

"The above, then, are the physical and psychological requirements for a doctor."

The Hippocratic Oath

Original Hippocratic OathThe Hippocratic Oath was administered in its original form for the first time to graduating physicians at the University of Wittenberg in Germany in 1508.
The main gist of the Oath is indisputable: each physician must hold him or herself to the highest possible standard of conduct. The Oath reminds the physician that all life is to be revered and preserved. Likewise, no practitioner can abuse his power to either harm or gain sexual favours. To respect those from whom he gained his knowledge and to pass that knowledge on to the next generation is crucial, as is maintaining confidentiality at all times. These are the principal directives of the Oath, and modern doctors are held to the same standards to this day.

Because parts of the original form is now antiquated – how many physicians still worship Apollo? I'm sure most doctors - I certainly will not-  wouldn't get very far if they were prohibited from cutting into their patients — modern versions have replaced the original wording. In addition, medical organizations evolved to include written codes of ethics instead of ones sworn aloud. The first modern code was written by Dr Thomas Percival in a 1794. In Nigeria, the oath sworn to by medical students upon their induction into the medical profession is the Physician Oath (Declaration of Geneva) which was adopted and adopted by the General Assembly of the World Medical Association, Geneva, Switzerland, September 1948 and amended by the 22nd World Medical Assembly, Sydney, Australia, August 1968:


I solemnly pledge to consecrate my life to the service of humanity;
I will give to my teachers the respect and gratitude that is their due;
I will practice my profession with conscience and dignity;
The health of my patient will be my first consideration;
I will respect the secrets that are confided in me, even after the patient has died;
I will maintain by all the means in my power, the honour and the noble traditions of the medical profession;
My colleagues will be my sisters and brothers;
I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient;
I will maintain the utmost respect for human life;
I will not use my medical knowledge to violate human rights and civil liberties, even under threat;
I make these promises solemnly, freely and upon my honour.


Also called the "Declaration of Geneva", the physician's oath has been lauded for maintaining the basic tenets of the original oath in an acceptable modern way. The underline basis of the oath is the universal declaration of human rights. It also alludes to many principles of medical ethics such as non-maleficence: "first, do no harm", beneficence: the helping of people as the primary goal of the physician; confidentiality: the inviolability of the patient-physician relationship; conflicts of interest: which implies that physicians should not allow conflicts of interest to influence medical judgement, dignity: which implies that the patient has the right to dignity; and truthfulness and honesty: the process of informed consent.
However, there are other aspects of modern medical ethics which were not expressly covered by the physician oath, but which have become very important. This include Autonomy: respecting the patient's decisions and beliefs. It is the basis of informed consents and a reaction to the paternalistic tradition of medicine. The final principle is Justice, the distribution of health resources and the decision as to who gets what treatment. For instance, justice is when the president gets the same quality of care as a servant.
My dear medical inductees, today, you will be taking this oath. Do not take it lightly. In a way, it is the most important aspect of your training, for it encapsulates what your peers expect of you. It is the shroud of honour that cloaks you with the dignity bestowed on you by the society. It is the conceptual basis of why your patients,  total strangers to you, will grant you access to their most private thoughts and to the most intimate parts of their persons. It is the reason why he or she trusts you well enough to place his or her life in your hand. This is why they will allow you to play God with their life.

The Views

In 2006, a study was published in the Mayo Clinic Proceedings, which asked fundamental questions about patients' views of the ideal doctor. It is a qualitative interview of 200 patients from 14 medical specialties in the hospital. The researchers were able to spot eight traits that patients favoured in their doctors.3 It is interesting what made the list:

 


Confidence: "The doctor's confidence gives me confidence". No patient wants to go into consultation with an unsure, dithering and hesitant doctor. Faith healers and traditional healers have this in abundance. 


Empathy: "The doctor tries to understand what I am feeling and experiencing, physically and emotionally, and communicates that understanding to me." It's important to understand and relate to a patient's feelings. This can be therapeutic: according to a study published in 2011 in Academic Medicine, patients of physicians that were more empathic were more likely to have good control over their blood sugar, while the converse was true for patients whose physician showed little to no empathy.4 This research suggests that when doctors respond empathetically at appropriate times, their patients tend to be happier and more motivated to stay on treatment.
Humaneness: This is the quality of having compassion or consideration for others. Here is an excerpt from one of the patients: "The doctor is caring, compassionate, and kind."


Personal: "The doctor is interested in me more than just as a patient, interacts with me, and remembers me as an individual." No patient wants to walk into a doctor's office and see a physician who is rude indifferent and arrogant. He wants a physician who knows him or her and shows concern about his or her condition. 

Forthrightness: "The doctor tells me what I need to know in plain language and in a forthright manner." Patients want a physician who is candid with all of their health information in layman's terms. When a patient feels that their doctor is straightforward with all the facts, it allows them to make educated decisions about their health care that could impact their life and well-being.

Respectfulness: "The doctor takes my input seriously and works with me." Patients desire a physician who treats them like an individual and not just another medical problem or lab experiment in their office. Patients want their medical conditions to be explained in simple language so that they're not made to feel inferior or bogged down with medical jargon.                                                            

Thoroughness: "The doctor is conscientious and persistent." One mistake in the medical field could have devastating effects.  Patients want to know that their doctor had not overlooked any aspect of their health care. Thoroughness and attention to detail will instil confidence in a patient that the physician's diagnosis is accurate. This trait also helps the physician to schedule the appropriate follow-ups or necessary extended care. Being thorough the first time can prevent the patient from future ailments or the discomfort of having to come back for additional visits.


Even more interesting are those things which did not make the list:


Credentials: Many doctors believe that their credentials are of highest importance to their patients. In actuality, a doctor's credentials are more important among their colleagues than their patients. What a patient values above credentials is humane application of knowledge and skill to their medical problems. This is one of the reasons why some specialist clinics fail to thrive while their non-specialist counterparts are doing well.


Technical skills: Technical skills are difficult to judge for the average patient. According to the authors, their findings "does not suggest that technical skills are less important than personal skills, but it does suggest that the former are more difficult for patients to judge,"  Most patients tend to assume that doctors are competent unless they see signs of incompetence. One patient in the study put it this way: "We want doctors who can empathize and understand our needs as a whole person. ... We want to feel that our doctors have incredible knowledge in their field. But every doctor needs to know how to apply their knowledge with wisdom and relate to us as plain folks who are capable of understanding our disease and treatment."

According to Li.5 "Unsatisfactory care resulting not only from failure to meet normative benchmarks for quality, … but also from experiences that leave patients feeling uncared for, affecting them in domains that are less easily measured (for example, feeling unheard, rushed, inconvenienced or humiliated; or being unable to access desired information, instruction or reassurance)….the extent to which the technical elements of care seem good on the basis of performance indicators but ultimately fail to be caring because of deficiencies not captured by these measures. The rudeness or insensitivity that patients encounter or the frustrations they experience in obtaining information and control over treatment decisions illustrate gaps in quality, of deep concern to the public, that often are not measured under normative standards."


I will conclude this aspect of my presentation by listing the undesirable physician behaviours which are the direct opposites of the 7 ideal physician behaviours:

 

Seven ideal physician behaviours by Bendapudi et al
Opposites of the 7 ideal physician behaviours

Confident

Timid

Empathetic

Uncaring

Forthright

Misleading

Humane

Cold

Personal

Callous

Respectful

Disrespectful

Thorough

Hurried

The quality of care and the quality of caring are inseparable. We can hope for a day when medicine is practiced by knowledgeable, competent, and compassionate physicians who create high-quality therapeutic and healing relation-ships with patients and their families in the setting of safe, effective, and efficient health care systems.


Final Thoughts

I will be leaving you with excerpts from a speech by Dr. Beth Lown, Medical Director of The Schwartz Center for Compassionate Healthcare, Boston MA to the 2012 graduating class of the Tufts Medical School, Boston MA. It was a wonderfully poetic speech whose spirit jibbed well with the modern Hippocratic oath.6


"Here is my first celebration hope for you – that you cultivate a sense of wonder and curiosity, tenderness and respect for the patients you will see as you learn, train, practice, teach or do research." Remember, there is no such thing as an uninteresting patient.  Let me share with you the result of the clerkship of a so-called uninteresting patient:
"She appeared to be suffering primarily from isolation and abandonment, but she had no big history to tell, no stories to share. She answered questions with one word sentences. The patient seemed singularly uninteresting… until the patient was asked how long she had lived in San Francisco: "Years and years," she said. Was she here before the earthquake? No, she came after. Where did she come from? Ireland. When did she come? 1912. Had she ever been to a hospital before? Once. How did that happen? Well, she had broken her arm. How had she broken her arm? A case fell on it. A case? Yes. What kind of case? A ship's case. How did that happen? The ship lurched. The ship? The ship that was carrying her to America. Why did the ship lurch? It hit the iceberg. Oh! What was the name of the boat? The Titanic."

Ask and Listen
When you put on your white coats, you will be crossing a Rubicon, a turning point of commitment to the profession of medicine. At first, you will feel the same, but others will view you differently whether you feel ready or not. But very soon you will be asking patients questions and they will be sharing details about their lives that they would share with no other stranger. You will hear about abdominal pain, chest discomfort, shortness of breath, yes, and you may hear the joy and happiness in the voice of a parent whose child has just recovered from a serious illness. You will also hear the pain of conflict, loss, and suffering if you care to listen.

Here is my second celebration hope for you – that you honour the trust of patients by caring enough to ask and to really listen. Listen to their stories about their lives, their hopes and joy, their fears and desperation.
Listening is not so simple – it is a learned skill that must be continuously honed. It is also a powerful diagnostic tool. It is often said that 70% of diagnoses can be made based on the patient's history alone. But beyond diagnosis, as fun and ever-fascinating as that is, listening is a therapeutic tool; perhaps one of our most potent but under-rated therapies. Because caring enough to ask and to really listen to the patient's story is the foundation of compassionate relationships and the relief of distress and suffering. And that is the pathway to healing.

Balance
Here is my third celebration hope for you: that you find ways to sustain your empathy and compassion for others without overly joining in their suffering such that you deplete your capacity for this process, nor overly distancing to protect yourself from distressing emotions. That you find sources of personal balance and equanimity.

Cure sometimes, heal often and care always

We have to work hard to bridge these gaps in culture and experience. At other times, it may be hard to be compassionate because you feel frustrated or angry – at patients who don't change unhealthy habits, behaviours or addictions, who don't take their medicines and come to clinic or are admitted and readmitted to hospital with all of the complications that then ensue. These situations will try your patience. It's okay to feel this way, but you still have to try to understand patients' worlds and experiences. Otherwise you will be completely ineffective in helping them change. I will tell you a secret it took me a long time to learn: you cannot prescribe change however much you wish you could. You can only try to understand the patient's perspective well enough to guide the patient so he can find within himself (or herself) the capacity to change, and to help them find support from others. This takes caring enough to ask and to listen.

So here is my fourth celebration hope for you: that you learn early that you can cure sometimes, heal often and care always. There is no medical remedy for the inevitability of death. So do your best and be compassionate with yourselves when things don't go as well as you hope.

Reflect
Don't get me wrong – medicine is filled with opportunities for joy. In fact, I can't think of too many activities that are more fun than using your head, heart and hands to help someone feel better. And on top of that, if you care about your patients they appreciate you! And you'll get paid for it! Patients will share their lives with you – births, graduations, weddings, divorces, promotions, book recommendations, home-made treats, photos… you name it. Some of you will see entire families of patients – grandma, grandpa, mom, dad, their siblings, the kids and their kids. You will find yourself holding entire villages of relatives in your minds' eye. You'll laugh and you may cry with them in the sanctity of your office or exam room. You'll hold their secrets in confidence. The rewards are great and often unexpected and sometimes intimate…..the shy smile of a recuperating child, the joyous whoop of a newly made father and the cry of a new-born baby. What can beat that as a source of joy!

Still, I want to give you a heads up – you will encounter many things that will conspire to diminish your joy, your curiosity, empathy and compassion along your medical journey. And there have been plenty of studies showing that this occurs. Some of these impediments are developmental and to be expected. Later on, you will be caught up in mastering the sheer volume of information you will need to know to be an effective clinician or a successful researcher. Buckle down and study as I know you have in the past. The foundation you lay now will stand you in good stead, I guarantee it. There will also be impediments that will seem beyond your control: too little time to pay close attention to the patient's needs, too many patients to see, multiple hand-offs of patients' care among various units so you can't really get to know the patients well. You will very likely hear the dialect of the culture of medicine; "Go see the chest pain in Male Ward." You will see tests being substituted for physical diagnosis and the magic that happens when a patient feels the expert, gentle, probing touch of a skilful physician. You will feel pressured to order tests or treatments that aren't necessary because their availability drives demand in the absence of evidence about their efficacy. Often we stop seeing and questioning because we see through the lens of the culture of medicine that shapes these very practices.

So here is my fifth and final celebration hope for all of you. That you will take time to reflect, to stop and ask yourselves, am I acting with compassion and integrity in the best interests of this patient before me? Do I know enough about this particular, unique patient as well as the medical literature to make this judgment? Am I integrating my own professional expertise with the expertise of the patient? The expertise that only this patient can bring to me about the experience that is her life with all of its richness and complexity?
If you can say to yourself: Yes, I am doing my best to sustain my wonder, curiosity, tenderness and respect for those who have trusted me with their care; yes, I do care enough to ask and to really listen; yes, I am trying to seek balance and equanimity; yes, I am trying to be compassionate with myself when things don't go well; yes I am taking time to stop and to reflect, to ask myself if I'm acting with compassion and integrity in the best interests of the patient before me….if you can say, yes, I am doing my best, then you will do honour to the privilege of being a doctor. And you can wear your white coats with pride."

I will conclude by quoting Monsieur Amiel once again "To me the ideal doctor would be a man endowed with profound knowledge of life and of the soul, intuitively divining any suffering or disorder of whatever kind, and restoring peace by his mere presence. The model doctor should be at once a genius, a saint, a man of God."

Dear new colleagues, perhaps such a person is sitting here among you, waiting to take up the gauntlet.

Thank you and God bless you as you set forth.

 

 

 

 

Prof Oluwadiya S. Kehinde
Provost

College of Medicine
Ekiti State University
Ado-Ekiti.

Download the Lecture in PDF

 

REFERENCES
1. California State Journal of Medicine Vol 12 Pg 392
2. The Ideal Physician, 320 BC" Eye Witness to History, www.eyewitnesstohistory.com (2008)
3. Bendapudi, N. Mayo Clinic Proceedings, March 2006; vol 81: pp 338-344
4. http://journals.lww.com/academicmedicine/Fulltext/2011/03000/Physicians__Empathy_an d_Clinical_Outcomes_for.26.aspx
5. Li, J. Mayo Clinic Proceedings, March 2006; vol 81: pp 294-296
6. http://commonhealth.wbur.org/2012/09/inspiring-words-hippocratic-oath