What makes a good doctor, and can we measure it?

I recently spoke to a quality measures development organization and it got me thinking — what makes a good doctor, and how do we measure it?

In thinking about this, I reflected on how far we have come on quality measurement.  A decade or so ago, many physicians didn’t think the quality of their care could be measured and any attempt to do so was “bean counting” folly at best or destructive and dangerous at worse.  Yet, in the last decade, we have seen a sea change.  We have developed hundreds of quality measures and physicians are grumblingly accepting that quality measurement is here to stay.  But the unease with quality measurement has not gone away and here’s why.  If you ask “quality experts” what good care looks like for a patient with diabetes, they might apply the following criteria:  good hemoglobin A1C control, regular checking of cholesterol, effective LDL control, smoking cessation counseling, and use of an ACE Inhibitor or ARB in subsets of patients with diabetes.  Yet, when I think about great clinicians that I know – do I ask myself who achieves the best hemoglobin A1C control? No. Those measures – all evidence-based, all closely tied to better patient outcomes –don’t really feel like they measure the quality of the physician.

So where’s the disconnect?  What does make a good doctor?  Unsure, I asked Twitter:

good doctor twitter

Over 200 answers came rolling in.  Listed below are the top 10.  Top answer? Having empathy. #2? Being a good listener.  It wasn’t until we get to #5 that we see “competent/effective”.

good doctor twitter results

Even though the survey results above come from those I interact with on twitter, I suspect the results reflect what most Americans would want. As I read the discussions that followed, I came to conclude one thing:  most people assume that physicians meet a threshold of intelligence, knowledge, and judgment and therefore, what differentiates good doctors from mediocre ones is the “soft” stuff.

It’s an interesting set of assumptions, but is it true?  It is, at least somewhat.  Most American physicians meet a basic threshold of competence – our system of licensure, board exams, etc. ensure that a vast majority of physicians have at least a basic level of knowledge.  What most people don’t appreciate, however, is that even among this group, there are large, meaningful variations in capability and clinical judgment.  And, of course, a small minority of people are able to get licensed without meeting the threshold at all.  We all know these physicians – a small number to be sure — that are dangerously ineffective.  We, the medical community, have been terrible about singling these physicians out and asking them to get better – or leave the profession.

In the twitter discussion, there was a second point raised by John Birkmeyer and that was likely on the minds of many respondents.  He said “I’d want different things from my PCP and heart surgeon. Humility. Over-rated for the latter” John was raising a key distinction between what we want out of a physician (an Internist or a family practitioner) versus a surgeon.  Yes, in order to be “good”, humility and empathy are important, even for cardiac surgeons. But when they are cutting into your sternum?  You want them to be technically proficient and that trait trumps their ability (or lack thereof) to be empathic. Surgeons’ empathy and kindness matter – but it may not be as critical to their being an effective surgeon as their technical and team management skills. For Internists, effectiveness is much more dependent on their ability to listen, be empathic, and take patients’ values into consideration.

A final point.  My favorite tweet came from Farzad Mostashari, who asked: “If your doctor doesn’t use the best data available to them to take care of you, do they really care about you?” In all the discussions about being a good doctor, we heard little about effective use of beta-blockers for heart disease, or good management of diabetes care.  That’s the stuff we measure, and it’s important. We use them as part of the Physician Quality Reporting System (PQRS).  But I’m not sure they really measure the quality of the physician.  They measure quality of the system in which the physician practices.  You can have a mediocre physician, but on a good team with excellent clinical support staff, those things get done.  Even the smartest physician who knows the evidence perfectly can’t deliver consistently reliable care if there isn’t a system built around him or her to do so.

So, when it comes to thinking about ambulatory care quality – we should think about two sets of metrics: what it means to be a good doctor and what it means to work in a good system.  In measuring doctor quality, we might focus on “soft” skills like empathy, which we can measure through patient experience surveys.  But we also have to focus on intellectual skills, such as ability to make difficult diagnoses and emotional intelligence, such as the ability to collaborate and effectively lead teams – and we don’t really measure these things at all, erroneously assuming that all clinicians have them.  For measuring good systems, we could use our current metrics such as whether they achieve good hypertension and diabetes control.  We need to keep these two sets of metrics separate and not confuse one for the other. And, alas, for surgeons, we need a different approach yet.  Yes, I still believe that humility and empathy go a long way – but these qualities are no substitute for sound judgment and a steady hand.

12 thoughts on “What makes a good doctor, and can we measure it?

  1. Good post. What are your thoughts on using Google Glass for routine, detailed monitoring of clinical encounters, and subsequently tailoring feedback to clinicians’ individual strengths and weaknesses? I don’t usually gamble, but I’d wager this will become widespread. Bob Wachter wrote a recent blog piece on this topic.

  2. We need to develop reliable ways to screen for “empathy” in prospective medical students and encourage the “soft” stuff among those who are accepted into medical school.

    • Beth – I agree with your comments, and with those of Dr. Jha. What I would offer is that we need to stop labelling the skills asscoaiated with empathy, listening and communication as “soft”. At the risk of appearing pedantic this mind-set is a large part of the problem. We label them in a way that implies that they are somehow optional, unimportant and easy to learn, teach and practice.

      I would also offer that this does not have to be an “either/or” conversation. From the work of Pat Lencioni, and his most recent book, The Advantage; organizations and people can be both “smart” (technical skill, sound judgment, steady hand) and “healthy” (humble and empathetic).

      • In my field (IT,) it’s well-known that the “soft” skills are the ones that are intractable to teach and measure, and also the ones most predictive of career success, since they’re necessary in public-facing position.

        Given that basically every position in medicine is public-facing, this observation can hardly have escaped that profession’s notice.

        Calling them “soft” implies the opposite of what you suggest. It suggests that they’re non-technical skills — that is that they *can’t* be taught, because there’s no technique to them.

        That’s not precisely correct, but social skills are very hard for people who don’t have them to learn, and are not well-understood by those who do.

  3. I don’t care how gentle or engaging the guy is who’s about to cut me open. Did he have a good night sleep, was he out carousing or did someone like his partner, child or pet tick him off before he left for “work” are questions on my foggy mind as I am rolled into the OR. No way to answer these.

  4. Both questions – What makes a good doctor? Can we measure it? – depend upon what criteria is being used to measure “good.” Unless specified, the chosen criteria for “good” defaults to the individual’s own immediate interest. In the case of patients, many will assume their physician’s expertise based upon the physician successfully completing medical school (why do you think so many physicians hang their diplomas on the wall?) After this assumed level of expertise, most patients screen their physician for their “soft” skills, i.e., emotional intelligence. Psychologists have studied the impact of empathy and compassion on patients’ perceived quality of care and have consistently found that physicians who demonstrated greater “soft” skills are thought of as being more competent by patients than than their lower scoring “soft” skill counterparts. So while health outcomes do matter, they may matter more to physicians, than to the patients they treat.

  5. Terrific post. YOu might want to explore how systems can make it easier, or much harder, for clinicians to ‘do the right thing’ as regards communication, empathy, humility, inquisitiveness, etc. There is a considerable literature now on the impact of organizational infrastructure, processes and culture not only on safety and technical aspects of quality, but on interpersonal quality, ethics, and team care dynamics as well. (shameless self-promotion, for short essays on this and some references, see: http://www.ncbi.nlm.nih.gov/pubmed/22818186 or http://www.equityofcare.org/blog/archives/10112012.shtml; or for a quick take on how the VA approaches these issues: http://www.ethics.va.gov/docs/integratedethics/VAnguard_Making_It_Easier_to_Do_the_Right_Thing.pdf)

    All this is just to say, measuring organizational factors is probably just as important to understanding why clinicians do or don’t act with empathy as it is to understanding why they do or don’t prescribe evidence-based interventions. Context matters.

  6. As a policy maker I would fight to lower the testing prowess if it increased the empathy level. I spend too much times with docs, they may be smart but not a smart as they think they are. Intelligence is compartmentized. Palliative care professionals seem to have an over abundance of empathy skills.

  7. Great discussion. What we often measure is the effectiveness of the system more than the physician. Even within good systems, there is variation among doctors. The public is unable to discern this because they use bedside manner as a proxy for quality. They don’t see variation in physician ability and clinical judgment. Yet we must continue to have quality measures on elements of medical care in areas which are not as dependent on physician judgment.

    Isn’t it possible that we are talking about precision medicine and intuitive medicine? This is a framework used by Professor Clayton Christensen from HBS and his book the Innovator’s Prescription.

    For example, diagnoses and subsequent treatments for hypertension and diabetes, for the most part, are well-defined, optimal outcomes are recognized, and in an ideal world, does not need a doctor’s day to day involvement except for perhaps initial diagnoses or oversight. Some of the work can be delegated to less expensive resources like pharmacists and others. This is precision medicine where protocols and workflows can be developed for best practices and work moved to others.

    However, intuitive medicine, which is what we and the public equate as a good doctors, is the realm of a primary care doctor, emergency medicine doctor, and surgical specialist, who sees patients with a constellation of symptoms. The diagnosis isn’t clear initially on presentation. Sometimes it still isn’t clear with a physical exam, lab work, and imaging studies. This part is far more difficult to measure. This ability to make diagnoses in uncertainty what separates good doctors from truly exceptional ones.

    Even in these two areas of precision medicine and intuitive medicine, we need to have technically competent and empathetic doctors. In the case of immunizations, precision medicine, we know scientifically the recommended age groups for influenza vaccination. A doctor could be graded on the outcomes of this which is more a reflection of the system she works in. Whether she is also able empathize, address a patient’s fears or concerns, and build on the doctor-patient relationship, to help a patient get recommended treatments or interventions, can make the extra difference which may or may not be reflected in the measure.

    Finally, why do we need to choose between either or instead of and? Why don’t we want doctors who are empathetic, good listener, compassion / caring / kind, humble AND competent / effective? Is it possible when we label empathy as a “soft” skill that that somehow it is interpreted with a connotation of being less important than technical skills?
    As doctors, we often denigrate things we don’t understand or are trained to do. As an example in the case of physician leadership, an excellent article, “Challenges of Physicians in Formal Leadership Roles: Silos in the Mind” by Thomas N. Gilmore noted:

    Because [doctor] training inculcates values of autonomy, learning from experience, and professional distance, physicians see a team (managerial) approach as ‘other’ and distance themselves from those colleagues who take up formal leadership roles.
    The consequences are ambivalence and splits, both among leaders and within individuals who accept such leadership roles. A maladaptive strategy is often silos in the mind, in which the different bodies of knowledge (clinical and business) are kept too separate, with the latter denigrated. Yet, many of the current challenges require closer linking of substantive medical knowledge with sophisticated organizational and managerial knowledge to invent and implement new systems…
    …No talented surgeon would enter the operating room without scrubbing, reviewing all the available diagnostic information, and checking the infrastructure and the team’s readiness. Yet, that same surgeon, as a chair going into a meeting, will grab a folder from his secretary and skim it en route to the conference room three doors down from his office and begin a meeting with no acknowledgement of absent members, and differentiating between those who, respectful of community life, informed the leader and those who simply did not turn up. The leadership of the meeting often ignores the interdependency of the various items to one another and to the overall well-being of the institution.
    What Langer (1989) calls ‘mindfulness’, when brought to the adaptive challenge facing academic medicine, will go a long way to bringing the inherent intelligence and aggression in physicians core training to the leadership task.

    As we go forward, I hope as a profession we continue to mindful of what patients really want and measure what we can both at a system level while ensuring we do everything possible to ensure a trusting doctor patient relationship that provides great clinical care.

  8. One great pitfall of attempting to measure physician in empathy is that it is inconsistent. How a patient behaves will influence how a patient behaves. If a physician comes from a well off background but has the ideal to work with socially disenfranchised patients, he may be unfairly rated low on empathy. And vice versa– if a doctor comes from a poor background and serves a wealthy population, he may not be deemed sophisticated by his clients. How a single doctor is rated by patients varies widely. Furthermore, how a doctor is rated by patients differ widely from how a doctor is rated by peers, and the doctor’s perception of the interactions differ from those still.

    • correction: how a physician behaves depends often on how a patient behaves. If a patient is unruly, unfocused, or annoying, the doctor likely will get frustrated, then that patient will give the doctor a low rating for empathy.

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