During the 1930s, my grandmother saw a specialist about a melanoma on her face. During the course of the visit when she asked him a question, he slapped her face, saying, ‘I’ll ask the questions here. I’ll do the talking.’ Can you imagine such an event occurring today? Melanomas may not have changed much in the last fifty years, but the profession of medicine has. Eric J. Cassel, 1985[i]
Today, a stinging slap to the cheek of a patient who asked a question of her doctor could lead to an assault charge. Doctor-centered practice–paternalistic authority is no more. Shared decision-making between doctor and patient has become the ideal. In short, the definition of a “good” doctor has changed dramatically in the past half-century.[ii]
Even with this 180 degree shift in defining “goodness,” there remains much variation even among former TV doctors Welby and Kildare and today’s Dr. House. All are seen as “good” in different ways as times change.
And that is why I put “good” in parentheses. Personal features (e.g., communication skills, empathy), expertise (e.g., credentials on walls, medical specialty), what others say, and context matter greatly in judging how “good” a doctor is.
Here is how one doctor puts the issue of defining “goodness” among physicians.
In my view, there are many ways a doctor can be good, so it’s difficult to know what someone means when he or she says a doctor is good.
For some people, being a good doctor is all about bedside manner, personality and communication skills. Other people value smarts, technical skills or expertise in a particular condition. Still others rely on credentials, such as where a doctor went to medical school or residency training. I’ve even known patients who care little about these other factors and instead care most about how the office runs, how quickly the phone is answered or how friendly the receptionist is.
The type of doctor may also determine how a person defines a good doctor. For example, many people I know say they don’t care about a surgeon’s bedside manner as long as his or her patients have outstanding results. Yet those same people might say that a good bedside manner is much more important for their primary care physician.
Then there are those magazines that list “best” doctors in their cities annually. How do they compile such lists? New York magazine, for example, depends upon a private firm that polls doctors for their recommendations:
The idea is that medical professionals are best qualified to judge other medical professionals, and if one recommendation is good (think of your doctor referring you to a specialist), multiple recommendations are better. Licensed physicians vote online (castleconnolly.com/nominations) for those doctors they view as exceptional.
So if the notion of a “good” doctor varies by time–doctor-centered then and patient-centered now– it also varies by what patients and doctors, each having quite different perspectives, value most in medical practitioners (e.g.,competence, empathy, bedside manner). In short, there is not one single definition of a “good” doctor that covers all settings, perspectives, and times.
Yet even with all of this variation over what constitutes a “good” doctor, even with all of those lists of personal and technical features that patients want in their doctors, two generic characteristics emerge from the flow of words time and again. These basic features: competence and caring–turn up in studies (see here) and public opinion polls among both physicians and patients.
Keep in mind, however, that even the most competent and caring doctor depends upon the patient for any success in diagnosis and treatment. The truth is that expertise and caring are necessary ingredients for any definition of “goodness” in medical practice but, overall, insufficient in the helping professions without the patient’s cooperation.
While doctors can affect a patient’s motivation, if that patient is emotionally depressed, is resistant to recommended treatments, or uncommitted to getting healthy by ignoring prescribed medications the physician is stuck. Medical competence and empathy fall short when patients cannot or do not enter into the process of healing.
This basic predicament in the helping professions of being dependent upon the cooperation of the patient for any success–often unremarked upon–hobbles any definition of a “good” doctor.
Does the historical shift in definitions about “good” doctors and the fundamental dilemma they face apply to teachers? I answer that in Part 2.
[i]Epigraph story in Christine Laine and Frank Davidoff, “Patient-Centered Medicine,” JAMA, 1996, 275(2), p. 152.
[ii] Ronald Epstein, Md., et. al. “Communicating Evidence for Participatory Decision-making,” JAMA, 2004, 291(19), pp. 2359-2366; Simon Whitney, Md., et. al., “A Typology of Shared Decision Making, Informed Consent, and Simple Consent,” Annals of Internal Medicine, 2003, 140, pp. 54-59.