What makes a good doctor, anyway?

It seems to me that the debate to take to the public is the one about Modernising Medical Careers. The public really are not interested in the kafkaesque unfairness of MTAS, and there is no reason why they should be.

As a patient* I don’t really care how badly junior doctors have been treated, but I do care how well, or badly I am treated. What I want from the medical profession is:

Doctors who are

  1. Good diagnosticians
  2. Competent and selecting and administering treatment
  3. Able to communicate clearly and appropriately what is going on
  4. Good at administration and able to steer you and your notes through the labyrinth effectively

I would certainly want my doctors to be ethically sophisticated and good at working with other professional carers. I’ve no idea how representative my views are of other patients.

It seems as if the medical profession itself is not united on what comprises a good doctor, and this has left a vacuum which the government have opportunistically exploited. Research and academic qualifications used to count – but were they being used to separate excellent Registrars from other excellent Registrars? In other words, was the increasing academisation of the middle level of the profession a symptom of the triangular structure with too many Registrars competing for very few Consultants’ posts? Don’t get me wrong. Research is a vital part of the profession, but is it being done in the right place and for the right reasons? Does being able to do research make you a better surgeon, because what patients want and deserve are good Consultants, not good academics.

Forgive me for saying this, but the architects of MTAS tried to use “frozen” interview questions to elicit information about the stuff that doesn’t show up in CVs, such as approach to communications, ways of interacting with other team-members, ethical stance. They f**ked it up, big time, but they did address the things which – simplistically – patients want their doctors to have.

The questions to put to the public are:

  1. Do you want to be treated by Consultants who have approximately 60% less experience than previously (shorter hours, fewer years)?
  2. Do you think that the service you get from the NHS will be improved or made worse by making 25% of junior doctors and specialist trainees redundant? (If only they were being given redundancy packages….)
  3. Do you think a Consultant will be better or worse if their experience of medicine outside their own speciality has been reduced from half a dozen years to two?

Tabloid questions, yes. But this is what will outrage patients, not the complexities of the MTAS computer system.

However, in order to shape this debate, the medical profession must consider the profession, both in terms of individual career options and in the more philosophical terms of “what is a good doctor” and “what do we want from the profession as a whole”. Specifically, the profession must consider:

  1. What qualities, skills and experiences are required in a good doctor, and how to assess them
  2. How to change the structure of the profession so that it is not limited to two tracks: pre-Consultancy and the rest
    and
  3. How to make successful, interesting and rewarding careers available within the profession without becoming a Consultant and without being sidelined and degraded

Just a thought before I post this: I am older than the MD of the company I work for and much the same age as most of his board. Yes, he is paid two orders of magnitude more than I am, but I love what I do on a day to day basis, my contribution is appreciated and valued by my peers and stakeholders (jargon – sorry), I have good career prospects, the assessment and promotion system is transparent and reasonably fair, and if I want to move around within my profession it is up to me do to it and the entry points are there. This is possible, because career progression isn’t based on the model of a railway track or a ladder, it is much more flexible than that.

I’m keen to hear the views of those not directly involved, those from other countries, and those who are patients or work elsewhere in the NHS. Also, I am curious to know if what I am saying makes sense, or if I’ve missed some fundamental points, so please feel free to comment.


* I do of course care personally about MTAS and its effect – (as Mums4Medics puts it) – on ‘my’ doctor’s career

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11 responses to “What makes a good doctor, anyway?

  1. I am an outsider, but I did spend some time in an NHS hospital having a baby. My experience seven years ago was of harassed and frantically busy staff. It was not good. My GP experience was the same. It seems madness to put extra pressure on the system by culling junior doctors and making sure that those that stay do not have enough training.

    I have been following this series with interest, and you do make it very clear. Thanks, AB.

  2. The public perception is that there are too few resources, not too many. Reducing the number of junior doctors seems to be more of an accounting exercise than a strategy for improving health.
    Of course, as Dr Crippen is very fond of telling us in his blog, doctors are being replaced willy-nilly by nurse practitioners, in whom he seems, generally, to have very little confidence.
    I can’t say I’m happy at the idea that a consultant physician or surgeon today is less experienced than someone with the same designation ten years ago.
    On a more personal note – my father did his medical training in the early 50s and went on to become a surgeon. He was still at Senior Registrar level when he died, prematurely, at the age of 38, just a few months before getting his consultancy.
    It was not uncommon then for doctors to be at least mid-thirties before becoming consultants, by which time they were very experienced people.
    Having said all that, my father’s promotion was not delayed because he was incompetent in any way; he spent two years after med school doing National Service in the Marines and had a consultant who didn’t want to lose him because he was bloody good.

  3. As a slight side-issue to MMC, another thing you want from your doctor – although you may not realise it if you have never had a complicated long-term illness – is at least a basic level of administrative ability. If you “belong” only to one doctor, it’s not so important, but once you start being passed around specialists for particular procedures, it becomes crucial. It wouldn’t even need doctors to be able to do admin if they had decent secretaries and knew how to use them, but they don’t. The whole system of consultant referrals is not fit for purpose, IMHO.

  4. Just to let you know that I’ve been reading and have passed on a link to several medics I know. Not up to saying much but have been reading with interest and horror.

    Am glad that the doctors that saved first my life then my uterus last friday, had the experience they did and were able to apply it. Feel sorry that this may not be the case in 5 to 10 years.

  5. Thank you for your comment, Charlotte. It really helps to know that it actually IS mad, and it isn’t that we’ve lost our sense of proportion.

    It worried me slightly when I met a Consultant Obs-Gyne at a black tie Do the other day, that I found myself feeling distinctly maternal towards him Abeerdeenquinie. One problem with specialising too young (at anything) is that you can lose context. As an example I know of an orthopaedic surgeon who is encouraging an old lady of 90+ to have her knees done, while even her GP is saying that it’s not worth the anaesthetic risk. Early specialisation makes it harder not easier for doctors to treat.

    Potentilla, you are absolutely right. Doctors do need to be good at admin. I hadn’t thought of that, but will add it to the list.

    Hi kelli, thanks for reading and posting. When you get up close and personal with it, it is absolutely terrifying. I am so glad that you and your uterous and your child all well, (for any given value of “well”, of course).

    AB

  6. I think you’ve hit the nail on the head in that a doctor needs to have a combination of personal skills and medical knowledge. That is the unique set of ingredients also termed as “bedside manner”, which sometimes cannot be taught! Therefore, I largely applaud the inclusion of “personal” questions along with knowledge-based questions in order to ellicit this quality, something the very best doctors have.

  7. It may not be possible to teach a bedside manner, but I would bet real folding money that it can be learned or, at the very least, improved upon.

    As you know, Alexandra, I thought the MTAS questions were actually rather good, and that it was feckless stupidity of the DoH to invalidate the selection process by completely messing up its introduction in that way. They won’t be able to use Self-Assessment Competency Questionaires with any credibility again.

    Thanks for dropping by and commenting.

    Aphra.

  8. Resolve to give the best possible care for his/her patient.
    On the floor experience, gained from honest work.
    Perceptive, intuitive and a thinker.
    Wide knowledge base.
    Theres only a few.
    In NHS,
    to see a good doctor is pure chance.
    On face, there is no way of knowing who is good.
    For letters and designation does not mean a thing.
    And few doctors really puts their patients welfare first.

  9. I do find myself wondering if you are right that there are only a few good doctors in the NHS, or if the problem is that the good doctors are all so pushed for time that they are not able to give good service? Of course, as the years go by that erodes their ability to be good doctors too.

    There is also the question of self-sabotage. Sitting on the fringes I have become more and more aware of the number of people who are – effectively – self-harming. At one end you have suicide attempts, at the other you have those who smoke, drink or eat too much, and in the middle you have a wide range of people who neglect or abuse themselves in some other way such as anorexics or bulemics, people who refuse to control their diabetes, and people who claim to be in pain in order to be prescribed morphine.

    The problem is, what is the best way to treat these patients? What the patient needs – their true welfare – is so different from what the patient wants. How do you square that particular circle?

    It’s a challenge that I am glad I don’t have to face, but it is one that makes me aware that there’s more to being a good doctor than accepting the patient’s self-diagnosis and prescribing what the patient asks for.

    I don’t know how many bad doctors there are in the NHS, but I can only claim to have been treated by one.

    Aphra.

  10. Our hospitals are full of good doctors. However, they are not neccessarily as good writers as they are to their patients in reality, indeed, not in 150 words.

  11. True.

    My one comfort in all this is that MTAS is unusable next year. They simply cannot fix it in time for October.

    Thanks for commenting and good luck.

    Aphra.

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