I know it’s hard and 2019 seems like a distant memory, but before the word coronavirus was trending there was a fad on social media called “The Florida man challenge.” Does anyone remember this? The challenge included googling “Florida Man” followed by your birthday as an example of the quantity and array of odd news articles coming from the Sunshine State. So for example when I did it, the top headline for my birthday was, “Florida man seen riding jet ski down state highway.” While the challenge drew lots of laughs, critics rightly pointed out how this niche market was pressured to capitalize on, “the travails of the drug-addicted, mentally ill, and homeless,” in Florida.
Well, unfortunately, a similar challenge could yield disturbing results about physicians. Just insert your state and search, “doctor arrested” and you will read articles exposing behaviors ranging from negligence in prescribing opiates to sexual abuse. True that what is reported in the media is not indicative of physicians at large. You can just as easily find news articles highlighting the generosity, compassion, and diligence of many health professionals. But the fact that “bad physicians” exists begs the question – where did these physicians go wrong?
These doctors had letters of recommendations, completed interviews, & worked with residents and attendings like any other. Did previous colleagues or supervisors witness any early warning signs? Some research is looking for patterns of behavior to improve the selection process to weed out potential “bad apples”. One example is Krupat et al. who reviewed a cohort of medical students that came before their medical school review board and sent surveys to previous residency faculty as well as obtained data on whether these physicians have been sued or sanctioned during independent clinical practice. There were no significant differences from non-medical school board review controls for being sued or sanctioned. However, a multivariate analysis showed a difference for individuals rated low in “treated colleagues with respect” or “required remediation or counseling.” Additionally, the comparison reviewed stark differences in faculty report on many character traits such as, “honest in representing actions/information,” “Incorporated feedback to make changes in behavior,” “functioned well as a member of the team”, or “took responsibility for shortcomings/errors.”1 A general conclusion would be that some individuals that struggle in medical school are more likely to require remediation in residency. However, this line of research is built on the presupposition that the problem exists as “character flaws” within individual physicians that need to be weeded out during the process of selecting and educating medical trainees. I think remembering a quote from our old friend Sir William Osler is helpful here, “The dictum put into the mouth of Ulysses, ‘I am part of all that I have met,’ expresses the truth of the influence upon us of the social environment.”2 Maybe instead of entirely blaming individuals, we should ask: are there distortions in the medical education system and culture of medicine malforming vulnerable health professionals?
If you haven’t guessed, I think there are and an antidote is finding a good physician. Which brings us back to our big question: What does it mean to be a good physician? How can we conceptualize the components of a good physician? Let’s dig into the conceptual framework I’m using.
But first, I must give credit to Dr. Walter Lee, a professor of head & neck surgery at Duke University with an interest in virtue-based professional development and leadership, who presented this framework at Duke’s Theology Medicine, and Culture Initiative back in 2018. A link to the episode is in today’s show notes to hear the background for their motivation to develop the framework and its impact since implementation.3 I found this model to be accurate, useful, and consistent with other accepted descriptions of a good physician (I’m specifically thinking of the ACGME’s core competencies of “being a new practitioner”).
Conceptual framework for components of a good physician:
I should mention what I have modified from Dr. Lee’s framework. First, the label for the domain of cognitive intelligence from what we “know” to what we “think.” I thought this alteration was necessary because labeling one component as what we “know” may implicitly exclude the other components as areas of knowledge. Additionally, the center of the diagram is labeled as who we “are” and further characterized as the domain of “moral knowledge.”
Certainly no one is coming into residency as a blank slate. We all have developed our own understanding of being a good person. But what we must recognize is that most people enter medical training as a blank slate contextually for what it looks like to be a good person as a physician within medicine. So if medical education does not direct who we are becoming in medicine, a plausible result is physicians who are formed in what they think, feel, or do but not in who they are becoming. Or in other words, if the institution of medical education does not direct or inform our moral intelligence within the medical context – as Dr. Lee points out – we may be enabling narcissistic sociopathic physicians to practice medicine. Talk about scary, but I think that shows why this is such an important area that needs more attention.
One subtle but important distinction brought up during Dr. Lee’s talk is the contrast between value and virtue. To paraphrase some of the discussion in that podcast, there was mention that values reflect our beliefs and show what is important to us, whereas virtue are dispositions or habits that inform what we do. I was lucky to get some feedback on this line of thought from next week’s guest – Dr. Warren Kinghorn – who reviewed an early, rough draft of this week’s episode. Here’s Dr. Kinghorn’s feedback on the value-virtue distinction:
Again thinking from the perspective of Aristotle and Aquinas, one thing is that I don’t personally, although I’ve used it a couple of times in our conversations today, I don’t like the language of value. Because it’s so often contrasted with fact, and it’s has a very modern history. And history, frankly, that’s tied up in values of exchange and prices, that kind of thing. I’d rather use the language of commitment. I think that that is often replaceable for value and actually a more helpful term to use. And so in that way, I’d see virtues and commitments as mutually related to each other, that our commitments are the ends or the goals that we are hoping to attain, that the virtues which are dispositions, or habits and patterns of behavior, the virtues are seeking. And so our commitments are the inner gold, that to which the virtues are pointing, and the virtues which Aristotle would define as disposition or as embodied a habit or disposition to act in a particular way in particular situations. The virtues are those habits which enable us to be able ultimately to attain those commitments. And so they they kind of both need each other virtues need commitments to understand where they’re going and commitments need virtues to actually have a chance of being attained.
Warren – if you’re listening to this episode – thank you so much for your perspective. And I agree, I think “commitments” more accurately and clearly reflect what is important to individuals influencing their desired ends and virtues informing their decisions and behaviors to get to that commitment.
So let’s circle back to those “bad apples” we talked about earlier. In light of this framework of the components of a good physician, I think the discussion of how to NOT be a bad physician shifts. If we can talk about these physicians as persons with commitments and virtues then I hope you can see how that frames the discussion in a different way, and quite possibly brings a unique critique on the system, colleagues, and attendings that interacted with this person as they displayed their commitments and virtues (or lack thereof).
What are the essential components of becoming a good physician?
Ask someone this week – a fellow resident, attending, a patient, a nurse, your friend, or your mom. You may be surprised with their response.
