Physicians

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.

Ashish Jha, MD, MPH (@ashishkjha) is the C. Boyden Gray Associate Professor of Health Policy and Management at the Harvard School of Public Health. He blogs at An Ounce of Evidence where this post originally appeared. He is also the Senior Editor-in-Chief for Healthcare: The Journal of Delivery Science and Innovation.

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  4. Then there is the evidence that the “soft” skill of empathy produces hard results when it comes to measurable patient quality indicators.

    One of the best examples is this study that showed provider empathy is directly correlated with Diabetic control.

    “The Relationship Between Physician Empathy and Disease Complications: An Empirical Study of Primary Care Physicians and Their Diabetic Patients in Parma, Italy”
    Canale, Stefano Del MD, et al
    Academic Medicine: September 2012 – Volume 87 – Issue 9 – p 1243–1249

    Dike
    Dike Drummond MD
    http://www.TheHappyMD (dot) com

  5. You only need to ask the healthcare team who the “good” and who the “bad” doctors are. Health care systems should consider 360 reviews of their physicians, including evaluations of them by nurses, techs, administrative assistants, and other physicians. The support staff ratings mean a lot more than any Press-Ganey score.

  6. Worrying about their patients is a big one: enough to discuss their patients in the coffee room, enough to bring their patient problems to committee meetings, enough to change their own work schedules in order to cover them, enough to call them at home with ideas about their care, and enough to research their problems on the Net and in the library. In short the patient becomes part of their lives for awhile.

  7. Dealing only with the cognitive element for the average patient and assuming a basic intelligence and ethical standing.

    Patients differ.
    Circumstances differ.
    Disease differs.

    Smarts help, but how much smarts? The smartest doc in the room might use those smarts to best his fellow docs very few times. But, can he manage the simpler more common problems that beset the physician practice and most physicians can easily manage by themselves or with consultation? Knowledge must be appropriately used.

    The present measuring sticks are too frequently misused and are inadequate. Such observation changes the dynamics so physicians focus on what is being tested. Other areas, perhaps more important, are deprived.

    What is that “one word”. Perhaps “communication”. If one cannot communicate one cannot adequately treat (language, culture etc.) The doc must be able to understand what the patient is telling him and must be able to communicate back so the patient follows reasonable advice and treatments. Empathy has to be communicated so that the patient is open and later can be reassured. Communication is needed with other physicians, nurses, family etc.

  8. So far the first piece where I have seen “quality” dissected, fairly accurately.

    A missing piece that Dr. Jha failed to point out, and once that I get to experience several times a day, is the ability to simplify the complex world of medicine into a patient’s cognitive world. Being an Endocrinologist is neither like being a family practitioner, nor is it like being a heart surgeon. Try explaining primary hyperparathyroidism or aldosternonoma to a patient with high school education. A doctor’s ability to patiently explain complex terms in a simple manner and help patients make an educated decision by trying to be in the patient’s shoes, is what makes a good doctor, in my opinion.

  9. 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.

  10. I agree that EMRs are not only desirable but essential. I worry however that today’s demands that docs use today’s EMR systems with all their rigidities will have serious unintended consequences, eg. Causing docs to miss important information from their patients that could be life threatening, etc. or lulling docs into bad habits that will be hard to correct down the road when better systems are available.

    I should add that I have yet to meet a doctor who doesn’t “hate” the EMR system he or she is obliged to use!

    Thus, my conclusion is that just as we force docs to use systems against their will, we should force vendors to improve their systems sooner, rather than tolerating them.

  11. I agree with Rob — we are in the early days of using EHRs and no doubt, for many physicians, they can feel like a distraction. Over time, as we redesign work flow, etc., I think technology will become a complement to, not a distraction from, the patient-physician interaction

  12. Good point Bobby, and that’s what scares me about the future of medical practices being hospital or very large group-based.

  13. I’m delighted to see you comment on this, Rob, since as I read it I was thinking about “non-system” docs like you, who are certainly part of the medical system but not fully enveloped within the constraints of XYZ Health System, Inc. and their IT/workflow decisions and planning.

    I can only imagine how tough it must be for a hospitalist, or an ER doc, to operate on a human level with all the data input/output requirements spackled onto their interactions with patients. Good docs find a way, but what a slog that’s gotta be.

    My lifetime (so far) has taught me that the MD who looks me in the eye and listens to me, even if it’s for a couple of minutes, seems like a good doc. And likely is a good doc, based on the ability to listen. So Jha’s survey results are spot on: empathetic. Observant sure belongs on that list, too …

  14. One more point: there are some docs who are performers/salesmen. They are very good with the patient in terms of leaving them feel satisfied and listened to, but they are satisfied with care that is not excellent. They lack the healthy self-doubt that makes a good doctor do the extra things to make sure care is good. They don’t organize their records, they don’t reach out to people unless it makes them appear to be good. These are the most dangerous doctors. Their patient satisfaction is high, but their priorities (or lack of them) put patients at significant risk.

  15. EMR systems can do good if they structure the thought of the physician in the exam room and offer decision support. The problem is that most EMR systems are distractions — tools for achieving meaningful use and submitting the proper documentation for payment by the third parties. The problem is not in the idea of the EMR, but in its execution.

  16. Agree 100% that to look at doctors as a group is not as meaningful as if this was broken down into segments. Primary care physicians (which is what I am) have strong needs for connection, as the ability to listen to the patients’ stories is and formulate a plan is the thing that separates the good physicians from the mediocre. It’s interesting that being observant was not high on the list (although it was included), as I see that as a huge plus. It’s one thing to hear the routine stories of people, but it’s a whole different level if you can pick out the few outliers, the ones who sound one way but actually are the other. This is why all of the distractions in our system are bad for care: we don’t have time to really listen to people, instead lumping them into categories, decision trees, etc.

    As I PCP I believe that every patient tells their story and it is our job to listen and come up with a reasonable plan to address their worries, their complaints, and their risks.

  17. “All the parts in the system must function together with a shared focus and with precision as a you seen with a pit crew!”
    ___

    Yeah. I use team sports and jazz ensemble analogies a lot (re both of which I have extensive experience as a rabid pickup hoops player and former bandleader), owing to the inevitable situational improvisational component of clinical workflow.

    One concern of mine goes to what I call the chronic “psychosocial toxicity” of many healthcare work cultures (by no means unique to the healthcare space, but all the more ironic) — e.g., the “bully culture,” FUD, work/social environments wherein one speaks truth to power at one’s peril. Such is inimical to high-performance teams. Error rates go up. Staff turnover is elevated, etc.

    It’s fundamentally a patient safety issue.

  18. Great article and thoguhtful comments!

    Quality metrics and satisfaction surveys have their place(even Press Gainey). But like a thermometer which tells us a symptom not a diagnosis, quality metrics measure only one aspect of the process. They help to guage where we are in one particular condition, at one particular moment and with one particular process. We are highly focused on those because they may be tied to individual pay and certainly to system performance and pay!. They are not good measures of the whole systen only parts of the system.

    Currently we don’t routinely measure the effectivenss of the team and the interdisciplinary care. AHRQ’s Culture of Patient Safety does look at the culture and attitudes of the team (if done honestly). And TeamStepps is a toolkit that works on developing team skills to improve pateint safety, quality and the dynamics of “the team”. Both may be better indicators of the overall “quality” and “health” of the system or organization.

    After nearly 20 years of working with physicians on core measures, satisfaction scores, peer review, perceptions scores, human factors analysis, error prevention, etc. It is clear that being great in one area tells us nothing but that we have checked all the boxes for that measure (now super simple with EHR) but is it menaingful? Do they measure more than that we gave ASA or timely ABX that one month/quarter? I don’t think so. But they are a good guage for how we are doing with condition or disease.

    All the parts in the system must function together with a shared focus and with precision as a you seen with a pit crew! In most healthcare organizations both IP and OP that is not what is happening, but we are moving in tha direction albeit at slow pace!

  19. What every good doctor needs:

    – Gray hair for the look of wisdom

    – Hemorrhoids for the look of concern

  20. Seasoned humility.

    Nonlinear thinking.

    Seeing faint pink as possible crimson red.

    Keen BS detector.

    Vision beyond sight.

  21. Agree completely to measure what it means to be a good doctor + worki in a good system. Given the impact of the interdisciplinary care team (MD, RN, MA, patient), perhaps we should also measure that.

  22. My view is that a good doctor will be able and willing to resist slavishly adhering to guidelines and incentives to force me to take preventative tests that have too many false positives or which haven’t been shown in randomized control trials to improve hard outcomes (reference Hadler on psa, statin tx, colonoscopy, annual physical exams etc).

  23. Is it fair to conclude from Dr. Jha’s observations that forcing docs to use EMR systems is making them less “good” rather than better docs?

    Required intensive data entry distracts most docs from focusing on their patients’ concerns so they can’t help but be — or at least appear to be — less empathetic, unable to listen well, etc.

  24. My family has had many very serious and rare medical problems. Doctor after doctor misdiagnosed or dismissed the conditions as unimportant. Thus my perspective may be different than most. I have come to the conclusion that the best measures of a good doctor are the following: deep care for the patients treated and deep curiosity. Deep care because it will cause the doctor to treat the patient correctly, spend time with the patient and motivate the doctor to spend sufficient time and effort to find the correct diagnosis. Deep curiosity because it will cause the doctor to find why unusual symptoms and/or test results show up rather than just dismissing them as a variant of normal.

  25. “All we can do today is try to establish an empathic therapeutic relationship so that patient and physician can collaborate to do the best they can.”

    This is a quote from Dr. Hadler in a previous post. This describes a good doctor. But I don’t think it can be measured by our current system.

  26. The qualities offered for physicians may in fact share much of what we seek in other service oriented HC professions: pharmacists, nurses, and social workers come to mind.

    I would like to see another crowd sourced twitter exercise for the above providers.

    The frequency of responses may have less to do with cognitive oriented physicians (after all, we all desire empathy and listening ability from nurses), and more to do with those who provide only a technical skill.

    Brad

  27. The desired characteristics of a surgeon versus those of a general practitioner run bang into each other in one very large area of care: maternity care. The US deviates from other countries’ practices in having obstetricians overseeing most births. Obstetricians are trained as surgeons (and thank goodness, for those times when we need surgery!). Labor and birth is a time when the interaction of hormones and muscle action (i.e. the cervix! the uterus!) are most strongly connected, so it is particularly unfortunate to have someone attending the birth who does not rate high in most of those “Top 10” qualities Ashish mentions, as the provider may very well negatively influence the course of the birth as a result.

  28. Very interesting, I agree with your thesis that there are different skills for different providers, but I also feel that collaboration trumps them all. You refer to this when you discuss leadership, because the most effective leader collaborates well. The patient must be included as a team member because without the patient we are all without any role.
    Re: surgeons? this would include surgeons, who do work outside operating rooms too, where other skills like humility (when delivering bad news or admitting the limits of his/her skills) or communication (when describing risks and benefits when asking a patient for consent) may be best handled by someone else on the team whom the surgeon has admitted does these jobs more skillfully.
    If we all recognize our limitations we will have everything to gain in healthcare. All of us providers have contributions to make, best we make them together and in concert to the benefit of our patients — one day we will be a patient too.

  29. ” Most quality outcomes currently (not rudimentary measures like ARB prescribing or measurement of Hba1c) that assess broader quality are really measures of the capability of the system. And a mediocre doctor in a good system trumps the good doctor in a poor system.”
    __

    Great observation.

    “the capability of the system”

    Deming 101. We’ve known this principle for a long time, yet we cling to the notion of the Iron Man Heroic physician.

    Dr. John Toussaint (ThedaCare Center) has a new book coming out entitled “No More Heroes.” Can’t wait to get it.
    __

    Excellent post, Dr. Jha.

  30. Fantastic post. I am a surgeon and the chairman I trained under will never win any personality awards. But operating with him was like playing with a violin virtuoso and if I ever need surgery, there is no question he would be my first choice as surgeon.

    There is also an incredibly important point about the ability of the
    Individual vs the system. Most quality outcomes currently (not rudimentary measures like ARB prescribing or measurement of Hba1c) that assess broader quality are really measures of the capability of the system. And a mediocre doctor in a good system trumps the good doctor in a poor system.

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