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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Dike Drummond MD
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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

Steph T, MD
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Steph T, MD

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.

Keith Frey, MD, MBA
Guest
Keith Frey, MD, MBA

Take a look at this article our team published in 2006, as some of the initial research from a patient’s perspective
http://www.mayoclinicproceedings.org/article/S0025-6196(11)61463-8/abstract

William Palmer MD
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William Palmer MD

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.

allan
Guest
allan

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… Read more »

Arvind
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Arvind

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… Read more »

Davis Liu, MD
Guest

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… Read more »

Katherine Murray Leisure MD
Guest

Profound comments, Dr Davis Liu. Thanks for sharing.

Rob
Guest

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.

Rob
Guest

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… Read more »

Mighty Casey
Guest

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… Read more »

Kaha58
Guest
Kaha58

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… Read more »

@BobbyGvegas
Guest

“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,… Read more »

Perry
Guest
Perry

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