A Great Doctor or a Good Doctor

Are we incentivised to be great doctors in medicine or is it adequate to be a good doctor? If there is such an incentive, then what is that incentive and what’s the source of it?

Not everyone wants to be great at what they do. Then again, medicine is a little different. Apparently it’s a privilege to be a doctor and nothing short of being a perfect doctor is acceptable. Let’s define what a great doctor is and what a good doctor is.

A great doctor

A great doctor is kind to their patients, stays up-to-date on medical information, and sets their own agenda aside, focusing on the patient’s needs. A great doctor isn’t there to make the most amount of money, or to perform the most amount of surgeries, and their goal isn’t to be famous.

A great doctor has to be honest with their patients which often means telling the patient what they don’t want to hear. Refusing a surgery, and refusing to prescribe a certain medication is as much a part of being a great doctor as being accomodating to a rude or angry patient.

A great doctor gives back to the scientific community by being involved in research or by teaching medical students and residents. They also volunteer their time within their specialty. They do community sports physicals, participate in health fairs, and go on medical mission trips.

A great doctor should be a good resource for other physicians. The great doctor is a resource for other physicians with complicated cases. This person can be relied on to be supportive when they are being curbsided. A great doctor isn’t dismissive and sometimes sees as many peripheral patients as they have plugged onto their schedule.

A great doctor needs to not only do right by the patient but also consider the overall health of the medical system and the community. This doctor won’t treat every single dysuria with antibiotics. They won’t overprescribe antibiotics for URI’s or put everyone on statins.

A great doctor will put the patient first. This means that this doctor will have to risk lawsuits, medical board investigations, and deal with management who may not be happy with their habits of choosing MRI’s over head CT’s. If a patient doesn’t have certain resources such as money or time or access, the doctor will be the patient’s advocate, going out of their way to make things happen.

A great doctor has to gain the patient’s trust. There is very little room for self-expression in medicine because a great doctor has to be appeal to the old man, the young woman, the minority parent, and the paranoid mother. But the great doctor will always focus less on their bedside manner and much more about the quality of care they deliver.

A great doctor can’t have any biases in their practice. They can’t dislike women or be racist. They must be able to relate to their entire patient population.

A great doctor realizes that most illnesses will resolve on their own without much intervention. The great doctor realizes that it’s public health which has made the biggest strides in patient health and no the medical interventions we’ve invented. This doctor knows that less is better. They aren’t delusional about their role in the patient’s life and that it’s 90% up to the patient to maintain and improve their health.

A good doctor

To be a good doctor, you need an MD or DO and a pulse. You should also avoid doing harm to your patients. Everything else is self explanatory. Essentially, don’t be a criminal.

A good doctor is the doctor who prescribed antibiotics for colds which have been going on for more than 10 days. A good doctor will move patients through the clinic quickly so that the administrators don’t get frustrated and so that the next patient doesn’t have to wait too long.

The good doctor is praised for never having a bad outcome. Every diverticulitis case is treated with antibiotics. Every pediatric fever case gets 3x blood cultures. IV fluids for anyone who is vomiting. And statins, blood pressure meds, and metformin for those with or at risk for any lifestyle disease.

A good doctor won’t prioritize money over patient care, however. If a test is needed, they will do their best to push for it – up to a certain point. They pick their battles and try to make the career a realistic one. A good doctor will balance career and lifestyle and don’t overextend themselves for patients.

A bad doctor

If you’re confused by the ‘good doctor’ criteria, here are the characteristics of a bad doctor:

• rude and dismissive to patients/staff/colleagues
• only cares about the income from the profession
• hates their profession but won’t leave because they don’t know what else to do
• lies to patients for their own benefit
• steals resources from various healthcare agencies for their own profits
• adds to common problems in medicine (over-prescribing, antibiotic resistance, opioid abuse)

Practicing medicine

Many of my colleagues and also the general population considers practicing medicine to be a higher calling. It’s a job with a halo. You become a god. This expectation comes with the unrealistic expectation that you cannot make any mistakes.

As for medical schools, medical boards, and many employers, being a doctor is a privilege. As in, nobody gives a fuck what you sacrificed to gain the knowledge to be a doctor, but to have their right to practice in your particular specialty, that’s a privilege bestowed upon by the queen. Long live the queen.

Aside from these loads on our profession, we are also expected to be infallible with the limited resources that we have. Patients ask us if they have cancer without us being able to order all the necessary tests. We have to rely on an inadequately trained staff to handle very sick patients. And we have to anticipate how patients could sabotage the outcome of a surgery and prevent that potentially bad outcome.

Of course, I’m focusing on the tougher aspects of medicine. Practicing medicine is also a beautiful endeavor – connecting with patients, catching diseases early, intervening with an appropriate operation, and being showered with gratitude.

Incentives to be great doctors

It’s a lot of work to be a great doctor but it’s rather easy to be a good doctor. Most doctors are good doctors, that’s the standards set by medical groups which hire physicians and residencies which train young doctors. The bar is set very low which is why we can bring in affiliate clinicians to replace physicians.

There are no current incentives for a physician to be a great doctor. If there was, it would look something like this:

• lower patient volumes
• higher income
• less risk of lawsuit or administrative actions
• recognition

The source for these incentives would have to come from medical groups (employers), medical boards, and from colleagues. But the problem is that ‘patient satisfaction’ is the leading metric measured these days; it’s pretty much the only thing employers care about. Even our colleagues are enamoured by the doctor whose patients adore them.

The great doctor isn’t going to enjoy a lower patient volume so that they can dedicate more time to each patient and become even greater. If anything, they will be stuck with the more complicated patients and will be asked to take the lead on more complicated surgical cases. This means more time spent preparing for cases or managing the patients, so less income, not more income.

Imagine you are this amazing doctor – the king-dingaling of physicians. You’ve met every metric to characterize you as a great physician and have maintained that status for a decade. But then you have a bad outcome, or you have a bad day, a patient has a shitty outcome and sues you. Your amazing track record won’t help you; if the case isn’t settled and you have to go to court, none of your good qualities will be highlighted. Instead, a random chart audit might be used to show how poor your documentation is or how you made similar mistakes in other patients.

Personal motivation

Maybe you want to be a great physician for your own sake. Perhaps you are internally driven to be the best you can be. But even if your motivation is the intrinsic value of being a great physician, it’s still an incentive – it’s just coming from deep down inside, somewhere near the colonic flexure.

Maybe it’s a religious thing or the way you were raised – to do the best work possible no matter what it is that you do. In such a case, your only critic is yourself. This is great until you stop incentivising yourself for this higher level of performance, such as when you get burnt out or you become jaded.

Maybe you’ll realize that no matter how hard you work to be a great doctor, your unionized staff will sabotage your hard work. Or maybe it takes one difficult patient to ruin your work-day and your patients will judge you only on how late you were to their exam room.

How to be a doctor

When I started practicing medicine in 2006 as a moonlighter and later as an attending in 2009, my goal was to be a really good doctor. I didn’t care how much effort I had to put into it, I was enjoying every aspect of it. And not in a million years did I think that I wouldn’t get the benefit of doubt. As in, if a bad outcome took place, I would totally be protected unless I was grossly or intentionally negligent.

This was naive and, like many, I learned the hard way.

I’m a little smarter now. I know that even if the outcome of a malpractice suit is favorable or you eventually get dropped, you still have to deal with the lawyers, the court dates, the subpoenas, and mention it in your future job applications.

So, should no resident aim to be a great doctor? Should we all settle to be good doctors? None of us should be bad doctors because the world just doesn’t need more negativity. But the standards are so fucking low to be a good doctor … that irks me. I suppose that I am okay with it now, until I go see a doctor in a clinic myself; that’s when I realize how shitty it can be to have just a good doctor when what I really need is a great doctor.

Where are all the great doctors?

Without a real incentive to be a great doctor, practicing medicine is nothing more than a job. Something I clock into and clock out of. A task which I’ll get done fast enough to not get fired but slow enough that I won’t be held to too high of a standard.

On this path of jobism, I’ll keep the patient happy enough to give me a good patient satisfaction score, anything short of giving them a handjob. I’ll give out meds, refer them for tests, refer them to specialists, perform requested surgeries, start IV’s, and feed into their neuroses. I’ll go far enough for customer satisfaction but not too far to risk a patient complaint.

Killing the great doctors

Our healthcare system is mass murdering these great doctors. I already mentioned that it’s hard work being a great doctor. The incentives help, they help a lot, but they aren’t enough. Because the chance that a great doctor will suddenly become a rogue asshole or a bad doctor is low.

Guilty until proven otherwise doesn’t work well for physicians practicing medicine in healthcare. We’re incentivising great doctors to become just good doctors or plain doctors. The only ones which remain great doctors are those who are resilient; those who have a lot of support around them and have the resources to remain great despite the pressures.

This isn’t something we observe around us. Look at your own career. When you first started, how quickly did you speed towards becoming a great doctor? And how much were you incentivised to continue working towards that goal and how much were you incentivised to add another case to the OR or see just one more walk-in near the end of your shift?

You might think that you’re a great doctor but really, are you? No doubt that you could be. But are you a great doctor?