Medical Matters:What is the role of the doctor? Before you decide that this week's offering is not for you and is simply an exercise in doctocentrism, consider this: there is a lot of change under way in our health system, much of which will alter the way doctors work.
As a result, patients may be exposed to a different kind of doctor-patient relationship. It is important, therefore, that lay people contribute to the debate about what sort of doctor we think will best serve our future needs.
What kind of attributes should doctors develop? In the past, distinguished medics such as William Osler placed great emphasis on imperturbability or "calmness amid storm, clearness of judgment in moments of great peril". Another attribute prized by Osler was that of equanimity. To acquire this he recommends doctors develop a tolerant, non-judgmental attitude to others.
A renowned teacher, Osler spoke of the need to tolerate uncertainty and, perhaps even more importantly, not to look for certainty where it cannot be found.
The notion of uncertainty lies at the heart of medical professionalism. A doctor makes many decisions each day based on intense unpredictability.
Experience and knowledge form the basis of such judgments. But you cannot measure wisdom, and so such decisions appear to lack transparency and accountability to an outside observer.
However, this wisdom, the ability to live with uncertainty, is central to good patient care. An experienced doctor knows when to go against guidelines in the interest of a particular patient. It may be the memory of successfully treated cases in the past, or even an acutely developed sixth sense; whatever the stimulus, it is at the very core of professionalism to follow a finely tuned clinical instinct.
A close bedfellow to tolerating uncertainty is an ability to do nothing. This is something I learned long after qualifying. It is not an exhortation to laziness and indolence but rather the exercise of a conscious, thought-out decision not to intervene in a patient's care at a particular time.
The ability to judiciously "wait and see", to use time to assess the progress or otherwise of symptoms, should never be considered negligent. In fact it is every bit as difficult as carrying out the most complex medical procedure or tailoring individualised treatment for a person who has not responded to standard therapies. I regard doing nothing as one of the hardest, but most valuable, of medical "interventions".
The ability to listen carefully to what you have to say is one of the key attributes patients should look for when choosing a doctor. Recent changes in the way doctors are paid in Britain pose a direct threat to the art of listening.
Under the NHS Quality Framework initiative, general practitioners are obliged to practise "tick-box" medicine. Because they are paid according to how well they meet a broad range of quality markers, it is now easier, quicker and more lucrative to ask a series of closed questions related to the boxes on a computer screen than it is to spend time listening for important, diagnostic clues in the patient's story.
Atul Gawande, a distinguished surgeon at the Brigham and Women's Hospital in Boston and a staff writer for the New Yorker, emphasises the importance of diligence and a will to do the right thing.
In his book, Better: A surgeon's notes on performance, Gawande lists five ways in which a modern doctor might make a worthy difference. In an exhortation to become what he calls a positive deviant, he says doctors should ask an unscripted question. On the surface it seems easy enough to ask a question in order to learn something about the patient sitting in front of you.
But "you still have three others (patients) and two pages to return, and the hour is getting late. In that instant all you want is to proceed with the matter in hand . . . but consider at an appropriate point taking a moment with your patient, make yourself ask an unscripted question: where did you grow up?"
His second suggestion is: don't complain. "Nothing in medicine is more dispiriting than hearing doctors complain." His third advice for becoming a positive deviant is to count something. "If you count something you find interesting, you will learn something interesting," Gawande says.
His fourth and fifth suggestions are to write something and to seek out change. "Look for the opportunity to change . . . be willing to recognise the inadequacies in what you do and to seek out solutions.
"As successful as medicine is, it remains replete with uncertainties and failure. This is what makes it human, at times painful, and also so worthwhile."
So what sort of attributes do you think are important for a modern doctor? I welcome your thoughts at the e-mail address below and look forward to sharing them with you in a future column.
Dr Houston is please to hear from readers at mhouston@irish-times.ie but regrets he is unable to reply to individual medical queries.
