Fertilising medical science with humanity

Stephen Chen 陳紹德

When asked what the qualities of a good doctor are, any clinical medical student can probably reel off desirable attributes like empathy, effective communication skills, proficiency in knowledge and technical skills, diagnostic acumen, ability to engender good rapport with patients and of course, in this modern age of high technology, one must not forget, the fashionable and oft-quoted "practice of evidence-based medicine", the currently favoured golden yardstick worldwide.

There is, at present, no universally agreed criteria on what makes a good doctor. Even if such criteria were to exist, their applicability would be akin to climbing Mount Everest. After all, the medical priorities of developing countries are conspicuously different from economically advanced societies and it takes more than learnt abilities to make a good doctor. The personae of hospital-based and community-based doctors are also different. Indeed, some desirable personal qualities such as "the ability to get on with people, to empathise with their distress, to inspire confidence in others .......... "¹ are difficult to train into a person; whilst such qualities alone are insufficient to make a doctor good without other prerequisites like professional knowledge and competence, experience, analytical acumen and responsible decision-making.

The ability to genuinely listen to patients has been most highly rated by end-users of medical services² and most patients - about 80% of the cohort study sample - do not require more than two minutes of active listening by the attending doctors.³ Thus, a good doctor, however pressed for time he or she may be, should make a patient feel that his/her "illness is of real concern to the doctor",⁴ and showing active listening with a genuine interest, is one way of achieving this. A good doctor "must be able to put himself in the patient's place"4 and this is exactly what empathy means.

Brandishing empathy as if it were a brand-name is easy, but actually practising this virtue daily is another matter and it takes more than learnt behaviour or attributes to achieve this goal. It also requires beneficence⁵ which is an inborn characteristic. After all, a so-considered good doctor can have bad or evil intentions. As George Bernard Shaw very appropriately pointed out in his book⁶ over nine decades ago, the good doctor must have both scientific acumen and compassion, Shaw was indeed a visionary because his ideas of scientific proficiency included not only a clear understanding of biological mechanisms, but also that of statistical analysis of outcomes, which would align him very well with modern day protagonists of evidence-based medicine.

The practice of evidence-based medicine should not be the ultimate Mecca of good-doctoring. It ought to be considered as another useful tool to help us all become better doctors - with the aid of pre-existing desirable attributes such as humility, humanity and a touch of humour. After all, evidence-based practice is no panacea⁷ for deficiencies in any healthcare system and one must be aware of potential pitfalls when extrapolating hospital-based results to the primary care setting⁸ or applying occidentally derived data to another culturally and politically different locality.⁹ Critics of evidence-based practice would quite rightly point out the inherent rigidity of such cookbook medicine,¹⁰ which makes no allowance for the uniqueness of individual patients, personal experience, circumstantial judgement and of course the rather elusive concept of the art of doctoring.

Continuity of care has often been promoted as an important element of good medical practice, the hallmark of family medicine and the Utopia of healthcare. A Dutch study,¹¹ however, has shown such insistence by doctors to be just another example of medical paternalism. In fact, patients in the study valued adequacy of consultation time and receiving detailed information about their illness much more than continuity, thus shattering the well-propagated myth. So we are, in a way, back to the desirable qualities of active listening and communication skills. Being humane and informed empowerment of patients in decision-making are also more highly rated than "competence/accuracy" by patients in yet another study,¹² hence reaffirming the fallacy of paternalistic assumptions of orthodox medicine.

In our quest for medical excellence, we must strive to be crystal clear about the significance of a vocation and its subtle differentiation from professionalism. We must never forget the idealism embodied in the good Samaritan doctor so well-depicted in William Small's sentimental drawing (1898) that can be viewed in the Wellcome Library in London, whilst keeping pace with realism. We may never be able to have a universally acceptable definition of the good doctor or succeed in becoming one, but hopefully in our endeavour to attain such accolade, we may have become "good enough"^1,13 doctors. Whilst not forgetting the essential ingredients of knowledge and competence, humanity and humility, interpersonal and technical skills, it is perhaps out of a sense of being called and its fulfilment and contentment that "goodness"¹⁴ is nurtured.