CHAPTER

9     Being and Becoming a Good Doctor

THE GOOD DOCTOR

CAN THE STORIES of these seven physicians be more than a collection of stories? Can they collectively provide insight into (1) what it means to be a good doctor in our times, and (2) how to become one?

With those questions in mind, I used a technique for organizing ideas and data developed by Japanese anthropologist Jiro Kawakita that is variably known as the KJ Method or Affinity Diagram. This approach can be helpful for bringing structure to discussions and analyses of topics that are complex and highly vulnerable to biases—like this one. This seems like a fitting place to note that the conclusions in this chapter are offered with appropriate humility. They are based upon seven physicians’ stories, interpreted by one author. I have no objection to others collecting and analyzing their own stories and data, and enriching our understanding of what it means to be a good doctor today. In fact, I hope some readers do and would love to see what emerges.

In the KJ Method, you start with data and build up from there. Data in this case are observations of key features of each of the seven doctors’ stories. I went through every page of their chapters, and wrote down facts and features of their stories that struck me as relevant to the questions posed previously, for example, “Merit Cudkowicz goes out with team after every clinic session,” or “Mike Englesbe was stunned by three consecutive liver donors dying because of prescription opioids.”

There were, of course, a lot of observations. But then I started organizing them into natural groupings. For example, Merit is not the only one with close relationships with her team. Mike said his public health work was “propelled by my coworkers.” Emily talks about the pride in the cross-training that enables her team to be flexible enough to provide same-day biopsies. These and other observations emerge in Table 9.1 under “Collaborative team-builders.”

Table 9.1. Common Characteristics

1.   Deep empathy

–  Joe Sakran cares for survivors of gun violence, as was he.

–  Mike Englesbe is moved by the stories of young donors’ journey to death.

–  Emily Sedgwick knows that when women are told they need to come back into the room for more breast images, “their hearts stop.”

–  Lara Johnson is honored to care for people who have the same types of struggles her family faced.

–  Babacar Cisse imagines his patients are members of his immediate family.

–  Laura Monson: can sense how important having friends with similar experiences is to teens with cleft palate.

–  Merit Cudkowicz is able to imagine what patients needed to hear as indicated by her email message, “We are here to help your friend.”

2.   Passion to go way beyond one’s job description

–  Merit drove to Connecticut to see patients who couldn’t come to Boston.

–  Emily redesigned breast imaging protocols to reduce patients’ fear.

–  Laura started a camp for children with cleft palate.

–  Mike, a transplant surgeon, works on opioid-prescribing patterns.

–  Joe is an advocate for gun violence reduction.

3.   Resilience

–  Merit has led so many disappointing drug trials for ALS, but draws resilience from patients—“If they can keep it up, so can we.”

–  Mike on being a surgeon: “Surgery is so humbling. . . . You have to be very self-critical, but not let it crack you.”

–  Babacar kept looking for a path to education even as an undocumented immigrant working as a busboy.

–  Laura learned her post-fellowship job evaporated as she scrubbed for surgery; she went back into the operating room and finished the procedure.

–  Lara graduated valedictorian despite caring for a father with AIDS and dealing with a mother who had major substance-abuse problems.

–  Joe decided to use being shot as defining moment to help others.

–  Emily didn’t give up when the only other MD in her group quit and left.

4.   Collaborative team-builders

–  Merit goes out with her team after every patient session.

–  Mike says his work on opioids is “propelled by my collaborators.”

–  Laura’s camp is staffed by her clinical and nonclinical colleagues, who donate their time.

–  Lara says she doesn’t get burned out because she “loves her coworkers.”

–  Emily built a team with cross-training and adaptability to give same-day biopsies, when volume fluctuates wildly.

5.   Sense of purpose

–  Mike is propelled by the realization that opioid dependence is the most common complication of elective surgery.

–  Merit feels that neuroscience is on the verge of being able to really help patients with ALS and other neurodegenerative conditions.

–  Emily brought breast-imaging redesign to facilities providing care for low-income and uninsured women.

–  Laura wants to make a difference in the long-term outcomes that her patients really care about.

–  Joe sees prevention of gun violence as an extension of his clinical work to help patients who, like himself, have been injured by firearms.

–  Babacar sees it as his duty to “choose to live like a candle,” and provide light even if it means he disintegrates.

–  Lara is motivated to give people struggling with addiction and homelessness the same respect and quality of care other patients receive.

6.   Ability to get outraged on behalf of patients

–  Merit: “I get mad when I hear about doctors telling patients with ALS that it is hopeless.”

–  Emily: “When patients aren’t treated well, it really makes me mad.”

–  Joe got “incensed” when reading NRA tweet and fired off responses that captured colleagues’ emotions.

–  Lara: “It’s simplistic to say I always want to root for the underdog, but that’s kind of what it feels like.”

And then I grouped the groupings, looking for patterns in the “data” that would provide insight. This method is, essentially, thinking—but it’s thinking in which the reader can see where the thoughts come from. For example, when I write that these good physicians tend to be collaborative team-builders, you can read specific examples that led to the conclusion and, I hope, bring that conclusion to life.

The three “uber-groupings” that emerged from this exercise examine these questions: (1) What are common work-related characteristics of these seven good doctors? (2) What are common features of their personal makeup? (3) How did they turn out the way they turned out?

Common Work-Related Characteristics

Six common characteristics emerged from the way these seven physicians do their work (Table 9.1). An obvious theme in every portrait is deep empathy for their patients. Like most people in medicine, these seven physicians are highly social creatures; they enjoy their interactions with patients and their colleagues. But these physicians have developed virtuous cycles, in which their empathy for their patients has led to extraordinary things, and those extraordinary things have led to even deeper relationships with their patients.

In some instances, the sources of empathy are painful events from the past that are far from generalizable—for example, Joe Sakran having been shot in the throat as a 17-year-old or Lara Johnson being the child of parents with drug, alcohol, and other problems. In others, empathy flows from the opportunity that every physician has to witness and relate to the suffering of their patients. For example, Babacar Cisse says 17 hours in the operating room can seem like five minutes when he is performing neurosurgery on someone who reminds him of his mother or his children. Mike Englesbe began working on the opioid crisis because of empathy with three patients who were no longer alive—deceased donors for liver transplantation. As he said, “How can you not be moved when there’s a naked donor on the table, and you’re hearing the story of this young person’s journey to death?”

These physicians have the emotional openness to fall in love with their patients and the emotional intelligence to recognize it. And they have acted upon their impulses to do good for their patients in ways that sometimes take them way beyond what anyone would consider conventional healthcare. Each step might have seemed logical at the time. For example, Merit felt bad she couldn’t see a family of patients with an inherited form of ALS who had become too sick to drive to Boston, so she drove to Connecticut to visit them at home.

For these physicians, step A logically led to B, and B led to C, and C led to D, . . . and suddenly they were doing something completely unexpected. A liver transplant surgeon finds himself leading a public health effort, and a plastic surgeon finds herself running a summer camp for children. All of these physicians went with their instincts, and those instincts took them someplace remarkable.

The resilience these seven people have shown along the way is impressive. No one should think of resilience as a personal characteristic that is the opposite of burnout. Resilience is something that influences how stresses and rewards are experienced, thereby making burnout less likely (see Chapter 1). Greater resilience enables one to respond to stresses, and makes it less likely that one might be crushed by them.

None of these seven has had a smooth and glorious path to success. In fact, how they dealt with setbacks might be the most durable message from their collective stories. Joe’s gunshot wound, Babacar’s six-year period when there seemed no path to a college education, Lara’s whole youth—these challenges might seem too great for readers to imagine enduring. But all of these physicians responded to setbacks, adapted, and persevered. Merit flunked her first test in medical school and has run clinical trials on so many agents that seemed promising for ALS, but ultimately had no benefit. She saves notes from patients—many of whom have passed away from their disease—encouraging her to keep working at finding treatments for ALS.

Mike was very good but not quite great in sports growing up, and that helped prepare him for work in which resilience is such an asset. He is humble enough to know when he has been humbled. When a surgical procedure has a bad outcome, he knows he has something to learn from it. But he is resilient enough to go back into the operating room and perform the next complex surgery.

Laura Monson was told that students from her medical school were never accepted for residency at University of Michigan, and described her reaction as a silent sarcastic one-word thought—“Great.” Then she worked her tail off and got in. Later, when she got a telephone call with the news that her dream job had disappeared just a few weeks before it was to start, she put it out of her mind and went back into the operating room to finish the procedure.

Another common characteristic they share is being collaborative and building true teams. I talked with enough of their associates to know that they are all really liked and respected by their various colleagues, who are proud to work with them. Merit is aware that her patients with ALS talk to her about their hopes, focusing on the next research trial of a promising agent. But when they meet with the nurse in the next room, they pour out their fears and their anguish. Merit knows that the nurses have the harder role to sustain—that burnout is a bigger threat for them–which is one of the reasons her team goes to an eatery across the street from Massachusetts General Hospital after every patient session to unwind together.

These first four characteristics—empathy, passion, resilience, and a collaborative nature—are integrated with a strong sense of purpose in these physicians. They all see a connection between their work with patients and something bigger. Laura wants to do more than fix the facial anomalies of children; she wants them to have good and rich lives. Merit wants to cure ALS. Mike doesn’t want to harvest another liver from someone who died because of prescription opioids ever again. Joe doesn’t want people to die from violence of any form. Lara serves the underdog. Emily wants everyone—not just doctors and doctors’ families—to receive care that minimizes unnecessary anguish. Babacar feels it is his duty to “choose to live like a candle” and provide light even if it means he disintegrates.

The final characteristic present in many of their stories is the ability to get outraged on behalf of their patients. Table 9.1 shows a sampling of the observations that led to the identification of this characteristic. This set of observations may be a subset of the second category, passion, but “getting mad” seems to imply something beyond deeply caring. The common theme is a fire for reducing the suffering of their patients, and they have used that fire in constructive ways.

Personal Makeup

The next uber-grouping of observations relates to their personal makeup (Table 9.2). There is obvious overlap and resonance with the work-related characteristics in Table 9.1, but this is where I put observations that were likely to transcend the work setting. They fell into categories consistent with the four psychological assets that Angela Duckworth has described in her research on grit—interest, purpose, practice, and hope.

Table 9.2. Personal Makeup

1.   Interest

–  Babacar spent five years after high school teaching himself science, and now runs a large immunology/oncology laboratory.

–  Merit spent weeks working on Rubik’s cube and decades on research on neurodegenerative diseases.

–  Mike asked medical students to collect data to find out how opioids were being prescribed and used after surgery.

–  Laura feigned illness as a child so she could stay home and read.

2.   Purpose

–  Mike describes his sense of duty: “I feel like I have had every opportunity. If I can’t be successful in making the world a better place, who can?”

–  Laura internalized her parents’ message on the importance of “being a good person and giving back.”

–  Emily lives by her parents’ counsel to be respectful of everyone and leave things better than she found them.

–  Babacar has adopted his parents’ maxim to “live like a candle, and help others even if it means disintegrating.”

–  Joe liked helping people as a firefighter and EMT.

–  Merit wanted to solve the energy crisis.

3.   Practice

–  Mike swam competitively, determined to be as good as he could be.

–  Laura describes herself as competitive as a young student, wanting to be “as good as I could be.”

4.   Hope

–  Merit is more excited than ever after two decades of trials of ALS treatments.

–  Mike is sure opioid-prescribing patterns can be improved even more.

–  Laura was ready to start camp without yet having data on long-term outcomes that she hoped to improve.

Her research has shown that gritty people have both passion and perseverance. They have goals that they really care about, and they keep pushing to improve as they pursue those goals for years and decades. They were all willing to make sacrifices along the way. In fact, it’s worth noting that patior, the Latin root of the word passion, implies willingness to sacrifice (e.g., the passion of Christ). It’s also worth noting that the word patient is derived from the same root and means “one who suffers.”

The first psychological asset that helps generate passion is interest. You have to find what you are doing interesting. You have to be curious. You can’t yawn and think, “this is one more child with a cleft palate,” or “one more woman needing a mammogram,” so a box on a list can be checked off. A gritty physician finds their patients interesting and wonders what is really going on in their patients’ lives. What are they worried about? How can they be helped?

All seven of these doctors are interested in lots of things—they are naturally curious. Babacar taught himself science during the five years when he couldn’t get a formal education, and still reads about astrophysics on his own. Laura’s mother was a librarian, and her daughter might have been her most active customer. Merit immersed herself in solving the Rubik’s cube with an intensity similar to that she applies to her efforts to find treatments for diseases. Mike wanted numbers to inform his thinking about opioid prescribing, so he worked with a student to find out how many pills were being prescribed by his colleagues—and how many were actually being taken.

The second psychological asset in Angela’s framework is purpose—the intention to contribute to the well-being of others. These doctors are idealistic. They are altruistic. They talk about the very clear and compelling messages they received from their parents—for example, Laura’s parents urging “to give back,” and Emily Sedgwick’s parents teaching “to be respectful to all.” Babacar and Joe both talked about their grandfathers when I asked them how they turned out the way they are. They felt their grandfathers had made altruism an enduring core value for generations of their families.

This altruism was a common theme even though most of these doctors did not come from privileged backgrounds. Babacar was an immigrant who arrived from Senegal with $26 in his pocket. Joe’s father arrived from the Middle East with even less. Mike and Merit, the two with the smoothest paths to medicine, both expressed their sense of obligation to do something meaningful with their education.

These physicians find an outlet for their altruism in their work. If you apply the four questions in Press Ganey’s tool for measuring “activation,” these physicians would probably have scored quite high at any point in their careers:

1.   I care for all patients equally even when it is difficult.

2.   I see every patient as an individual with specific needs.

3.   The work I do makes a real difference.

4.   My work is meaningful.

* * *

The second key component in Angela’s grit framework is perseverance, and the first psychological asset in its development is practice. Now “practice” means more than putting in time; it means “deliberate practice” in which you are really trying to get better. You have to have a growth mindset, to use the terminology developed by Stanford psychologist Carol Dweck. You have to believe you can get better, and you should get better. Even if you are at the top of your field, you should try to improve. It means being chronically restless and willing to suffer to make progress.

Mike’s swimming career presages how he has approached his professional life. He literally plunged into a grueling sport and rose to a high level on the basis of hard work combined with natural gifts, which were considerable but he knew were never going to get him to the Olympics. He realized that one of his core strengths was that he was unafraid to do the hard, grueling thing. He has been drawn to tasks like completing the many years of training in surgery and performing long arduous operations like liver transplants because he knows no one is going to outwork him.

He was not the only competitive person in the group. Laura described herself as being this way as a child—she said she wasn’t necessarily trying to beat the other children in spelling bees, but she would be really upset if she had not performed her best. My observations of all the rest indicate that they, too, have been ready to do more than put in the hours to learn their crafts. They have pushed themselves to be as good as they could be.

The other psychological asset that contributes to perseverance is hope. As Angela makes clear in her book Grit, hope is not optimism that things will get better. It is the belief that things could get better if one works hard, learns, and tries new approaches. She invokes the Japanese saying, “Fall seven, rise eight.” You keep getting up because you think it might come out differently this time, because you are going to try something different. Angela makes a clear distinction between “I have a feeling tomorrow will be better” and “I resolve to make tomorrow better.”

These physicians all display that second type of hope. Merit is more excited than ever after two decades of trials with ALS treatments. Mike believes that opioid-prescribing patterns can continue to improve. Joe believes that real progress on problems as vexing as gun violence and Middle East peace can occur if people with opposing views listen to each other. Lara believes she can make life a little less painful for homeless and LGBT patients. And so on.

None of them believe that anything is written in stone.

How They Became the Way They Are

Table 9.3 has observations that may help explain how these seven doctors developed the features of their personal makeup summarized in Table 9.2 and the work-related characteristics in Table 9.1. All seven are tuned into the importance of families—those of their patients’ as well as their own. For example, when Merit talks about the size of her ALS program, she routinely says, “We take care of 500 families.” This isn’t lip service. As described in her chapter, her program has added a psychiatrist to help patients with ALS and their spouses talk to their children. And Joe, Babacar, and Lara all made comments about how, when taking care of their patients and talking to patients’ families, they routinely had thoughts about their own.

Table 9.3. How They Became the Way They Are

1.   They are attuned to families.

–  Merit: “We take care of 500 families.”

–  Joe thinks about impact of trauma/violence on families of patients.

–  Babacar sees his family members in his patients.

–  Lara said, “I have the privilege of taking care of patients with the same challenges as my parents.”

2.   They are aware and proud of values important in their own families.

–  Babacar: “We are a family of knowledge.”

–  Mike feels like teaching students comes naturally to him because his mother is a teacher.

–  Lara’s father emphasized independence and made her drive when she was 12 years old.

–  Joe feels that his grandfather in Nazareth set an example for him as community-minded leader, even though they never met.

–  Emily sent an email with a final thought: “My mom taught me to leave a place better than I found it.”

–  Merit’s mother would call her to make sure she woke up in time for rounds.

–  Laura’s mother was a librarian, and Laura became an avid reader.

3.   They were open to the influence of mentors and role models.

–  Laura was impressed by the family practitioner who cared for her mother when she had breast cancer.

–  Laura’s third-grade teacher was first to tell her she should go to college.

–  Emily’s sixth-grade teacher had gone to Berkeley and made her want to, too.

–  Lara never forgot the Parkland neurosurgery fellow who treated her mother with respect.

–  Lara’s high school teacher got her to apply to college and paid her tuition.

–  Mike met a transplant surgeon when he was in seventh grade and decided he wanted to be a transplant surgeon.

–  Babacar developed multiple close relationships, including with the current neurosurgeon-in-chief.

4.   They have been exposed to multiple cultures.

–  Babacar is an immigrant who was undocumented for a while.

–  Joe is the son of Lebanese immigrants from Israel.

–  Merit is the daughter of Italian immigrants.

–  Mike is married to a Chinese American.

–  Emily is married to a Mexican American.

5.   They are self-aware.

–  Emily was embarrassed by having two standards of care.

–  Mike knew he wasn’t going to be an Olympian.

–  Babacar knows he makes friends easily.

–  Joe’s hands were shaking when he worked in front of surgeons who, years before, had saved his life.

6.   They have a growth mindset.

–  Laura is the first in her family to go to college, and graduated summa.

–  Lara is first in her family to go to college, and graduated summa.

–  Joe took major pay reduction so he could attend Harvard’s Kennedy School of Government.

–  Emily refused to accept status quo of breast imaging.

–  Mike wants to learn how to eliminate opioid prescribing for many surgical patients.

They all spoke with pride and appreciation about their families and the values they had learned from their parents. They talked about the emphasis on education, whether in West Africa or western Michigan. Some of their parents were, as Joe put it, “deeply involved” in their children’s educations. Merit’s mother would call her daughter at four in the morning to be sure she had woken up in time to go to surgery rounds. Mike thinks teaching medical students and residents comes naturally to him because his mother was a teacher.

They told vignettes illustrating how their parents taught them to be independent—like Lara’s father encouraging her drive at age 12 and Mike’s father dropping him off at school with the message that if adjusting was difficult, he shouldn’t think coming home was an option. And as already noted, many of them explicitly cite altruism as a core value emphasized by their parents.

They had other role models and mentors, including physicians who made a real difference during serious illnesses of members of their families, and teachers who took a strong interest in them. Laura is still grateful to her third-grade teacher, who started a club for gifted children and taught them to build and launch rockets in the era of the space shuttles. Emily still appreciates the impact of her sixth-grade teacher, who treated her like an adult; he had gone to Berkeley, so she wanted to, too. And of course, Lara’s high school teacher completely changed her life by paying her college tuition.

Perhaps these physicians had the good fortune to run into great mentors when they were young. But it is also possible that some qualities made them wonderful mentees. Probably both are true.

As noted in Table 9.3, they have moved around and been exposed to multiple cultures and influences; none of the physicians in this series live in the same town as their parents or grandparents. Babacar is an immigrant, and Joe and Merit are the children of immigrants. Mike is married to a Chinese American, and Emily Sedgwick is married to a Mexican American. It seems reasonable to wonder if variability in the cultural influences in their lives contributes to openness in their thinking about the nature of their work.

On the other hand, this degree of cultural heterogeneity may be within statistical norms for US medicine in our times. It is a good field for immigrants and their children, and residency (where both Mike and Emily met their spouses) is an ideal setting for hard workers to realize they have much in common, even if their ethnic backgrounds do not match.

As a group, these seven doctors seemed unusually self-aware—one of the qualities psychologist Daniel Goleman identifies as key ingredients of emotional intelligence. They know their own strengths, weaknesses, values, and impact on others. In fact, they displayed strength on all five of the attributes Goleman says constitute emotional intelligence; the other four are self-regulation (controlling or redirecting disruptive impulses and moods), motivation (relishing achievement), empathy (understanding other people’s emotional makeup), and social skill (building rapport with others to move them in desired directions).

Finally, they all displayed a growth mindset. They believed that things could and should get better, and they were willing to work hard and sacrifice to make that happen.

* * *

What have we learned from these good doctors? The obvious starting point is we are fortunate to have them among us. Their stories are extraordinary, but in fact, their strengths are not. They don’t think of themselves as special. They all describe themselves as “lucky.”

They are all smart, but intelligence is not what sets them apart. They all work hard, but so do many others in medicine. In fact, I was impressed by the extent to which these doctors find the time for lives outside their work. Merit had to delay an interview because she was playing in a soccer game. Joe’s interview was squeezed in during a visit to his parents. Emily had just taken her kids swimming. In every one of my interviews, it felt like family was lurking just out of sight or hearing range. And often, children interrupted, doors slammed, and the physicians were summoned by loved ones to come eat.

The characteristics that emerged from the analysis of their stories, summarized in Tables 9.1 to 9.3, are actually quite common among people working in healthcare. However, these physicians seem to have them in unusual abundance. Pretty much every physician or nurse I know delivers care with empathy, goes beyond their job description, and is a good team member at least some of the time—but perhaps not with the reliability of these seven doctors or to the same extent.

The implication is that healthcare offers clinicians opportunities to do extraordinary things—and these physicians have recognized those opportunities and seized them. They have the same generous instincts as the rest of us; they have just been more diligent in following them.

They were all fortunate to be in circumstances in which it was possible for them to be their best selves. Although they might have had difficult circumstances in youth or encountered obstacles along the way, they all work in organizations that have supported their desires to follow their best instincts.

Massachusetts General Hospital has essentially given Merit the message, “Figure out what is the best possible care for your ALS patients, and we will figure out how to make it work.” (It’s probably not quite that simple, but it seems pretty close.) Michigan Medicine CEO Marschall Runge is proud that his highly trained transplant surgeon is working on a public health problem. Texas Children’s encourages employees to donate time to Laura’s camp. Parkland Hospital wants to give good care to homeless and LGBT patients, and its leaders are delighted to support Lara in that work.

One takeaway from this book for leaders of healthcare: If you want good physicians like these, just give them the chance to emerge. They are there. I know they will step forward and make you and your organizations proud.

To mitigate physician burnout, organizational leaders should work on reducing the burdens not directly connected to patient care—the “external stresses” described in Chapter 1. But leaders should also help physicians find meaning in their work. Providing physicians with the opportunity to be at their best is more than being nice; it is strategic. This is a way in which you articulate your values and make your personnel proud to be part of the organization. And that pride has direct business performance rewards. You have less turnover, better safety, better patient experience, and better technical quality. (Trust me, the data are there.)

For my colleagues who are physicians, and the students who seek to become one, my expectation is that these seven good doctors seem familiar. You probably all know physicians like them. In fact, there is a chance that others think of you in the same way.

What I like about medicine and what makes it so challenging is that you are starting from scratch with every patient. It doesn’t matter if you have done a fantastic job technically with every patient in the past 10 years; if you relax and provide care that is unsafe with the next patient, the result can be catastrophic. It doesn’t matter if your survey ratings yield a magnificent set of numbers; if you are in a foul mood and behave like a jerk with your next patient, you are a jerk.

The past is the past. The future is what matters. It’s all about the next patient you see. And that next patient offers the chance to be a good doctor.

How great is that?