Introduction

THE GOOD DOCTOR

I WISH I COULD SAY that this book began with a full-blown vision of what it means to be a good doctor in the modern era and how to become one. The reality is that it began with nothing more than the pleasure of telling a good story. And then another. And another.

The conversation that led to this book occurred in the late spring of 2018, right after Pat Ryan, the CEO of Press Ganey, learned that one of his closest friends, Sean Healey, had just been diagnosed with amyotrophic lateral sclerosis (ALS). I told Pat that I knew a wonderful ALS specialist who worked with a really excellent team—Merit Cudkowicz, MD, at Massachusetts General Hospital.

It turned out that Pat’s friend had already made his way to Merit—no surprise, since in the ALS world, everyone knows who she is. She is famous among neurologists for leading clinical research trials on some of the most promising agents for this disease. She is famous among patients because she and her team offer wonderful care—and even hope—for a condition that so many others label “hopeless.”

Our conversation shifted from admiration for what Merit and her team do, to amazement that they have been able to keep it up for decades for patients who are sure to have a downhill course. Merit and her colleagues remain deeply empathic with these patients and their families, even though one might expect them to have developed defense mechanisms to protect themselves from emotional involvement.

“She should be the most burned-out physician on the planet,” her colleagues say. “But somehow, she is the least.”

“Merit is incredible,” Pat said.

“She is,” I agreed. “But let me tell you about Emily Sedgwick.” And then I told him how I had recently met a young breast radiologist at Baylor College of Medicine in Houston. A decade ago, when she was just in her early thirties, she re-engineered breast imaging at her institution with the goal of reducing fear. She knew that, even when women whose mammograms reveal suspicious abnormalities got their core needle biopsies the next day, it could be a very long and difficult night. So in her program 95 percent of the biopsies are done the same day. Women don’t leave the mammography room right away after their initial images are taken because Emily and her colleagues know that when women get the message that more images are needed, their hearts stop. Instead, women stay in the room with the imaging equipment until a radiologist has looked at the mammograms and decided whether any other shots should be taken before the patient leaves.

“That’s a great story,” Pat said. I told him that there were plenty more out there. We agreed that it would be interesting to collect several of them. In an era in which so many doctors and nurses feel burned-out from their work—overwhelmed, ineffective, and depersonalized—maybe there were patterns in the stories of those who avoided burnout and lessons to be learned from them.

As soon as I began to mention that I was working on such a collection, I started getting suggestions for other remarkable physicians to interview. “You have to talk to Lara Johnson.” She is the primary care physician who leads the healthcare program for homeless patients at Dallas’s Parkland Health and Hospitals System. Or Joseph Sakran, who survived a serious gunshot wound to his throat when he was 17 and went on to become a trauma surgeon at Johns Hopkins. In the fall of 2018, he became nationally known after he reacted with anger to a tweet from the National Rifle Association (NRA) that physicians advocating for gun control should “stay in their lane” and started the “@ThisIsOurLane” hashtag on Twitter. But his story was already remarkable even before he tweeted, “Where are you when I’m having to tell all those families their loved one has died?” and struck a chord with so many physicians and others alarmed by gun violence.

And so on, and so on. The names poured in—and they are still pouring in. I did podcast interviews with the physicians profiled in this book and have continued doing so after I finished writing about the seven in this book. I’m not one bit concerned about this well running dry.

The reason to collect these stories is not to suggest to clinicians experiencing burnout that there is something wrong with them, but to offer some examples of how physicians handle the stresses that lead to burnout.

As a practicing doctor (and the spouse and father of practicing doctors), I am tuned in to the stresses and frustrations that are driving a burnout epidemic among clinicians. I hear doctors whom I really respect say that they no longer find pleasure in their work and are retiring sooner than they otherwise would have. And these are people whose sense of self is based at least in part upon the belief that they are doctors—and good ones at that.

But the fact is that I also meet physicians whose passion for their work endures. The physicians I profiled in this book take care of patients with the same empathy and the same high standards as the best physicians of any era. They live in the real world and are every bit as exasperated by bureaucratic hassles and information technology dysfunction as the rest of us. They don’t describe themselves as “great,” but they are finding greatness in their work.

These physicians are younger than I am and older than my oldest daughter (a 31-year-old cardiology fellow), and they have something to teach both of us. They are defining how to be a good doctor in our times—and showing that being a good doctor remains something pretty great. Figuring out what they have figured out and reverse-engineering their grit have yielded some insights that could help healthcare organizations shape their cultures—and might help some individuals find their way.

The individual stories were an inspiration, and the physicians behind them a delight. They are all self-aware, self-effacing, and funny. They were all amused that doing what they considered logical led them into activities that others find remarkable. The common theme to their stories is that they empathize with their patients and really want to take good care of them. And by adhering to their values, they found themselves—like Laura Monson, the craniofacial surgeon who started a summer camp for children with cleft palates—doing things that fell outside their job descriptions. None of them seem motivated by a desire for promotions, more money, or fame. What makes them remarkable are the accomplishments that have logically followed from their efforts to be a good doctor.

I realized that their collective stories were a story in themselves—with the three basic elements of that story being conflict, crisis, and resolution. For physicians and other clinicians today, the conflict is the tension between the desire to do good for their patients and the barriers, hassles, and dysfunction that slow them down and make it hard to do so. There is the gap between the life they imagined when they decided to go into medicine and the life they currently live. This conflict will be explored at greater length in Chapter 1.

The crisis is the burnout epidemic—the well-documented increase in feelings of ineffectiveness, being overwhelmed, and depersonalization that are associated with compromised quality of care and increasing rates of suicide among physicians. That, too, will be explored in greater detail in Chapter 1.

The physicians profiled in this book are not superhuman and not immune to the stresses that drive burnout. But they have found resolution by changing how they experience those stresses, which has made them more resilient. They began with the same passions that draw most people to healthcare (most notably, easing the suffering of patients), and something happened to make these passions unusually intense. As a result, these physicians have been able to persevere in their pursuit of improvement over years and decades, often doing work that falls outside of traditional patient care.

Passion and perseverance are what University of Pennsylvania psychologist Angela Duckworth describes as the key ingredients of grit. These physicians are gritty. They are great. And they are good. In Chapter 1, I will introduce some of the language and knowledge needed to put these physicians’ stories in perspective.

And then we’ll get to the good part—the stories themselves.