What makes a good doctor?
There are two important characteristics. The first is clinical skill: the ability to find a pattern in the patient’s signs and symptoms, the ability to identify the patter, and the judicious use of medical tests to fill in the blanks of the pattern. The second characteristic is compassion: the ability to care about the patient and empathize with his or her situation.
Many doctors have one or the other. Some of the greatest clinicians have excellent clinical skills, and poor bedside manner. And some of the most popular doctors have terrible clinical skills, but are easily able to deceive patients because they are kind and compassionate.
Both characteristics, whether alone or in combination, depend on one variable: time. Even the most clinically skilled doctor needs adequate time to listen to the patient, to elicit and think about all the relevant details of a patient’s situation. In the textbooks, diseases have straightforward signs and symptoms, and typical courses. As any doctor can tell you, patients don’t read the book. In other words, their signs and symptoms can vary from “textbook” descriptions or can be modified by other diseases or conditions that the patient might also have. And it goes without saying that the most important requirement for compassion is also time, the time to listen, empathize and offer comfort.
Yet if there is one thing that contemporary American doctors lack, it is time. That’s because the people who “manage” healthcare are obsessed with efficiency. In their minds, being efficient means seeing the most amount of patients in the smallest amount of time, as if efficiency in medicine should be measured by the number of patients “processed.” That’s not what it means to be efficient in the practice of medicine, though.
In medicine, efficiency means the ability to successfully treat as many patients as possible using only the tests and procedures necessary, and leaving the patients happy with their care. In the ultimate irony, the pressure to make doctors more efficient has made them progressively less efficient. That’s because no doctor can be efficient without adequate time to do the job. Simply put, no doctor can do a good job without spending substantial amounts of time meeting with and thinking about patients. Yet over the past quarter century, doctors have been pressured to devote ever smaller amounts of time to each patient, making doctors less, not more, efficient.
How have doctors become less efficient? All the evidence suggests that doctors make more mistakes, and order more unnecessary tests and procedures, without a concomittant rise in successful diagnoses or longer lifespan. Moreover, patients are increasingly dissatisfied with their care. Yes, patients are “processed” faster, but medical care has arguably gotten worse, not better.
The deterioration in the quality of medical care is directly linked to the reduced time that doctors spend with patients. Because a doctor has less time to talk with a patient, he or she is less likely to make the correct diagnosis. Because a doctor has less time to thoroughly examine a patient, he or she will order unnecessary medical tests to fill in the gaps. Because a doctor has less time to think about a patient, he or she is more likely to make an avoidable medical error. And, of course, when a doctor has less time to spend with a patient, he or she is more likely to be brusque and unsympathetic.
Good medical care takes time. Forcing doctors to see more patients in less time does not make them more efficient, because they can’t make diagnoses faster, examine patients faster, or think about them faster. They can only push them through the office faster. And that’s not efficiency.
