What is the essence of a good doctor and how can we choose the right applicants at medical school?
The traditional way to choose doctors was mostly based on knowledge/memory tests. Choose the brightest students and you will get the best doctors, or so the theory went. However, there is a problem. Some very clever people have ended up as very poor doctors. Whilst it is likely that it will always be necessary to have and maintain a high level of learning in order to be a competent doctor, this is clearly not the whole picture. The general theory that IQ is the key to success has been undermined in recent years, and it has been clearly shown that there are other important aspects of intelligence that are not measured by IQ tests or tests of memory recall. Some would argue that today’s easy availability of vast data banks of knowledge will further erode the preeminent position of the learned doctor.
One area of active development has been to look at ways of testing for ’emotional intelligence’ or EQ. These theories are based on the work of a several psychologists over the past 50 years or so, particularly that of Daniel Goleman’s 1995 Book called ‘Emotional Intelligence’. His domains of EQ may be summarized as follows:
- Knowing your emotions.
- Managing your own emotions.
- Motivating yourself.
- Recognizing and understanding other people’s emotions.
- Managing relationships, i.e., managing the emotions of others.
This does seem to make a lot of sense, but some have expanded the concepts to encompass such a broad sweep of ’emotional competencies’ that the term seems to lose all validity. To my way of thinking, desirable characteristics such as fairness or trustworthiness cannot be considered as subtypes of intelligence. Studies have shown a poor correlation between the EQ scores of employers and their employees’ assessments of their employer. A person with a high EQ will not always act with empathy/respect/fairness to the people around them although they should be in a good position to understand and practice these positive behaviours.
The media coverage of medicine in the UK over the past decade has been coloured by the dark shadow of Harold Shipman. A clever doctor who knew how to get patients to trust him (high IQ and EQ) but one who fundamentally lacked compassion for his patients. There has been a growing recognition that we need to take more care to recognize and weed out doctors like this but nobody seems to have any clear idea as to how this could be achieved. Appraisal, revalidation and multi-source feedback have been introduced but many feel that as currently set up it is not able to identify the next ‘Shipman’. Reflective practice is a good thing to encourage, but for many doctors their reflection relates mainly to their professional educational activities.
How can we encourage doctors to reflect more on the things that influence their quality of caring? I propose that it would help if we introduced the concept of a ‘caring quotient‘ to complement the IQ/EQ domains. We all recognize that doctors should be caring, but how much and in which situations? This could be tested by proposing challenging clinical situations and getting the opinions of a number of physicians as to what they would do in the same situation.
Is it possible to be TOO caring so that professional boundaries are crossed to the detriment of the patient or other patients under our care? Is it possible for a doctor to be very caring 90% of the time but ‘lose it’ from time to time? If this behavior is not a fixed characteristic it may be useful to consider it as a continuum that can vary, perhaps in predictable ways. Research has shown that, in general, doctors and healthcare workers tend to be biased against patients with alcoholism, dementia or the ‘heart-sink’ patient with the thickest file but the lowest rate of serious pathology. I have seen a number of medical errors over the years that have arisen because an alcoholic has not been accorded the same level of care and attention as others. Difficult behaviour by patients often provokes a negative reaction in us and if we don’t learn to recognize and compensate for this we will make mistakes. Some of our individual biases are so deeply ingrained that we will transgress again and again. I try and teach medical trainees to actively watch out for these biases – as I try to do – and change their behavior to compensate.
So, can a doctor actually learn to recognize situations or patients that ‘make their blood run cold’ and change their behavior accordingly? Doctors would benefit from building up a self-reflective narrative portfolio to include their reflections on difficult or challenging interactions with patients. We could hope that this would encourage more insight into where we are going wrong, where our ‘CQ’ was inappropriate for the particular situation we were faced with at the time. I have put together a ‘mind map‘ to begin to tease out some of the positive and negative factors that could affect a doctor’s ‘CQ’. This is a work in progress!