From 1969 to 1976, “Marcus Welby, M.D.” was one of television’s most popular shows. Dr. Marcus Welby was often called “the good doctor” because he made house calls, oozed wisdom, and had a caring bedside manner.
Since then, television has depicted a host of other smart, compassionate doctors. There’s even a series currently running called “The Good Doctor.” Most of these TV physicians are amazing. They can save lives while flirting across the surgical table. Some are known for their unique ability to make an accurate “zebra diagnosis.” That medical term refers to situations where run-of-the-mill diagnoses abound (picture a big herd of common horses), but then a gifted doctor shows up and offers an exotic, but accurate, “zebra” diagnosis that no one had previously considered. This especially savvy doctor identifies the problem right away, prescribes the best treatment, and saves the patient.
Good doctors like Marcus Welby might seem rare (in fact, like zebras themselves), but the reality is that they’re out there. I know this from many years of medical practice, and also from being a patient myself. So why do so many patients have trouble finding them?
How does one choose? What criteria make for a good doctor? While “good” may seem somewhat nebulous, there are a few qualities and traits you need to look for when selecting a primary care physician. In “Principles of Biomedical Ethics,” Tom Beauchamp and James Childress list four ethical standards as non-negotiable for doctors:
Beneficence: acting for the patient’s good
Non-maleficence: doing no harm
Autonomy: giving each patient a right to voice her own values and make her own choices about medical care
Justice: distributing health care resources equitably and treating patients fairly
Let’s unpack and expand that list from a patient’s perspective.
Is a Prospective Doctor Trustworthy?
Above all, you must have confidence in your physician. You must believe that she will act in your best interests at all times.
Trust is something that’s earned, generally over time. It’s not abstract, and it’s deeply personal and visceral. You need to be able to trust that your physician knows when to refer, that she will send you only to doctors she believes in, that your clinician won’t simply tell you what you want to hear or give you what you want to receive.
If trust is present, you’ll have a satisfactory doctor-patient relationship.
Is a Prospective Doctor Competent?
All physicians, upon completion of training, take the Hippocratic Oath, which includes the statement about non-maleficence, the concept of “doing no harm.” This ancient pledge has many statements that reflect the qualities of a good, if not great, physician. However, an oath doesn’t guarantee the actual delivery of those qualities, therefore, we must look further.
Here are some more specific questions that can help you get a sense of a physician’s competence.
Is he board certified? Check out the website www.CertificationMatters.org. Due to the changing dynamics and cycles of how certifications are reported, it’s also wise to check with your state’s medical board.
Is a prospective doctor in good standing with the medical board? This information is readily available through each state’s licensing board.
Is a prospective doctor affiliated with a hospital? If he is, discover which hospital. If he isn’t, discover where he sends his patients if it becomes necessary for him to do so. You’ll want to confirm that if you become ill, the hospital where you would receive care is where you would want to go. The website www.Medicare.gov has a hospital comparison search feature for those living in cities with multiple hospitals.
What do other patients say or write about the doctor? Take the time to look at websites that allow patients to post reviews. However, as you do, realize that a few unhappy patients don’t automatically mean that a doctor is bad, as some people will always be negative. Multiple poor reviews, however, probably are a warning sign that you should keep looking for your “zebra.”
Do trusted friends and neighbors regard this doctor as competent?
Does a Prospective Doctor Respect the Autonomy of Her Patients?
Will she take the time to listen to you? Will she get impatient or annoyed if you ask questions or interrupt you and dismiss your concerns or opinions or objections? Will she explain obscure medical terms, rush through medical exams, or give you time to think through your options? If two days after a doctor visit you’re wondering, “Why did I let her do that procedure, or pressure me to get on that medicine?” then your autonomy has suffered. Chances are you haven’t yet found your “zebra.”
One way to keep this from happening is to prepare for doctor visits by writing down key points or issues before your visit. Express to the nurse or medical assistant that you would like to discuss your list of questions before completing the visit. Oftentimes, they’ll then communicate this to your physician before he enters the room. You want a physician who will take the time you need and deserve, to make an autonomous, informed decision.
For an older patient who’s more conditioned to giving away autonomy and accepting a doctor’s word as gospel, it’s wise to have a family member or friend accompany him to his doctor’s appointment so all his medical questions get asked and answered.
Realize that there will be occasions when you disagree with a decision your doctor has made. For example, you tell your doctor about your sore throat and cough. The last time you had such symptoms, a nurse practitioner at a walk-in clinic treated you with antibiotics. This doctor examines you and discovers your drainage is clear and that you don’t have a fever. He states that your symptoms are viral and that you don’t need antibiotics. You leave frustrated because you believe the doctor is wrong.
In this case, he was operating by the principle of “first, do no harm” by not prescribing antibiotics that you don’t need and potentially creating resistant bacteria in your body. His medical knowledge trumped your desire to decide your own health care. In a relationship of trust, you accept that your doctor is both trained to make this decision and acting in your best interest. And you could leave comforted by the knowledge that your symptoms will improve without intervention.
In a relationship that’s marked by patient autonomy, the doctor would discuss his rationale for any and all medical decisions. And you could also ask for and receive a list of symptoms that would call for antibiotics—in case your current illness changes, and so that in the future you can avoid scheduling unnecessary doctor visits.
The average doctor spends his days maintaining accurate clinical information in high-tech, electronic medical record systems, keeping up with ever-changing reimbursement strategies from government entities and private insurance companies, overseeing a medical office that employs multiple staff, and staying abreast of medicine’s rapidly growing knowledge base—all while seeing enough patients to keep the doors open and giving each one excellent, compassionate medical care. Whew!
As you might imagine, it’s a constant challenge to do all this and ensure that patients sense that they’re top priority. Even though modern medicine is a tough juggling act, you want a doctor who consistently gives her patients the time they need.
Participatory Decision-Making Style
While this falls somewhat under the category of autonomy mentioned above, the point here is that a good doctor facilitates meaningful health care conversations, invites questions, and presents options so that patients always have their voice respected and are able to make informed decisions.
Two aspects of empathy allow for optimal doctor-patient relationships. The first is “cognitive” empathy, or the ability of a physician to correctly identify a patient’s emotions and reflect those emotions back when discussing aspects of care. The second is “affective” empathy, which is the ability of a doctor to truly feel the emotions a patient is feeling.
While cognitive empathy should be a minimum standard of good patient care, and genuine affective empathy should be on display in crucial conversations, both can sometimes be absent in the clinical world. The good news is that over the past several years, empathy training has been added to health care education.
Studies show that brief conversations between doctors and patients about non-medical topics improve a patient’s perception of the visit. However, speaking from my own experience as a patient, I know that this can sometimes be awkward, as making conversation isn’t a natural strength for all doctors. It’s easy for some to unconsciously hide behind a white coat and a stethoscope to inadvertently create an invisible barrier.
This is where patients can help (or teach) their physicians. A simple greeting such as, “Hi, Dr. Ryan, how are things? How’s your family? How were your holidays?” can make for a better relationship. Speaking as a doctor, I can say you’d be surprised how infrequently anyone asks their physician such questions or how much we doctors appreciate such exchanges.
I place high importance on this in my practice. I realize that because I work mostly in a hospital setting, this is appropriate even if I’m new to the patient. I offer each patient a handshake and an introduction and greet all others in the room. As you ponder your physician choices, you should expect a greeting and a handshake as the bare minimum of each interaction.
Finding a zebra takes time, and I highly recommend establishing a doctor-patient relationship even if you’re young and healthy. You’ll then be equipped with preventive health measures for a healthy lifestyle and prepared in the event of an illness.