Richard Smith: It’s hard, perhaps impossibly hard, to be a good doctor

Richard Smith

How would you feel if your patient said to you: “I want you to be my Virgil, leading me through my purgatory or inferno, pointing out the sights as we go?” Or how would you respond to: “I would like to discuss my prostate with you not as a diseased organ but as a philosopher’s stone.” A “good doctor” would smile and be able to do exactly as the patient has asked. But you, perhaps not such a good doctor, might think “This guy is nuts.”

The General Medical Council is charged with defining a good doctor rather in the way that the L’Académie Française defines what is acceptable French. But surely defining a good doctor is not best done by a bunch of middle aged men, instinctive bureaucrats, with the occasional younger woman thrown in to lighten the mood.

The BMJ had a theme issue devoted to the question in 2002, and Brian Hurwitz, a GP and professor of medicine and the arts, got the issue off to a marvellous and controversial start with this quote: “I remember the time Shipman gave to my Dad. He would come around at the drop of a hat. He was a marvellous GP apart from the fact that he killed my father.” I always misremember the quote as “Shipman was the best GP my dad ever had until he murdered him.” (I find it wonderfully ironic that Shipman will be remembered long after most worthy and brilliant doctors of the 20th century are forgotten.) Hurwitz’s answer to how you make a good doctor was: “By marrying the applied scientist to the medical humanist.” Perhaps some special pleading there.

I had a go at defining a good doctor for an article in the Financial Times that annoyingly I can never find. I started by saying “Finding a good doctor is like finding a good lover: there are lots of anecdotes but no data.” My conclusion was that there was no such thing as a good doctor in that you wanted different sorts of doctors according to circumstance and taste—perhaps a skilled technician, an inquiring scientist, a philosopher, a mother, or a stand up comedian.

But now I have read a piece that looks piercingly at what makes a good doctor. It’s an essay called “The patient examines the doctor” by Anatole Broyard in his book Intoxicated By My Illness.  It’s as powerful a piece of writing as I’ve read in years and now has a place in my small pantheon of writing to be endlessly reread.

Broyard was a literary critic and editor for the New York Times who died in 1990. He has a certain notoriety in that he was of mixed race but criticised for “passing” as white and denying his ancestry. He may have inspired Philip Roth’s book The Human Stain about a professor with a black background who pretended to be Jewish, although Roth denies it.

The essay was written at the end of Broyard’s life as he was dying of prostate cancer. It was his illness that brought him into contact with doctors and prompted his examination. He thought back as well to when his father was dying, and what he wants from a doctor is much more than technical skill. The questions at the beginning of this blog come from Broyard’s essay, but there are many more excellent quotes:

  • To get to my body, my doctor has to get to my character. He has to go through my soul.
  • The doctor puts [the technical information] into a poem of diagnosis. So I want a doctor with a sensibility.
  • I want my doctor to have magic as well as medical ability.
  • I would like [my doctor] to know what I mean if I told him, like Baudelaire, “I cultivate my hysteria with joy and terror.”
  • I would like my doctor to understand that… I feel “the panic inherent in creation” and “the seriousness of infinity.”
  • I would be happier with a witty doctor who could appreciate the comedy as well as the tragedy of my illness.
  • Whether he wants to be or or not, the doctor is a storyteller, and he can turn our lives into good or bad stories, regardless of the diagnosis.
  • A doctor like a writer must have a voice of his own, something that conveys the timbre, the rhythm, the diction, and the music of humanity.
  • Every patient invites the doctor to combine the role of priest, the philosopher, the poet, the lover. He expects the doctor to evaluate his entire life, like a biographer.
  • Just as a mother ushers her child into the world, so the doctor must usher the patient out of the world of the healthy and into whatever physical and mental purgatory awaits him. The doctor is the patient’s only familiar in a foreign country.

Perhaps as you read these quotes you conclude that you can never be a good doctor. It’s clearly hard.

Broyard advises doctors on how to go about their work, not to be afraid of failure:

  • A doctor’s job would be so much more interesting and satisfying if he simply let himself plunge into the patient, if he could lose his own fear of failing.
  • Importantly Broyard wants his doctor to “enjoy” him but crucially to understand that the patient is his superior not inferior, an understanding that might be close to the heart of what it is to be a good doctor.
  • I would also like a doctor who enjoyed me. I want to be a good story for him, to give him some of my art in exchange for his.
  • I’d like [my doctor] to know that I feel superior to him…that he is my patient also and I have my diagnosis of him.

PS. After I wrote this I read a review of a biography of William Harvey, indisputably a great doctor. What fascinated me was that Harvey performed an autopsy on his own father and in public lectures would refer to the huge size of his father’s colon. Truly there are many ways to be a great doctor.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.