Priorities

Although I’m not really qualified to do so, there I was, talking to a predominantly American audience about what makes a good doctor. It’s a subject on which most of us have some opinion, and who was I to tell them anything they didn’t already know? So I was expecting harrumphs and snorts from the audience at least some of the time. But they sat and made eye contact and listened, which was interesting but also unnerving. 

I rattled on about role models and curricula and evaluations and feedback. The audience—mostly specialists, some trainees—continued to listen. They laughed politely at some, but not all, of my jokes. Toward the end of the presentation, I listed what I had referenced as the essentials for the future of the medical profession. What I really had meant to say was that without these qualities, the medical profession will lose its aura and standing and become little more than a trade. In other words, I saw them as qualities not just for making a good doctor, but for actually making doctors at all. These essential qualities were (1) having clear ethical values, (2) putting patients first, (3) constantly trying to improve, (4) basing what we do on evidence, (5) education, (6) leadership, and (7) collegiality. All motherhood stuff, and surely uncontroversial. Following the lead of my rock idols, I closed with a rousing chorus of “here’s what I wanted to say, here’s what I said, and here’s the end” and sat down, radiating an impression of having nothing left to say. 

A question-and-answer period followed. In my experience, Americans in settings like these are astonishingly polite and pleasant. Their questions are often prefaced by personal reminiscences, but these are not uncommonly positive and generous tributes to revered colleagues, and who can begrudge them these? We all need more positive and generous tributes. So I was drifting on a tide of bonhomie when I realized that someone at the microphone was directing her question to me. What, she asked, did I mean by “putting patients first”? Wasn’t that a requirement that was simply unworkable in today’s professional environment? How could anyone have a satisfactory balance of work and home life if patients always came first?

I was more than a little taken aback by her question and its implications. How can anyone be a physician and think primarily of his or her own welfare? How would that have affected the profession’s responses to the SARS epidemic, for example? I began to feel irritated and vaguely self-righteous, until I realized that we were talking at cross-purposes. Of course it is important to have a balance of personal and professional satisfaction, and of course it is prudent for physicians to take precautions for themselves against life-threatening illness. But at the same time we must be seen as a profession of advocates for people who are ill, and even for those who are potentially ill. If we are not seen to be dedicated to the well-being of patients, even at personal cost, we are not worthy of the respect we still have.

My friend and colleague David Mathews put it well when he said that he tells new patients, “I’m here to provide you with the best care I possibly can. But besides being a doctor, I have two other jobs—I’m also a husband and a father, and so I cannot promise that it will always be me taking care of you. In that case, I promise you that someone of equal skill will always be available to look after you.” The days of a physician being all things to all people at any cost are surely gone. But patients are the reason for our professional existence, and their care must remain our first priority. No ifs, ands, or buts.

—TCR