Good Doctors

Samuel Gorovitz
The behavior of physicians can fail to meet the expectations that patients
and the public might reasonably impose on them. But the burdens faced by
physicians are severe, the problems complex, and the expectations sometimes
unreasonable. In this (essay) I will offer an account of what is involved in being a
good doctor and some recommendations about how medical training could increase
the likelihood that doctors will turn out that way. So the (essay) will focus on
medical education. That seems, on the face of it, a rather specialized concern, and
the general reader may wonder why it is included here.
There are several reasons. First, the physician is the central player in the
transactions of medical care. To the extent that we all are concerned with the
quality and character of medical care- as health care professionals, patients, or
citizens- we are concerned with what physicians do and how well they are prepared
to face their responsibilities. We each stand to be directly touched by the effects of
medical training, in various ways, at various times. Also, medical education is
largely supported at public expense. Even after the substantial reductions in public
support for education that have been proposed in the early 1980s, the costs of
educating physician will continue to be largely borne by public resources. Since we
all are affected by the result of medical education and since we largely pay for it in
the first place, it is surely appropriate to pay some attention to what it is and how
well it is working. The better we all understand what is involved in being and
becoming a good doctor, the easier it will be for us to be supportive of the efforts
physicians make to maintain a high standard of performance.
An independent reason for attending to the training of physicians, especially
to their preparation for dealing with moral issues, is that we have good reason to be
concerned about the professions generally, and the medical profession can be an
instructive case study for those whose concerns lie elsewhere. Whether it is a mark
of increased social complexity, greater public awareness, or other causes, all out
professions are having to grapple with the ethical dimensions of their professional
lives. Scientists, teachers, lawyers, jurists, politicians, and others have come under
the same sort of moral scrutiny that has been brought to bear more visibly on the
more visible profession of medicine. To the extent that we can gain an increased
understanding of what is involved in being a good doctor and what is likely to make
doctors good, we will also have gained a model for the illumination of professional
standards and professional training more generally. It is with this broader agenda in
mind that I invite you now to consider the question, in both its senses, what makes
a good Doctor?

The need for reform in medical education persist because clinical medicine is
based on a rapidly changing body of scientific information, because of changing
social expectations in regard to health services, and because of a changing
understanding of how people learn and of what it is most important for them to
learn. I do not presume to offer comprehensive view of what medical education
should be or to suggest that it can ever be structured in a definitively correct way. I
merely offer some suggestions about how it can be improved in some respects.
The objective of medical education is primarily the training of good
physicians. It is not possible to provide an uncontroversial definition of species. But I
will emphasize those characteristics that are central to the concerns of this
discussion I then want to consider how the goal of producing such physicians can
be more successfully achieved.
Primary among the characteristics that I associate with the good physician
are these: The good physician
has and maintains a high level of technical competence, including both the
knowledge and the skills appropriate to his specialty;
is unfailingly thorough and meticulous in his approach to his specialty;
is aware of the dependence of clinical medicine on medical research and equally
aware of the experimental nature of clinical medicine;
sees patients as persons with life stories, not merely as bodies with ailments;
sees beyond simplistic slogans about health, nature, add life to the complexity
involved in selecting goals for treatment;
has a breadth of understanding that enables transcending the parochialism of his
own specialty;
understands his own values and motivation well enough to recognize that they
can be in conflict with the patients interests;
is sensitive to the diversity of cultural, interpersonal, and moral considerations
that can influence a patients view of what is best, in process or outcome, in the
context of medical care, and has the judgment to respect that diversity without
undermining the integrity of his own moral commitments;
has a respect for persons that shapes his interactions with patients, staff, and
colleagues alike;
has the humility to respect patient autonomy, the dedication to promote it
through patient education, and the courage to override it when doing so seems
justified;
has the honesty to be truthful both with himself and with his patients about his
own fallibility and that of his art; and
has the sensitivity to recognize moral conflict where it exists, the motivation to
face it where it is recognized, the understanding to consider it with intelligent
reflection where it is faced, and the judgment to decide wisely following such
consideration.

It is a tall order. But many physicians meet it, and more approximate to it
reasonably well. The question is whether it is possible to increase the extent to
which physician on the whole are of this character.
A good physician obviously must know a great many things. Medical schools are
notorious for requiring the assimilation of an enormous mass of factual material and
for requiring little in the way of reflection. This is not peculiar to medical schools, of
course, but is characteristic of professional training generally.
From Doctors Dilemmas: Moral Conflict and Medical Care (New York:
MacMillan, 1982, reissued New York: Oxford University Press, 1985), pp.
191-224.