What Makes a Great Physician?

At this blog’s inception nearly five years ago, I asked myself the following question: “When you watch impressive doctors at work,
what is it that most impresses you?” In other words, what makes a great
physician? I was a third-year medical student at the time and I couldn’t
answer the question. At the beginning of training one can hardly keep up
with the incoming information, let alone consider the characteristics that
make a great physician. I liked and disliked certain doctors depending on
the way they treated residents, medical students, or patients. But beyond
kindness, their traits varied widely. During residency I have been
fortunate to work with many admirable doctors, and consequently my sample
size has grown. Seeing what I’ve seen thus far, I think
curiosity and humility are the two most impressive characteristics of a
great physician.

Wikimedia

Galen of Pergamum (AD 129–ca. 216), the Greco-Roman doctor, wrote extensively about how to
make physicians great again in his treatise That the Best Physician Is Also a Philosopher. He bemoans the lost art of medicine and the
corruption of the profession. He advocates for a temperate lifestyle,
arguing that if a physician puts virtue above wealth, he or she will be
“extremely hardworking” and will therefore have to avoid “continually eating or drinking or indulging in sex.”

A doctor must also be “a
companion of truth.” “Furthermore, he must study logical method to know how
many diseases there are, by species and by genus, and how, in each case, one
is to find out what kind of treatment is indicated.”

He continues,

So as to test from his own experience what he has
learnt from reading, he will at all costs have to make a personal
inspection of different cities: those that lie in southerly or northerly
areas, or in the land of the rising or of the setting sun. He must visit
cities that are located in valleys as well as those on heights, and cities
that use water brought in from outside as well as those that use spring
water or rainwater, or water from standing lakes or rivers.

Notice that Galen does not endorse brilliance as a required characteristic of a
physician. No, he advocates for the intelligent use of one’s faculties.
Indeed, he seems to favor curiosity about the surrounding world as a
necessary quality for a doctor.

Curiosity, a desire to discover and a desire to know, is inseparable from a
great physician. In residency we are often told by our attending physicians
that we must be “lifelong learners.” Curiosity naturally creates lifelong
learners. Medicine, after all, is not confined to what one learns in
medical school or residency. If it were, our doctors would not be very
good. One does not see every disease process in residency, one often
forgets certain things, and

the evidence

and guidelines are forever changing and improving. Thus, we must always be
looking up the latest evidence on the diseases we see.

Moreover, there isn’t always a clear diagnosis or treatment, and
physicians must scour scientific literature for the answer. When, as so
often happens, there is a diagnostic mystery, curiosity works against our
inclination towards laziness and forces us to stay on our toes, question
what we believe and why we believe it.

Curiosity also aids the clinician-researcher. Physicians since Galen’s time
have participated in various forms of research, attempting to answer
questions that have not yet been answered. For many of our predecessors
the questions were quite basic, given the general ignorance about the world
of biology. Yet there are still vast areas of medicine for which answers
are needed. The most obvious examples in the specialty of neurology concern
brain tumors or diseases like

Parkinson’s
. The lifespan for patients with certain brain tumors is a year and a half
– how does one improve treatments for these virulent neoplasms? For
Parkinson’s disease, we can only treat symptoms but cannot slow the disease
down – what treatments might reverse this pathology or at least stop it in
its tracks? Curiosity drives physician-researchers to make discoveries and
to seek answers to these questions.

But there is another characteristic, too, necessary in order to be a great
physician. The sheer volume of material one must know and understand about
medicine as well as the natural world is enormous and infinite. Because of the infinite knowledge they cannot possibly possess,
doctors must also confront this world with humility, humility about how
much one must truly know and understand in order to be great.

What was true in Galen’s life is doubly true today: There is a vast world of knowledge
in the realm of medicine. Humility, like curiosity, provides doctors with a
sense of the struggle to accumulate a vast amount of knowledge.
It helps them confront the possibility of being wrong. And
as I’ve written on this blog,

doctors are often wrong
. Humility makes us more likely to double-check ourselves, to re-examine
the patient when we’re unsure, to look things up when we feel insecure in
our diagnosis. It makes us more thorough. It urges us to listen to the
opinions of other doctors, of nurses, or even of patients.

What, then, when I watch doctors at work, most impresses me? What, then,
makes a great physician? Curiosity and humility are necessary
characteristics. There is not a single physician I look up to who does not
have both of these qualities. These alone may not be sufficient but I have
also noticed that other remarkable characteristics tend to accompany
curiosity and humility: kindness, self-discipline, intellectual rigor,
equanimity.

William Osler
Wikimedia

In his valedictory address to the University of Pennsylvania School of Medicine in 1889
(also known as the essay Aequanimitas) Dr. William Osler, one of the original four physicians at Johns Hopkins Hospital and a
legendary professor of medicine at the Hopkins medical school and later at
Oxford, discusses the quality that he thinks is most integral to being a
physician – imperturbability or equanimity. He writes:

A distressing feature in the life which you are about to enter, a feature
which will press hardly upon the finer spirits among you and ruffle their
equanimity, is the uncertainty which pertains not alone to our science and
arts but to the very hopes and fears which make us men. In seeking absolute
truth we aim at the unattainable, and must be content with finding broken
portions.

What lies behind Osler’s idea of equanimity is an acknowledgement of
uncertainty in medicine. And such an acceptance arises first from a humble
and inquisitive outlook. Curiosity and humility acknowledge this
uncertainty and the need to prepare for it, with equanimity.

Modesty, Humility, and Book Reviewing

I am not ungrateful to Issues in Science and Technology for presenting, in its spring 2016 issue, a review (available here) of my book Eclipse of Man: Human Extinction and the Meaning of Progress. I wish it were not such a negative review. But as negative reviews go, this one is easy on the ego, even if unsatisfying to the intellect, because so little of it speaks to the book I wrote.


The reviewer gets some things right. He correctly points out, for some reason or other, that I teach at a Catholic university, and also notes that the book does not conform to the narrow dogma of diversity that says that in intellectual endeavors one must always include discussion of people other than dead or living white males. All true.

On the other hand, the reviewer also claims that “a good third of the book is devoted to lovingly detailed but digressive plot summaries.” He also speaks of my “synopses” of Engines of Creation and The Diamond Age. This is a very telling error. Actually, about 4 percent of the book (9 of 215 pages, by a generous count) is devoted to plot summaries of the fictional works that play a large role in my argument. How do we get from 4 percent to 33 percent? The reviewer apparently cannot discern the difference between a plot summary and an analysis of a work of literature or film. These analyses are indeed “lovingly detailed” because they involve a close reading of the texts, and a careful effort to understand and respond to the issues raised by the authors of the works in question. The same goes for my reading of Drexler; it is an analysis, not a summary or general survey of his book, as is asserted by calling it a synopsis.

Now, it may be my failure as an author that I could not interest the reviewer in my arguments as they emerged from such analyses, and of course those arguments may be wrong or in need of revision in a host of ways that a serious review might highlight. But my reviewer avoids mentioning that the book has any arguments at all. For example, a key theme of the book, announced early on (page 15), is that if we want to understand transhumanism, we need to see how it emerged out of an ongoing intellectual crisis that faced Enlightenment views of material progress when they had to face the challenge of Malthusianism and Darwinism. This point is right on the surface, consistently alluded to, and is one of the main threads holding the book together. Yet you would know nothing of it from the Issues in Science and Technology review.

There is one point raised by the reviewer which is substantive and worth thinking about. He accuses me of recommending modesty when I should have recommended humility. Oddly, he does so in a mocking way (“Are we to establish a federal modesty commission to enforce a humble red line…?”) when of course his own suggestion could just as easily be made to look unserious (Are we to establish a federal humility commission?).

But here at least there seems to be a real issue between us. By speaking of modesty I highlighted that moral choices are both central to our visions of the future and inescapable. The reviewer bows in this direction, but his notion of humility is actually an effort at avoiding moral questions in favor of supposed lessons drawn from a particular take on the history and philosophy of
science. By “humility,” the reviewer means that we need to acknowledge that we never know as much as we think we know when we project the utopian/dystopian possibilities for the future in the manner of transhumanism:

Every major technical advance or scientific insight leads to the opening up of a vast world of undreamed-of complexity that mocks the understanding we thought we’d achieved and dwarfs the power we hoped we’d acquired.

This is a beautiful, poetic sentiment. But it is quite irrelevant to the crucial question of how to deploy the new knowledge and powers that we are plainly achieving. Self-directed genetic evolution, for example, may indeed be far more difficult to achieve than was once thought, but that does not at all mean that we are not on path to gaining the knowledge and ability to undertake it. Even if it were true that we always overstate our powers, that does not mean we are not becoming more powerful, and in such a way as to encourage us to think that more power is coming. And it certainly does not mean that, as a moral question, there are not many who, eschewing both modesty and humility, are anxious to travel that road.