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.

The Case for “Pimping” in Medical Education

Illustration by William Sharp (National Library of Medicine)

“What are some common causes of

pancreatitis
?”

The attending physician looked at me as we stood outside of the patient’s
room. It was as if she had turned a stage light on over my head while
medical students and residents silently waited at my flanks, watching with
bated breath. I stammered and said, “alcohol.” 

“And what else?”

This time the question was directed at another medical
student. I breathed a sigh of relief. It was my first time experiencing
what everyone in the medical field calls “pimping.”

***

On

rounds
 in the hospital, attending physicians “pimp” — that is, publicly interrogate —
medical students and residents about various aspects of disease and disease
treatment. Physicians have practiced this method of teaching and testing
for years.

Dr. Frederick Brancati popularized the term in “The Art of Pimping,” a 1989 article for the Journal of the American Medical Association that satirized the practice. He humorously (and seemingly apocryphally) tells us how the word was first used in the seventeenth century by

Dr. William Harvey
, the physician who discovered the circulatory system. Harvey allegedly
said of his students:

They know nothing of Natural Philosophy, these
pin-heads. Drunkards, sloths, their bellies filled with Mead and Ale. O
that I might see them pimped!

Brancati continues with his satirical history by relating how William Osler,
the father of modern medicine, used the method and its moniker in the
United States. Abraham Flexner, an educational reformer and eponymous author of the

Flexner Report
, which detailed the failure of American medical schools to teach science
properly, supposedly described Osler’s method in his diary:

Rounded with Osler today.
Riddles house officers with questions. Like a Gatling gun. Welch says
students call it ‘pimping.’ Delightful.

(For what it’s worth, neither the Oxford English Dictionary nor Merriam-Webster list this usage of the word. But one irked respondent to Brancati’s article offered an alternate etymology, arguing that pimping is actually a malapropism of pumping, meaning “to question persistently.” The writer insisted on correcting the record, “Lest this word, possibly used as a sensational catchword, become a neologism.”)

***

Pimping, though used often in the hospital, does not comprise the bulk of
medical education. Prior to the third year of medical school, a student’s
knowledge is tested with a plethora of multiple-choice exams. Some of these
are higher-stakes than others. For example, one must pass Step 1, the first of three exams
comprising the medical licensing process, in order to apply for residency,
and one’s score determines where one trains.

It might seem, then, that pimping takes a back seat to such exams. But in
reality they complement and build on each other. Given that Step 1 is a
multiple-choice test, if you can recognize the answer then you can get the
question right — you don’t have to be able to recall it from memory.

But
pimping takes medical education to a different level. Not only does one
have to recall the precise answer from memory when being pimped, but one has
to do so in a kind of theater, in front of the whole medical team and,
occasionally, the patient.

To answer these unpredictable questions correctly, one must know a great deal and
demonstrate that knowledge under great stress. This is very
difficult indeed. The cellular and sub-cellular aspects of human biology are
dizzyingly complex. Proteins, hormones, cell membranes, hemoglobin, acids,
bases, and many more players all interact with each other in different ways.
The biochemical and cellular processes merge together into systems like the
cardiovascular and nervous systems. One could study these systems
for years and still not be comfortable with them. And they all affect each other. The kidney can compensate for a respiratory issue. The
respiratory system can change because of a musculoskeletal issue. One has
to understand these interactions to treat disease. Consequently, a medical
education must be broad and deep.

***

How does one memorize or even recognize all of this information? One method
involves creating mnemonics or poems. This is a perennial trick used not
just by medical trainees but by religious groups as well.

In an
article for Aleph, Maud Kozodoy explores this technique within the medieval Jewish tradition. Medieval Jewish scholars used poetry to memorize religious and medical
facts. As Kozodoy writes, “versification facilitates memorization.”
Moreover, “verse preserves the integrity of a given text or, putting the
point negatively, reduces the possibility of its corruption.” Galen, the famous Greek
physician of the second century AD, recognized
this:

drug prescriptions in verse form are more useful than those written
in prose with a view not only to memory, but also to the accuracy of the
proportion in the mixture of ingredients.

Kozodoy offers another example, translating from the Hebrew a verse by Yannai, an Israelite poet circa the sixth century AD, “based on the rabbinic dictum that the 248 limbs/organs of the body correspond to the 248 positive commandments given at Mount Sinai”:

Then, two hundred and forty-eight limbs / You fashioned in man and attached
to him. // You chose thirty for the soles of [his] feet / accustoming them
for good and for evil. // You decreed ten for [his] feet / so that they
would not slip…in the receiving of the ten commandments.

Modern medical education draws from this rich tradition of versification.
Though we don’t typically memorize poems in medical school or residency, we do come
up with short phrases that allow us to retain important information. Take,
for example, the side effects of an anticholinergic
medication like diphenhydramine (Benadryl), which blocks acetylcholine receptors in the nervous system. Most students
and physicians memorize the overdose effects using the following short
mnemonic:


Hot as a hare, blind as a bat, dry as a bone, red as a beet, mad as a
hatter.

When you overdose on anticholinergic medications your body temperature
increases, your pupils dilate, your skin dries up and flushes, and you can
become delirious. We try, whenever possible, to find mnemonics like these when studying for exams, as they often make memorization easier.

***

Another method that helps us memorize information, though it sometimes
goes unrecognized by its victims, is being the target of pimping. This makes pimping both a
way to test knowledge — as in the story that opened this post — and a way to accumulate
knowledge.

An attending physician once pimped me about the treatment for a

pulmonary embolism
, a clot that has migrated to the lungs and cut off blood supply, leading to
rapid deterioration and death. One of my answers was to use

nitroglycerin
, a drug that causes vasodilation.

But I was very much wrong. The attending
immediately said to me in front of the whole team, “you’ve just killed your
patient.” Because nitroglycerin dilates vessels, it decreases the pressure
of blood being pushed into the heart, and consequently decreases the force
with which the blood is pushing into the pulmonary circulation and
bypassing the embolism. If you do this, the body can no longer push blood
past the clot, and you can die.

I will now never forget this fact. It
was a stark reminder of how much more I had to learn, especially given how
terrifying the consequences of my treatment would have been had I used it
on a real patient.

Pimping is equal in potency to poetry and
mnemonics in searing facts into one’s memory.

***

Recently, there has been some controversy over pimping as an educational
method. Dr. Dhruv Khullar, a physician at NewYork–Presbyterian Hospital,
wrote in a post for the New York Times’s Well blog that this style of teaching, in which we are only expected to demonstrate how
many facts we know, “encourages us to learn to show, not grow — to project
confidence, and dismiss uncertainty.” Suzanne Gordon, a
medical journalist, wrote in

a blog post for
 the British Medical Journal that pimping discourages health care providers from admitting mistakes:

If a fundamental
communications skill learned in medical training is to confidently
communicate knowledge that one does not actually possess, never express
doubt, and avoid at all cost embarrassing a medical superior then patient
safety truly becomes a mission impossible.

But this seems to miss the point. Pimping, if not done
maliciously, is an effective exercise in testing and teaching. After four years of medical school and two years of residency, I still get pimped and there
is still much that I do not know. Every question directed toward
a student or resident is also a lesson in humility, about how much there is
to learn.

What we need instead, as Dr. Khullar argues, is a shift in attitude about what it means to get
something wrong.

As part of the learning process in medical school, students should be
encouraged to fail, and to learn from those failures so that they better
succeed as physicians. As a 2012 study in the Journal of Experimental Psychology: General demonstrated, children actually perform better in school if they are told
that failure is a normal part of the learning process. They have a better
working memory and are more effective in solving difficult problems.

Failure also teaches us to adapt because we remember what to do when the
same situation arises again. When I face a real patient with a pulmonary
embolism, I am certain I will not give that patient nitroglycerin.

There is a relatively small and brief price to pay for getting a question wrong while
being pimped. But the stakes are far higher when you are the one making the
decision about a real human being. And to learn from such failures as a
medical student is in the best interests of both the budding physician and of his or her future patient.

Editor’s Note: This post has been updated to clarify that the poem by Yannai was not specifically written for use in medical education.

Why this blog?

In Robert Louis Stevenson’s The Strange Case of Dr. Jekyll and Mr. HydeDr. Jekyll says, “when I reached years of reflection, and began to look round me, and take stock of my progress and position in the world, I stood already committed to a profound duplicity of life.”

It is appropriate that Stevenson chose a physician as his protagonist who is tortured by that duplicity, because doctors regularly experience the opposition between their own training, which uses reason to make logical sense of intricate systems, and the apparently disorganized nature of malfunction, dysfunction, and illness. This opposition comes to the fore when we as patients must reveal to our doctors the private history of our families, our surgeries, our secret habits, our likes, our dislikes, our tenebrous deeds — all for the purpose of helping our doctors make ordered sense of our often disordered selves.

One of the very first lessons a medical student learns is that of eliciting a thorough history from a patient, a history that can clue the physician in to what might be going on. The aphorism “Listen to your patient, he is telling you the diagnosis,” or some version of it, is commonly attributed to Dr. William Osler, one of the great physicians of the late 1800s and a grandfather of modern medicine. How can a physician diagnose a patient with a sexually transmitted disease without knowing about a patient’s sexual history? A patient reveals secrets to a physician in the hope that this might help the physician in his diagnosis and treatment.

While we learn this fact during the first two years of medical school, the actual work of those two years is to cultivate a rational detachment from medical practice. The major task is to memorize as much information as possible about physiology, pharmacology, biochemistry, pathology, and anatomy — to immerse oneself so thoroughly in this new and strange language that it becomes second nature. The first big standardized exam, called STEP 1, covers these basic sciences and must be passed by every aspiring physician in the country. It is the gateway between a life based on books and pure mental work and the practical work of the third year, where I am now. During this third year, medical students spend about a month or more in each general specialty area: surgery, pediatrics, psychiatry, neurology, internal medicine, emergency medicine, obstetrics and gynecology, and family medicine.

During each month, we are considered a part of a medical team on that “service.” We interview, assess and help treat patients; we sit in on conferences, draw blood, and start intravenous lines to deliver drugs into the body. We begin to speak the language of medicine. We see what doctors see but we see it for the very first time. Like a child discovering the ability to walk and speak, a third-year medical student discovers how to live and breathe the complexities and uncertainties of a life in medicine.

This privilege elicits all kinds of reactions as death and life, sickness and health, are laid bare before us. We straddle the line between the physician and the patient, between the rationalist and the sufferer. The only side we have known until this point is the latter, but we are quickly initiated into the former. We stand committed to the profound duplicity of life. This singular position, which we don’t occupy for too long, as the novelty begins to fade, provides an opportunity to see with eyes still fresh a world that for many outsiders is shrouded and hopelessly complex, with a confusing array of specialties and subspecialties accessible only by the expert. Inevitably, in one way or another, all of us participate in this drama, whose plot centers on the relationship between physician and patient. In this blog, I hope to shed some light on my introduction to the inner workings of the medical field — and in doing so to illuminate some of its theoretical, practical, and ethical complexities.