Opinion

A PIECE OF MY
MIND
Ragini Bhadula, MD
Department of
Pediatrics, Loyola
University Medical
Center, Maywood,
Illinois.

Corresponding
Author: Ragini
Bhadula, MD
(rabhadula@lumc.edu).
Section Editor:
Roxanne K. Young,
Associate Senior Editor.

The Good Physician

There exist in this world infinite measures and
parameters by which we judge the goodness of things. In
the field of medicine, in particular, a mastery of these measures is considered the most noble of quests. Thus as physicianswearetrainedtobeconfidentinourscience.Inthat
incredible, edible, empirical! We make recommendations to our patients on a daily basis: Mrs S should lower
her cholesterol, Mr M should take that antibiotic. Advice
offered reassuringly on our collective confidence in tangible outcomes. Yet a physician is more than the sum of
her scientific chutzpah. Medicine in its entirety is as much
art as it is science. To the novice physician this concept is
unformed, theoretical at best. To the seasoned physician
it is care within the context of a profound awareness of the
human condition. Mastery of this art is a key component
of good physicianhood. Yet unlike science, art is a study of
intangibilities.Beautiful,spiritual,elusive.Whenjudgingthe
relativegoodnessofourart,weareconfounded.Whothen
is the good physician? What makes a physician good vs
average? This distinction seems subjective, threatening. In the empirical world, we have tests that can determine the extent of our knowledge, but what scales exist
to measure the weight of our empathy?
Generally, good physicians are recognized as dedicated, compassionate, and curious individuals. They extol a number of desirable traits. They are distinguished
among us as those we would entrust with the care of our
loved ones. But how does one measure such faith? While
we may be able to identify a particular physician as a master of his or her art, we cannot directly measure that skill.
What we cannot measure objectively, we cannot reproduce or learn with certainty and must instead acquire individually by experience. Leaving then the quality of our
physicianhood vulnerable to experiential fate. We hope
that our encounters with patients and mentors over time
will render us masters of understanding and alleviating
human suffering, but we cannot be certain. As physicians seeking the best for our patients, this possibility is
disquieting. So we try to bring order to chaos. We create curriculums, post surveys, attend workshops, all in
the hope that we might understand the formulaic success of exemplary physicians.
Asathird-yearmedicalstudent,eagerandbright-eyed,
I remember experiencing first-hand the frustration of this
intangibilitywhileworkinginanoutpatientclinic.Itwasmy
second month of internal medicine, halfway through third
year. At this point in my training I considered myself an expert at the diabetic visit. I knew what questions to ask, I
knew what laboratory values to jot down. I was a polished
health care delivery machine. I even made some basic recommendations,allbeforetheattendingphysicianhadmet
thepatient.Mypatientthatday,MrsK,hadthusfarallowed

me to babble on happily with mild amusement and much

disinterest in my conversation. Nevertheless pleased with
my work, I sought my attending Dr S, certain I had pulled
off a flawless encounter. Amused by my enthusiasm, Dr S
in his unassuming way waltzed into the room. He introduced himself and began to ask Mrs K the same questions
Ihad,butwithin5minutesitwasapparenthehadachieved
what I had not. Under Dr Ss questioning Mrs K began expressing her fears about her diagnosis. She was worried
about affording testing strips and glucometers. She was
concerned about how diabetes would impact her day-today life. That day I was left both impressed by Dr S and
slightlywoundedbyMrsKsrejection.Ihadaskedthesame
questions. I had smiled my warmest smile, but I lacked that
something. That important something that had made Mrs
K confide in Dr S and not in me. How could I measure up to
astandardthatwasanythingbutstandardized?Inthatmoment I was frustrated but determined to measure the relative goodness of physicianhood.
The flaw inherent in this pursuit is that when it comes
to physicianhood, we cannot render unto science that
which is not due to science. Yet we are so accustomed to
living in a world of dogmatic regulation and proof that we
assume that all we see can, or rather should, be dissected
for its parts. The truth I eventually realized through my
trainingisthatgoodphysiciansarediverse,andwhilethere
may be general guidelines, there are no formulas. Thus we
must accept, against our empirical natures, that the art of
medicine is by definition dependent on our individual investments, experiences, and flaws. We may not have tests
to numerically measure empathy, but we also do not need
them. Art is unique to each physician, and thus it is best
perfected through self-reflection.
What I lacked in my encounter with Mrs K was a masteryofthatself-reflectiveprocess.Asanaveragephysicianin-training, I had empathy, but the mark of a good physician is the manner of conveying that empathy. In between
my examining and advising had I stopped to reflect, perhaps I could have made that connection. Perhaps I could
have noticed how little room I had left for Mrs Ks questions. That pause of breath in a string of medical interrogation.Thatmomentofopportunesilencethatcanbefilled
with thought, emotion, concern, is not something I can
measure. It is not a singular quality I need to hone; it is the
naturalconsequenceofhumbleself-awareness.Inthisway,
good physicianhood becomes the flawless expression of
our human desire to relate to the pain of others. Excellent physicians inspire faith in the unmeasurable. Their excellence inherent in that space beyond which we can state
that something is 41.2% likely or 78% effective. After all,
thatisthepurposeofart,toinvokesomethingbeyondthat
which is purely tangible.

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

jama.com

Downloaded From: http://jama.jamanetwork.com/ by a Universidad de Costa Rica User on 09/07/2013

JAMA September 4, 2013 Volume 310, Number 9

909