During an early morning conference many years ago, we were discussing what makes a surgeon competent. Just as the clock was showing we had to start our clinical responsibilities, one of the post-doctoral fellows asked me, “well, then, what makes a physician great?” The question was probing. Names came to mind: Hippocrates, Pasteur, Avicenna, Rush, Freud, Osler. Did I want the new trainees to model themselves after them? Surely these men were famous. But were they great doctors? What did it mean that there were no great women physicians in my mental list, when for most of human history the healing arts were often the province of women? It was clear that she was eager to learn, and perhaps to become great herself, but regrettably, I did not give her a meaningful answer.
After years pondering the issue, I have an answer to her question. It was unexpected. Let’s start with trying to characterize a good physician. Logically, a good physician is one who fulfills the primary purposes of a physician. Although medical doctors play many roles, their fundamental purposes are to help individuals and communities to remain healthy, and to help diseased individuals and communities to heal. This divides the task into two different stages: the first, related to the healthy, the second, to the sick.
How can a healthy person be helped to remain healthy? They must be motivated to live a healthy lifestyle, educated in how to do that, and supported in making that happen. How do healers facilitate that? Hippocrates, for example, discusses at length the importance of exercise and lifestyle, particularly a healthy diet that promotes being lean. Specifically, he wrote: “walking is a man's best medicine,” and “each of the substances of a man's diet acts upon his body and changes it in some way and upon these changes his whole life depends…” and he emphasized the importance of mental health.
However, he also wrote, in his oath, that physicians must swear not to share their knowledge with any except their fellow medical practitioners. Either this oath was not written by him, or was mistranslated, because this language represents the desire of a guide to protect the very secrets which give the group power. Ultimately, we have no knowledge regarding how successfully Hippocrates motivated his patients to follow a healthy lifestyle, to learn how to care for themselves well, or even how he supported them in doing that, even though he advised, “if you are not your own doctor, you are a fool.”
Regarding the trainee’s query, the first attribute of good physicians is that they effectively lead people to take care of themselves well.
How can a sick person be helped to return to health? This second part of the physician’s task requires somewhat different skills and methods, often including an advised intervention such as using medication, or an actual mechanical manipulation, such as surgery. But, also necessary for recovery, is a lifestyle that promotes healing, such as eating more wisely, exercising more consistently, sleeping more regularly, keeping the fracture immobile, and taking medications faithfully. So, again, the competent healer needs to persuade the sick person to live differently; no matter what method is used, none of the interventions in themselves cause the sick person to become well. What they do is make it possible for the sick to heal themselves. The surgeon may remove a cancer, but cannot make the tissues heal. The so-called healer may reposition a broken bone in the proper position, but cannot make the bone grow back together. The physician may advise a medicine to return the rhythm of the heart to normal, but the sick person has to take the medicine and the sick person’s cells have to respond to the medicine appropriately. But, importantly, all that those hoping to assist others to return towards health can do, is help the others heal themselves. To paraphrase the old aphorism, “you can lead a horse to water but you can’t make her drink.” So too, “you can treat people and perform surgery on them, but you cannot make them well.” Furthermore, how well that self-healing happens is heavily influenced by how fully engaged the person is in their own healing process.
To complicate the issue further, what does it mean to be well? Health is an internally generated feeling, a sense of being the way one wants to be and being able to do what one wants to do. Because those wants differ from person to person, there is no universal standard of health. Good health is not the automatic result of findings such as blood pressure and serum cholesterol being in the range of normal. This makes even clearer the central role of individual patients making sure their doctors understand their central concerns, hopes and expectations. It also emphasizes that good physicians excel at understanding what is likely to make each unique person feel well; Jill’s hopes are different from Jack’s.
Living things are remarkable. Myriad feedback loops work to keep us alive and well, and by “us” I mean all living creatures – amoebae, horses, and humans. Contemplate what is happening constantly in each of us: every second, approximately one million red blood cells are being recycled as one million new ones are made. The heart’s feedback mechanisms cause it to pump just the right amount of blood to provide 30 trillion cells with what they need to function properly in circumstances as different as sleep or rapid running. It continues that process almost 4 million times without needing to go to a “service station.” Each one of those cells is making chemicals, disposing of wastes, and cooperating with other cells. Meanwhile, the liver removes toxic substances from the blood, and provides the exact right amount of fuel in the blood so each cell can do its particular tasks. Wounds heal themselves as damaged tissues are replaced by new ones, and threatening intruders are battled by armies of warrior cells and fluids lethal to the invaders; then the gash closes, and new growth miraculously stops.
When something within our bodies goes awry and the self-healing is interrupted, it is similar to when the battery of a watch dies–external help is needed. When a fresh battery is installed the clock may run well again, but this only happens if all the clockwork is still functional and working properly. A new battery does nothing more than “fuel” the clock; the clock does all the rest.
Over time, my fellow’s question has resurfaced, and since then it has triggered new readings and a renewed sense of scrutiny. During one search of the net I found the following list of “great” doctors: Canadian astronaut Roberta Bondar, former Miss Sweden winner turned physician Eva Anderson-Dubin, the man who proposed the DNA double helix, James Watson, United States Senator Rand Paul, television celebrity Mehmet Oz and neurosurgeon/politician Ben Carson. Famous, perhaps. But are these great physicians?
When this post-doctoral fellow asked what makes a physician great I don’t think she was interested in being ranked or famous, but rather was genuinely hoping for guidance so she could direct herself properly. What became clear to me was that a good physician was one who was successful in assisting others to care for themselves so as to be healthy, and who knew how and when to intervene skillfully so that the person could heal. The great physician was the one who did those things especially well. Greatness was and is unrelated to fame or ranking.
I let my fellow down by not answering her promptly, but if I could go back in time, I might say to her something like,
“Thank you for challenging me with that question. A good physician is lovingly and knowledgeably present; a good physician skillfully facilitates a person’s own restorative abilities so as to facilitate healing. Good physicians consciously remain in the background, listening actively, teaching, encouraging, inspiring, intervening skillfully when necessary, and creating environments which support people's amazing abilities to heal themselves. To do that well is an accomplishment. To do that extraordinarily well is rare. Such doctors are seldom celebrities. But they are great physicians, and are loved by those they love. I have a hunch you'll be one of them!”