The Making of a Physician

Abstract

Introduction

Medicine is a science, but healing is an art.

Of what stuff are good physicians made?

A good physician should be empathetic, but not condescending; analytical, but not critical; detached, but not indifferent; enquiring, but not inquisitive; knowledgeable, but not dogmatic; and humane, but not emotional.

Good diagnosis is an art. As the physician listens to the story of a patient, a delicate mental process is set in motion. He puts the facts in their correct places. His mind races back to look for parallels in his treasury of past experience. He compares facts, accepts or discards them, tries to form patterns and to give shape, trying to solve a mental jigsaw puzzle. He is careful that a premature shape is not given to the jumble of facts. Slowly, very slowly sometimes, a nebulous shape is formed, and then as the mental process continues, newer information flows in during the clinical examination; and later come the investigations–gradually gathering together toward a central focus–all of which then crystallize into a diagnosis. He tries to explain away the incongruous facts, or sighs philosophically if they are irrelevant ones. Often, the physician is fortunate that he does not have to go through this painful process, because a few initial clues fall into pattern and offer a diagnosis.

When the scientist in him becomes fascinated by the purely academic exercises of a scientific diagnosis, the human counterpart becomes genuinely concerned about the complete personality of the individual before him whose load of worries are unburdened to the physician. He often learns, early in his career, the art of “clinical detachment.” This is the delicate state of balance between the scientist and the human in him.

The Good Physician

The good physician will have depth and breadth of knowledge in his subject. His clinical judgment is sound, based on years of observation, study and analysis. In Sir William Osler’s words, “Observe, record, tabulate and communicate” (Anderson et al., 2001). An enquiring mind and a flair for detection are the attributes of a good physician. He often becomes childlike in the delight he feels when a new clue is discovered, or when an important point in the clinical history is elicited. This delight is highly satisfying because of the sense of intellectual achievement, and helps to boost his ego for sometime. The detection of such clues, even in a hopeless case, is to the physician a small mercy, a battle won even though the war is lost.

While good physicians may be born, it is possible to cultivate these qualities at an early stage of medical studentship. A good teacher is the best example and is emulated often unknowingly. The qualities of such a teacher permeate young trainees slowly and imperceptibly, pervading his entire personality. Many of us can look back and gratefully recollect the indelible influence some of our great teachers have wielded on our careers.

A physician who succeeds in establishing a rapport with his patient has half his job done. A look, a word, a gesture is often enough to instil confidence in the patient. It is all too common that toward the end of an exhausting day, the physician tends to be impatient and bored, but a good physician bears in mind the fact that for a patient his woes are unique. An empathetic listening to his tale of woes works faster than a long list of drugs. However, most physicians would realize that this is more easily said than done. In any case, it always helps for the good physician to be well behaved, for along with evidence-based medicine, we also need etiquette-based medicine (Kahn, 2008).

Humour, Children and Incurable Disease

A sense of humor is an asset in any physician. It will help him ease out of many embarrassing situations. A small humorous remark might immediately gain him the confidence of his patient. Such a remark puts the patient at ease. Such humor should not be at the expense of the patient or his illness, and can have a disarming effect when it is at the physician’s own expense, because the patient suddenly realizes that the physician is also human and loves him all the more for it. Some physicians have a sense of dramatic. It occasionally helps for an effect or to ease a tense situation, but is better not overdone. A physician who expresses visible delight on eliciting an unusual physical sign perplexes his patient.

Examining a child is an art. The child is very observant and watches every move of his physician. He listens to him too and forms impressions. Give the child respect, and give him a chance to observe you. A child has a sixth sense to distinguish a friend from foe. Children particularly may enjoy the eccentricity in the physician.

The hardest task for any physician, perhaps, is to face a patient with an incurable disease. Many of us have been confronted with the dilemma of whether or not to tell the patient. Many patients would like to know about their illness, even if incurable. They would not like death to be stalking round the corner, ready to spring unawares.

After a hard and eventful life, one would like to be told of approaching death, to unburden, forgive, be forgiven, or simply to pass a few lingering moments in the company of loved ones. But, the revelation of an impending death should be a matter decided in individual cases in consultation with near relatives. Death is universal and cannot be prevented. But the process of death can be made less agonizing. The kind and understanding physician can be a balm on the sore of impending death. To live is to hope. The physician should never appear to lose heart. His very presence may sometimes defuse a tense atmosphere and infuse confidence.

Reading, Observation and Tolerance

The good physician would have read widely and wisely but never accepts the printed word without questioning. Moreover, he never accepts anything that is illogical. Sometimes, one’s experience may be quite contrary to what is read. One should not conclude that one’s observations are faulty. Many great discoveries were made because somebody’s observations did not conform to accepted facts. At the same time, one should not be mulishly dogmatic.

Tolerance to the fault of colleagues is a laudable virtue. To err is human. A colleague’s mistakes are never to be projected. A good doctor, as the good scientist he is, has never a closed mind. He is receptive to ideas, even if they come from his junior-most colleagues. Many physicians who have given a good listening to their junior colleagues have had occasions to rejoice later.

Use of Drugs, and a Philosophical Attitude

The good physician is always judicious in the use of drugs, aware of their potentialities, sparing in their use. He realizes the wonderful fortitude of the human system, its capacity for self-preservation and the limitations and fallibility of human knowledge. His aim is to console always, relieve often and cure sometimes. Or, as Singh and Singh (2006) put it, “To cure sometimes, to comfort always, to hurt the least, to harm never.” When he succeeds he is not elated, but gains confidence; when he fails, he accepts it with humility and learns from his mistakes. Failures are necessary in the making of a physician. It makes him humble, and realize his limitations.

Finally, a good physician is a good philosopher. He wonders at the beauty of human life, is aware of the futility of strife, accepts the limitations of human endeavor, and is ever-conscious of the all-pervading power that shapes our lives.

Concluding Remarks

A physician should essentially be human. He deals with human beings with their burden of worries, sorrows and sufferings. Scientific training helps him to provide relief to the patient’s physical ailments, but a humane, compassionate approach touches and consoles the patient’s aching mind and soul. No physician or medicine can prevent death, but a caring physician can make the transition from life to death less painful. Every physician should know his limitations, keeping in mind the great panorama of life and the universal power that shapes it all. Thus, a good physician is also a good philosopher.

About the Author

Professor Balakrishnan is a professor and former Chairman of the Department of Gastroenterology at Amrita Institute of Medical Sciences, Cochin. He completed his medical education from Trivandrum, and postgraduate training from Delhi University and Chandigarh. He underwent advanced training at Edinburgh and London. He has developed one of India’s first GE Departments at Trivandrum. He was a WHO Fellow in the UK and a Fellow at INSERM in France. He is the past President of the Indian Society of Gastroenterology and a recipient of the Dr. B. C. Roy National Award in Medicine. His area of research is Pancreatic Diseases and he coordinates the Indian Pancreatitis Study. He has published about 100 scientific articles and edited four books. He has practiced and taught medicine for 50 years.

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