PhD Thesis
What Makes an Exceptionally Good Doctor?
If we have a risky operation coming up for ourselves, a friend or family member we would very likely try to find the best doctor available. The same applies if we have been to multiple doctors and didn’t get help with a diagnosis or a treatment is not working well. In other words, we assume that some doctors are better than others.
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Most of us would also accept that some doctors are inherently better than others, i.e. two doctors with the same training and experience could be of a quite different quality.​
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It fascinated me that scientifically speaking that wasn’t at all established. Medical science knew there are bad doctors and that more experienced doctors can be better than less experienced doctors but there was simply no systematic research to find out whether, when and how doctors make a difference to patients’ physical health and whether some doctors are inherently better than others, having the same medicines, same experience, equally ill patients but get quite different results.
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​That curious blind spot in research meant that scientifically speaking doctors are replaceable with somebody of equivalent training and experience and only the worst doctors needed training or removal but nobody knows who the good doctors are and therefore nobody could learn from them how to be an excellent doctor, not just a well-educated or experienced doctor.​
In fact, in 2002 the British Medical Journal (BMJ) put out a special issue, asking “What makes a good doctor” and concluded that it is too hard to even define what makes a good doctor.
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Clearly, a wide open field where a treatment (the doctor him, or herself) gets employed more than a billion times worldwide each year but hardly any research.​
In 2019 as a PHD Student, I joined Bond University’s Institute for Evidence-based Healthcare in their Faculty of Medicine to investigate medical doctors’ performance.​
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The first step was to see whether doctors do make a difference to patients’ physical health even after accounting for all known factors but there were only a handful of journal articles that asked this question in their title. I therefore needed to review more than 10,000 journal articles to find a bit over 70 articles that gave at least a partial answer to one aspect of this question. That work led to two published systematic reviews, one for surgeons, one for all other doctors, and a methodological review explaining that it is easy to find when, where and how doctors make a difference.​
​And, yes, just as one would suspect, doctors depending on the intervention (treatment) can make anything from hardly any to a massive difference with some being consistently substantially better than everybody else.​
None of the papers found tried to identify by name who the best doctors were and none of the papers made any suggestion as to what could be accomplished by knowing who the best doctors are.
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Therefore we (my supervisors Mark Jones and Jeremy Howick and I) decided to ask those who are most likely to know who is an exceptionally good doctor – other doctors and I interviewed 13 doctors whether they knew any exceptionally good doctors and what their experience was of these doctors. Each of the interviewees knew one or more exceptionally good doctors and was deeply affected by them.
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That gave me a list of characteristics of what makes an exceptionally good doctor and I could then use that list to create a survey which was subsequently completed by 580 members of the general public. The large majority of respondents also knew at least one exceptionally good doctor.
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Altogether I published seven scientific papers on this subject and these papers were then put together to complete my PhD.​​
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Once the PhD was done, I was able to finish writing my book on evidence-based medicine as evidence-based medicine at the moment fundamentally believes – and it is a belief not a fact – that doctors are replaceable with other doctors and more and more with guidelines. A surprising number of problems with evidence-based medicine such as worsening population health is affected by this belief in the replaceability of doctors.
What Makes an Exceptionally Good Doctor?
Abstract
Background ​
It is unknown what makes an exceptionally good doctor or even if such doctors exist. While there has been some research, specifically surveys, on what makes a good doctor, there is no research on whether there are exceptionally good doctors, how common they might be, or how to differentiate between a good doctor and an exceptionally good doctor. It is unknown what effect and what difference medical physicians, who are substantially better than their peers, have and make on a patient’s physical health, outside of known factors such as patient and doctor demographics. What is known, is that in clinical trials doctors have a clustering effect but said trials do not establish whether that is due to patient demographics or varying doctor abilities.
Aims
To assess whether doctors make a difference to patients’ physical health and, if so, to what extent does that have on patients’ physical health. To determine whether there are doctors who could be considered as exceptionally good. Should they exist, this thesis further aims to identify the characteristics of exceptionally good doctors.
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Methods
Two systematic and one methodological review and two primary studies were conducted. We conducted systematic and methodological reviews of cohort and case control studies, and randomised controlled trials to assess surgeons’ and non- surgical doctors’ performances regarding patients’ physical health, after all known prognostic information had been accounted for. A qualitative study collected, and analysed data gathered from interviews conducted with 13 medical doctors regarding their opinions on what makes an exceptionally good doctor and what their experience is of such doctors. Further, a survey of 580 members of the public was conducted on their experiences of exceptionally good doctors.
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Results
The results of the systematic reviews showed that, outside of all known influencing factors, doctors do affect patients’ physical health. Effects are heterogeneous, ranging from negligible to large, and positive and negative performance outliers appear regularly among doctors.
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The methodological review concluded that many existing datasets could be reanalysed to assess doctors’ performance and provided suggestions on how to analyse and report in a standardised way to enable future meta-analysis of findings
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The qualitative study included interviews with 13 medical doctors and demonstrated that the participants had each met exceptionally good doctors and tended to retain detailed knowledge of those doctors and experienced them as long-remembered role models. This study also showed that exceptionally good doctors may be both celebrated and vilified by their peers and the health system they work in, precisely for being exceptionally good.
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The survey yielded results showing that most participants had met at least one exceptionally good doctor and the majority had met two or more. The doctors who received the most positive evaluation from the public, were doctors who willingly listened to the patient to the end. The results also showed that participants who expressed more positive attitudes towards an exceptionally good doctor, were more negative than other participants when rating average doctors. This could potentially provide a motivation for doctors to undermine exceptionally good doctors.
Conclusions
Doctors can make a substantial difference to their patients’ physical health, independent of known factors including intervention, doctor, and patients’ demographics. Even a minimal positive difference applied to the billions of consultations each year could yield a clinically useful improvement. Exceptionally good doctors can be identified and are well known to medical doctors and members of the public. Members of the public particularly value doctors who willingly listen to the end and evaluate average doctors more negatively than other members of the public, giving a potential motivation for exceptionally good doctors to be undermined by other doctors.