Tag Archives: attributes

Alliterative Attitudes for Medicine and MedEd

Recently on Twitter there was some discussion about what were the essential characteristics of a good doctor. The initial tweet said:

This was followed by replies suggesting other words beginning with C: “I’d add curious and concerned.” And “whatever synonym for humble that begins with c”. Others said “great mnemonic. I might add: Considerate.”  And  “Can I add a fourth C?  Communicative”.  All worth discussion. The occasional game tweeter suggested additional words beginning with A.

 

Someone else noted it reminded them of a poster for the 6 C’s (in the NHS) and a reply to that was “Interesting. “C” is obviously key.  The signs I put up in our department are “Caring, Clean and Courteous”.

 

My contribution was to note the three  words beginning with C that I used to quote, for many years, to GP registrars at the end of an observed session of consulting. When worried about the exam I tried to encourage them that, as long as they Cared, had Curiosity and were Conscientious they would be good doctors.  Why did I say this?

I wasn’t promising them that they would pass the exam on their first attempt. I wasn’t even promising that they would tick all the required competency boxes in the next twelve months. This was more about capability (when they need to keep learning), patient safety and future career satisfaction – maintaining enthusiasm and avoiding burnout.   It was more about continuing professional development than measuring a good doctor in the here and now.  More about attitude than current knowledge or skills.

About ten years ago I thought this off-the-cuff advice through in a bit more detail and with a bit more rationale to see where the options might lead.   The powers that be want those finishing training to be competent.  I took this as the starting point (at least as judged by various training assessments) and then looked at what might happen if they were also caring, curious or conscientious.  My exploration produced a few more words beginning with C along the way.  Perhaps a negative way to view this is to speculate on what happens if one of these attributes is not present.  If you miss one of these things, it can all go awry.   I guess I could have constructed the algorithm in a few ways but here is one version anyway (I’m sure you could come up with your own list to generate discussion).

 

Curiosity

I agreed with some of the tweeters that curiosity is essential. If you’re not curious you can stagnate.  You might not seek out the new knowledge you need to manage problems, develop new skills or be intrigued by new presentations.  If you’re not curious about the people you see every day you are at risk of boredom.  You might still be caring and well liked but eventually you risk becoming incompetent without being aware of it.  Perhaps this picture demonstrates curiosity along with a bit of tenacity!

If you are curious about medicine and about people you will never be bored.

Conscientiousness

If you aren’t conscientious, safety goes out the door. If you are conscientious you will keep up your professional development (regardless of any carrots and sticks) and you will follow up patients and ensure their safety.  But without the curiosity and the caring this might become a soulless pursuit or even an anxiety ridden approach.

That over-used concept of caring

Caring is a bit of a vague (and over-used) concept but in some of its manifestations it modifies the other two attributes. If you care about the person in front of you, you will be more inclined to conscientiously follow up and be curious about what is happening to them.  Caring can imply compassion for the person or passion for medicine and the profession.  If you don’t care – you will find it difficult to develop a doctor patient relationship, you will lose interest and motivation to head into practice each day.  A curious and conscientious doctor is likely to still be competent (and safe) in ten years’ time but they may miss some of the rewards of general practice that come with caring.  If you care about people and care about your profession then you have motivation and passion that helps you hang in there.

Obviously, if you lack all three attributes things may not turn out well, regardless of the starting point, and I would acknowledge the growing relevance of collaboration (and perhaps collegiality) in the initial tweet.  it should be somewhere in an expanded algorithm!

Here is where I add a “Caveat”. Will caring always make you more content in your career and help you avoid burnout?  Not necessarily so.  Problems with boundaries or system constraints that limit how you can help patients may cause frustration and burnout so these are things to bear in mind.  You may be a good doctor for your patients but not for yourself!  A discussion for another day.

The above is just a discussion that attempts to go beyond the current focus on measuring competencies to what keeps us going in a challenging career. In rapidly changing times we need to be capable as well as competent.  The conclusion for me is that GP training and education should also focus on these other aspects.  A training program should encourage and reward curiosity. It should recognise that sometimes a focus on ticking boxes and the often perverse incentives of quality frameworks can decrease the intrinsic conscientiousness that is part of professionalism.  It should explore the importance and implications of caring and being compassionate.  Perhaps this may also lead into the recognition of broader system issues that affect our ability to be good GPs and providers of effective primary care.

“You’ll make a great family doctor!” How do we know?

The above is a phrase which I have often seen written on Teaching Visit Reports.  The enthusiasm almost jumps off the page (/screen) and it comes across as a comment (feedback) by a colleague, recognising certain (not always clearly articulated) perceived attributes of the trainee.  Similarly, medical educators frequently make a global judgment about whether a registrar is likely to proceed through training successfully. What are these experienced assessors seeing?

bark grandma treeAssessors are always searching for valid methods to assure/measure/predict training outcomes and much of this is currently focussed on competencies. This is a topic for a later blog but this post is about a slightly more elusive topic.  It is about “pre-competencies” or perhaps “beyond competencies”.

Three essential ingredients 

Over the last twenty years or so I have come to the conclusion that there are at least three crucial attributes.  If a registrar is obviously 1. Curious 2. Caring and 3. Conscientious then I think “this is the sort of family doctor I would be happy for my family to see” and I relax, to some extent, as an educator.  These qualities assure me that the registrar will achieve that desired outcome of a safe and competent (and, dare I say, good) GP.  Let me explain why I feel reassured that these global judgments predict and reflect some of the more atomized competencies that programs try to measure along the way.

  • Curiosity as an intellectual/cognitive attribute is obviously important to a scientific approach but it can remain cold and objective without also the interest in the person that is central to general practice (http://curriculum.racgp.org.au/statements/philosophy-and-foundation-of-general-practice/ )  In practice, curiosity means that the GP will not have the intellectual laziness that is happy with easy answers.  It drives self-directed learning and ongoing professional development. The curious GP can’t help asking questions and searching out answers.Curiosity ensures you search out what you need to know (ie the curriculum, in more formal terms)
  • In terms of “caring” I am thinking more about a passion for the job not just the soft and fluffy emotion that is sometimes claimed for GPs.  The registrar who cares is motivated about being a good GP, is concerned about the person as a whole (not just their disease) and cares about what happens to the patient in the health system. It is articulated somewhat in domain 1 of RACGP and in the widely applied CanMEDS framework
  • Conscientiousness is representative of the ethical and professional framework that is so difficult to measure during training.  It rates of course in various training frameworks (domains 4 & 5 in RACGP, ACRRM domain 6 and the Professional Role in CanMEDS http://www.cfpc.ca/uploadedFiles/Education/CanMeds%20FM%20Eng.pdf ).  It contributes to patient safety and ensures the registrar commits to ongoing learning.  These are the learners who get their paperwork done, meet deadlines and make study plans and who ensure that patients are safety-netted and followed up.

paperbark fernleigh

I am often tempted to add Communication Skills to the above three attributes but, although some people appear to be inherently better communicators, there is a sense in which communication is a skill which can be taught and learnt.  Certainly training programs assume this although the debate continues.  The attributes identified above precede the competency tick-boxes.  It is hard to imagine a trainee with the above attributes who does not go on to acquire the required competencies unless some impossible obstacles hinder their progress.  There are people who seem to have the above attributes in spades.  As educators we just need to point them in the direction of what they need to learn.

I guess some would want to add other attributes such as insight or resilience and I wouldn’t argue with that. They are perhaps even more basic to life generally.

There have been attempts to describe and operationalise some of the occupational attributes of the GP (eg Situational Judgment Tests – a topic for another post) in the hope that these will have predictive validity.

The recipe – the benefits of a training program

 Of course the main question for educators is whether such attributes can be taught or their lack compensated for.  Some trainees commence training with these attributes evident and seem to grow organically.  They make it through regardless.  Other learners need to have a top up in one or more of the ingredients and some need a bit more stirring or leavening before being put in the oven.  These ingredients need to be mixed together in appropriate quantities and cooked for the required length of time.  This is the benefit of an appropriately-resourced training program that articulates the best recipe for success.  Hopefully an effective program optimizes this process with less wasted trial and effort of the ad-hoc approaches of a generation ago.  To push the metaphor however, shortcuts may also decrease the quality of the product so we should beware in the future.

A bit more necessary spice

These basic ingredients have always been relevant in the making of a good GP but perhaps historically the preferred flavour has changed over the decades – a basic sponge is not good enough for current needs and percotyledonhaps different spices are required in certain practice contexts.  This means that specific curricular content and required skills change over time – and the curious, caring, conscientious doctor takes this on board. Over the years we have recognised and encouraged the crucial ingredients and added in some of the specifics needed to produce the outcome appropriate to the needs of our community at this point in time.

The garnish – exam technique 

Although being a good GP is the ultimate goal, passing the relevant exams is obviously crucial so, as educators, we are required to add a collection of more or less exotic “garnishes” which represent the methods of assessment appropriate to each sub-culture.  Thus the registrar who we believe will be a good GP also needs to ensure they are acquainted with the relevant exam strategies before their task is finished – be they OSCEs, KFPs, or MiniCEXes etc.  The appropriate garnish may just make the difference in the reality cooking show metaphor of training!

I will look at other potential, more measurable, predictors of training outcomes later.