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The Challenge of Becoming a Distinguished Clinician

  • Edward C. Rosenow III
    Address reprint requests and correspondence to Edward C. Rosenow III, MD, Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, 200 First 5t 5W, Rochester, MN 55905
    Division of Pulmonary and Critical Care Medicine and Internal Medicine, Mayo Clinic Rochester, Rochester, Minn
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      A few months ago, I was asked by Dr Pasquale J. Palumbo, chair of the Department of Medicine at Mayo Clinic Scottsdale, to present my thoughts on “the challenge of becoming a distinguished clinician” at the first Mayo Scottsdale Distinguished Clinician A ward banquet honoring Dr John D. Eckstein. At Mayo, the distinguished clinician is selected by peers.
      It takes time, in fact many years, to become recognized as a highly respected physician because, like many other things in life, we must prove ourselves in a consistent pattern for a fairly long period. During this time, we become role models, whether we know it or not. I call this “silent leadership” or “silent mentoring.” All of us are role models, especially to our children, but as physicians practicing the art of medicine, our qualities as caring individuals become more and more obvious to those around us. An ideal role model does not serve only peers; on the contrary, a tremendous amount about the art of medicine is learned from younger physicians, including residents.
      The Mayo culture is difficult to define, but Dr William J. Mayo said in 1910 that the “spirit” of Mayo is the team collaboration of patient care, education, and research that makes Mayo physicians unique. Being salaried removes the incentive to do extra unnecessary tests or procedures and returning all surplus to research and education contributes an institutional and individual sense of self-satisfaction with our culture. A culture such as this becomes an ongoing memory of its good qualities. All Mayo physicians, as well as research scientists, administrators, and allied health personnel, perpetuate these qualities.
      An institution does not develop culture in a few years; it has taken Mayo decades to be truly recognized for what it has. At Mayo, in our interactions with each other, we are fortunate to be playing on a level field; we are “they” in leadership. Prima donnas do not fit in; there is a collegiality of respect for each other and a concern for each other's professional as well as personal life that acts as a tremendous “support group,” further enhancing our own concept of the Mayo culture. This includes concern and respect for allied health personnel as well, as best demonstrated by the qualities of the highly respected physician who especially considers such people a part of the “Mayo family.”
      In 1910, Dr Will Mayo also said, “The best interest of the patient is the only interest to be considered.” I agree, but I do not think that Dr Will would object to the word “only” being changed to “most important”; this change allows other interests to be considered, such as family and the people around us. The late National Football League coach Vince Lombardi once said, “The difference between mediocrity and greatness is the feeling you have for one another.” I feel very strongly about the value and the importance of the physician role model to the allied health personnel, who can be counted among the absolute strengths at Mayo. When the respected physician becomes a role model to paramedical personnel, it creates or enhances in them a dedication, a loyalty, a belief in the future of the organization, and, in tum, a sense of security that is invaluable in nurturing an already strong work ethic. All this reduces the level of stress, a critical factor in the workplace where “faster and more” are sometimes the motto. For the respected physician, being a role model is now a part of the job description.


      Consistency of good behavior, both vocal and nonvocal, is essential for the development of the respected clinician. It means never speaking disparagingly to or about anyone, being able to roll with the punches, and “not sweating the small things.” It means not becoming angry, as a person's point can almost always be made with calm reasoning and discussion. These characteristics lead to dependability, which, in tum, leads to predictability. This is an integral part of integrity that people assume all professionals have, but, like many other things, it comes in various levels of quality. Consistency, dependability (reliability), predictability—these qualities allow the people we work with (and our patients) to know where we stand at all times. These qualities are also important in reducing stress in those with whom we work and in our patients.
      Most physicians have a strong work ethic or they would not have reached their achievements. However, having a strong work ethic is not the same as being a workaholic; in fact, being a workaholic can be counterproductive because other priorities in life may suffer. Priorities must be put into perspective. People expect a role model to have a balanced family life—someone who can have fun and can put medicine aside for at least short periods. One of my favorite sayings is “There has never been a case report of a man or woman on their deathbed saying, Gee, I wish I had spent more time at the office.’” A strong work ethic is working in a steady, consistent pattern and never giving the impression of not enjoying work or looking to get out of extra work, although the latter is something that has to be done at times. A physician cannot say yes to everyone, but occasionally going the extra mile is a sign of dedication and loyalty that ultimately leads to greater respect. Mixed with a strong work ethic is a sense that we cannot take ourselves too seriously.


      Following our intuition may not seem to be an important attribute for becoming a respected physician, but it is. It is responding to our intuition in the manner in which we care for our patients and in our relationship to the people around us. I think many people in all walks of life have “turned off” or suppressed the ability or desire to respond to their intuition. Intuition seems to be only a step up from instinct in animals. Both intuition and instinct are critical in nature, and both are “acts of coming to direct knowledge or certainty without reasoning or inferring,” “revelation by insight,” and “not reasoned conclusions.” Some might even call intuition “a divine empathy that gives insight into reality.” Intuition is thought to be inherently good, and intuitionism is “self-evident truths intuitively known which form a basis of human knowledge; a doctrine holding that rightness or wrongness is immediately intuited.”
      Intuition is really an intrinsic system of ethics, and when consistently applied to everyday acts instinctively allows a physician to always do what is best for a patient; this system produces a trust that is absolutely imperative in practicing both the art and the science of medicine. Dr Will said that intuition should be a sixth sense. Suppressing this to any degree leads to compromise and a loss of trust. One author described prayer as humans speaking to God, whereas intuition is God speaking to humans. Integrity, in medical parlance, is the subacute to chronic conscious acting on intuition and is the discerning of what is right from wrong, then acting accordingly.


      I think people view arrogance in physicians as a sin greater than greed. Arrogance is “a genuine or assumed feeling of superiority.” It is an aura of infallibility, an overbearing manner or attitude. An arrogant person is always right. An arrogant physician does not need to say “I'm sorry,” “I do not know,” “I care about you,” “I want to help you,” or “I will call or promptly write the patient's physician or return the patient's call.” An arrogant physician does not need to ask whether the patient has any questions or answer any questions.
      Mild arrogance may be hard to describe, but a person can sense it. Once the patient senses even a slight degree of arrogance, the relationship between the physician and the patient is tainted. I think the consensus is that an arrogant physician cannot be compassionate. Arrogance is the opposite of empathy or sensitivity. It is a diminished awareness of or, worse, uncaring for the patient's feelings. Physicians cannot charge for the extra moments it takes to display caring or empathy toward the patient, and unfortunately this is the area in which cutting corners may save time. Maybe the physician is not really arrogant but seems that way because of lack of time with the patient, an unfortunate compromise. The respected physician always finds time to show genuine caring for the patient and the patient's family as well as the other people involved. The patient equates quality of care with time spent with the physician. It behooves physicians and patients to work with third-party payers to allow more time together. I think that physicians will someday be graded by their patients, and even a competent physician, well versed in the science of medicine, will score lower, maybe much lower, as a result of arrogance. This “grade” may well become public knowledge, possibly even on the Internet.


      Attitude is everything. “I am as I thinketh.” This can be taken one step further to “I am as I doeth” and “I am respected as I am perceived.” A positive attitude is picked up by all the people, including the patients, involved with the respected physician. Consistency in this attitude, even during a bad day, brings an aura of calmness and security to the people around us and conveys a sense of confidence without arrogance.
      A recent newspaper editorial described our society as becoming a society of whiners. Whiners are always looking for someone else to blame for their problems rather than taking responsibility for the situation and doing something about it. Mature people are not whiners. One of the most common definitions of maturity that has become the creed of most organizations dealing with addiction is “the art of living in peace with that which we cannot change; the courage to change that which can be changed; and the wisdom to know the difference.” When asked what one piece of advice he would give his children, noted philosopher Sir Bertrand Russell said, “Accept change!” This becomes a part of loyalty to our institutions, even if we do not always agree with the decisions made-we still must support their mission, their vision, their culture.


      Ability to communicate, through either our actions or our words, is imperative in our rapidly changing society. Miscommunicating unintentionally leaves lasting wrong perceptions. It is not what is said, it is what is heard! Good communication skills are an art, with an important component being the ability to listen. The respected physician knows not only when but also how to listen. Body language is a powerful form of communicating. Patients are watching us all the time we are with them, looking for signs of interest in them, a sense of hope. Eye-to-eye contact, the appropriate touch, a smile, the absence of a frown are extremely important, as is the ability to look relaxed and unhurried, even though we may be behind schedule. Of real concern to me is the computer screen coming between the physician and the patient.


      Character is what we do when we think no one is watching; it really is what we are. Character complements honor—they are gifts we give ourselves. It is a consistency of integrity, a continuum of relying on intuition, a positive attitude. Character is a journey, not a destination. Morally accountable character over a long period leads to one's reputation. A reputation takes years to build, but it can be lost overnight.
      A belief in a Supreme Being may not be necessary to be a caring physician, but it is important. World War II correspondent Ernie Pyle said, “There are no atheists in foxholes.” Most of our patients near death, in very serious condition (a foxhole like they have never experienced), or just worried about their unexplained symptoms become believers in prayer, as do their families and friends. Blinded studies have described the positive effects of prayer in these situations that the caring physician cannot ignore.
      Establishing trust with a patient is imperative; integrity is the basis of trust. Trust is a bonding of caring, and when the prognosis for trust is poor, the chances for a good outcome diminish. Trust and caring are almost synonymous. The therapeutic effect of caring with dignity by the respected physician is incalculable: “Cure if you can, alleviate if you can't, but listen and comfort always, and never take away hope.” Thomas J. Watson, Jr, former chief executive officer of IBM and Mayo trustee, said to a large group of Mayo physicians, “A close relationship between the patient and you may not be valuable to you but it can be absolutely priceless to the patient.”


      Some years ago I read a statement that should be a creed for all physicians, and it certainly is for the respected physician practicing the art of gentle humanism. It was the last sentence of a landmark article, published in JAMA in 1927, on the care of the patient by Dr Francis W. Peabody of Boston. He said, “One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for (italics added) the patient.” He said it all in one short sentence!
      In my more than 35 years of practicing medicine, I have learned one more rule that every clinician can relate to that is equally important but in another connotation; I call it the “Platinum Rule of Medicine” in contrast to the Golden Rule: “Care for every patient like you would want your family cared for!”


      I dedicate this commentary to the multitude of highly respected physicians, allied health staff, friends, and family I have had the privilege to associate with in my almost 40 years in medicine, both at Mayo and elsewhere. These people are too numerous to list, but they know who they are-they are or were my role models! I am indebted to them for teaching me so much.