Today I do not want to be a doctor (by Glenn Colquhoun)

Today’s medical students face a career in medicine that may span 30 to 50 years. Some days you will feel mired in the mundane. You may wonder why you ever decided to study medicine. Like the doctor in Glenn Colquhoun’s poem, you may say, Today, I do not want to be a doctor.

My challenge to you as future leaders of medicine in New Zealand is first, to learn how to be a good doctor; and secondly, if you want to be a leader, learn how to be a servant leader, using your medical and leadership skills in the service of your patients and the community.

The last five years have seen renewed emphasis, in New Zealand and overseas, on the concept of professionalism in medicine. Professionalism is not a patient-friendly term. It can very easily sound like what Ian Kennedy (in his Bristol Inquiry Report) called “club culture” or what Harvard physician David Blumenthal has described as “a refuge of scoundrels”.

In 2002, the European Federation of Internal Medicine and the American Board of Internal Medicine launched a new charter on medical professionalism, which has been endorsed by the New Zealand Medical Association. It is based on three principles—patients’ welfare, patients’ autonomy, and social justice. It is very clearly about putting patients first. In December 2005, the Royal College of Physicians issued a significant report on “Doctors in society: Medical professionalism in a changing world”.[1] It describes medical professionalism in the following terms:

“Medicine is a vocation in which a doctor’s knowledge, clinical skills, and judgement are put in the service of protecting and restoring human well-being.”

The Royal College goes on to describe the good doctor in day-to-day practice as committed to:

The first three aspects—integrity, compassion and altruism—are hallmarks of a good human being, not just a good doctor. But the stakes are different in medicine. Even in this age of the Internet and the informed patient, as a doctor your knowledge, skills, and understanding of the mysterious workings of the hospital and health systems (never mind the human body) place you in a position of power vis-à-vis your patients.

Integrity means being honest about yourself—admitting what you don’t know and the limits of your experience; sharing your own results (successes and failures) in treating the particular condition; being open to your patients (listening to them, engaging them in conversation, answering their questions); and openly disclosing your mistakes.

Compassion means bringing kindness and caring to your work—seeing your patient not as a case, but as a fellow human being experiencing fear, uncertainty and suffering. In The Lost Art of Healing: Practicing Compassion in Medicine, Boston cardiologist Bernard Lown dissects the heart of medicine. He describes medicine as having indulged in “a Faustian bargain. A three-thousand-year tradition, which bonded doctor and patient in a special affinity of trust, is being traded for a new relationship. Healing is replaced with treating, caring is supplanted by managing, and the art of listening is taken over by technological procedures...The distressed human being is frequently absent from the transaction.” Lown quotes the 12th century philosopher-physician Maimonides, who prayed, “May I never forget that the patient is a fellow creature in pain. May I never consider him merely a vessel of disease.”

Altruism is putting the needs of others—your patients—before your own. This does not mean that doctors are called to be saints. As the novelist Albert Camus wrote in The Plague, doctors are called to be “not saints but healers”. You will be required to work long hours. You will at times put your own health at risk. Society places heavy demands on doctors—which is one reason why it is so important that society supports doctors in their work.

The next values that the College lists as hallmarks of a good doctor are continuing improvement and excellence. You need to make a commitment to lifelong learning and maintenance of your skills. Troy Brennan, a US physician and lawyer who was part of the landmark study of adverse events in New York hospitals in 1988, has described doctors’ professional responsibility to improve the quality of care as follows:[2]

Finally, teamwork is key. As noted in the Royal College report, “most discussions of contemporary medical practice are plagued by manufactured and often false conflicts: between doctors and managers, specialists and general practitioners, employers and employees”.[3] At the heart of the Code of Patients’ Rights is the statement in right 4(5), Every consumer has the right to co-operation among providers to ensure quality and continuity of services.

To my knowledge, this provision is unique. Yet it goes to the heart of modern healthcare. To be a good health professional, whatever your work setting, you need to be an effective team player, making sure that your patient does not fall through the many cracks in a complex health system.

Leadership week was recently commemorated in New Zealand, and July 2006 marked the 10-year anniversary of the introduction of the Code of Health and Disability Services Consumers’ Rights. There has been a lot of earnest discussion and hopefully some useful reflections on what we mean by leadership.

There have been outstanding leaders in the history of New Zealand medicine. Dr Maui Pomare was the first Māori medical graduate (he graduated MD in 1900 from the American Missionary College in Chicago), the first Māori health officer, an influential figure in improving Māori health in the early 20th century, and later the first and only medically qualified Minister of Health (1923–26).

Although there continue to be fine leaders within medicine in New Zealand, leadership of the profession has become fragmented and has sometimes seemed more concerned with service of the profession than the community. The words of an English trainee doctor strike a chord:[4]

This is not a recent phenomenon. On Christmas Eve 1912, the Daily News in London ran a cartoon showing the spoilt child (the British Medical Association) saying, “I want it all, and I want to carve it myself”—in response to Lloyd George’s Insurance Act reforms to provide free healthcare for workers, with guaranteed fees for doctors.

Lack of leadership and foresight was evident in New Zealand medicine 30 years ago. In a 1974 publication entitled The Future of New Zealand Medicine: A Progressive View, Dr Eric Geiringer (writing on ‘Medical Ethics’) bemoaned that the delivery of skilful advice and treatment “has been to all intents and purposes handed over to external regulation”—an extraordinary claim given the lack of medical regulation at that time, and the very limited recognition of patients’ rights and the need for proper ethical review of research. As events at National Women’s Hospital showed, and Judge Cartwright’s Cervical Cancer Inquiry Report highlighted in 1988, reliance on self-regulation and the internal morality of medicine was not in itself sufficient to protect patients.

We have heard a good deal from medical professional leadership in New Zealand in recent years about MECAs, new fees arrangements, the working hours of junior doctors, the impact of complaints on doctors, the need for the profession to appoint members of the Medical Council, the risks that the threatened influenza pandemic poses for doctors, the need for a more tolerant approach to doctors entering relationships with their patients, the unfairness of proposed 360-degree assessment of doctors’ performance.

Where is the advocacy for patients in all this? On some issues (notably the workforce and access to hospital-based services) professional voices have been eloquent and powerful. But on other issues the professional response has been impoverished. This is less than the community deserves—but also less than the vast majority of competent, committed and hardworking doctors deserve. If medical leadership is really about serving the interests of patients and the community, the first question whenever a health policy issue arises for public debate should be—how will this proposal affect the health and well-being of the community?

There are plenty of opportunities for future leaders of medicine in New Zealand. We face major challenges to improve the gaps in health outcomes for Māori and Pacific Island people. I salute a leader like young Māori Dr Lance O’Sullivan, practising as a GP in the Far North with Te Hauora O Te Hiku O Te Ika, driving the dusty roads of Tai Tokerau to deliver marae-based healthcare, with a vision of providing his people with gold-standard medicine delivered in a way that embraces tikanga Māori.

I salute leaders like Dr George Downward, President of NZMA, who has challenged the profession to be brave and to tackle healthcare induced harm, and is leading by example at Christchurch Hospital ICU. We need a concerted effort to improve the safety and quality of health services in New Zealand—as noted recently by Alan Merry and Mary Seddon in their article Quality improvement in healthcare in New Zealand. Part 2: are our patients safe—and what are we doing about it?[5]

In July 2006, Liam Donaldson, Chief Medical Officer of the NHS in England, in a major report entitled “Good doctors, safer patients”, commented: “Most doctors know of another doctor whom, on balance, they would prefer not to treat their own family. Unsatisfactory practice compromises patient safety. The medical profession has a duty to identify such practice and to remedy it. The profession owes this not only to patients, but to itself.” [6]

Looking further afield, there are major challenges in the Pacific, in Asia, and in Africa, where New Zealand doctors can serve people suffering a level of poverty, disease and starvation that is difficult to imagine. We need medical “missionaries” to be global health workers. If you want to be inspired about what being a medical leader means, read Catherine Hamlin’s biography The Hospital by the River, the story of her and her New Zealand-born husband Reg’s lifetime of work and service in surgical repair of fistula in Ethiopian women—truly “restoring human well-being” to society’s outcasts.

In closing, I remind you of the challenge—to be a good doctor, and to be a servant leader. Let me close with Glenn Colquhoun’s companion poem.

Author information: Ron Paterson, New Zealand Health and Disability Commissioner, Auckland

Acknowledgements: This paper was delivered to the Medical Development Leadership Seminar in Wellington on 22 July 2006. I thank Glenn Colquhoun for kindly allowing me to reprint his poems from Playing God (2002).

Correspondence: Ron Paterson, Health and Disability Commissioner, PO Box 1791, Auckland. Fax: 09 373 1061; email: rpaterson@hdc.org.nz