COMMENTARY

How to Be a Good Doctor: The 4 C's

Manoj K. Jain, MD, MPH

Disclosures

January 10, 2012

On July 2, 1989, I walked into a patient's room for the first time as a doctor. I was an intern on a night float rotation at Boston City Hospital. I addressed my patient's concern and then left the room asking myself, "How can I be a better doctor?"

After more than 20 years, I still ask myself this same question, but I have discovered something since that I did not know then: the 4 C's. They are not my inventions; rather, they represent learned wisdom from my mentors, colleagues, and patients. The 4 C's are based on what patients want in their doctors: competency, communication skills, compassion, and convenience. Let me explain.

Competency

A middle-aged man who enjoyed hiking and golfing was experiencing chest pain. He was about to be wheeled to the cardiac catheterization lab. His ECG had shown "nonspecific changes," but his x-ray did not show pneumonia, his cardiac echo did not show any vegetations, and his white count was within the normal range.

As an infectious disease doctor, I was called in to see him for unexplained persistent fevers along with the chest pains. The problems had persisted despite empiric treatment with ceftriaxone and azithromycin.

A detailed history revealed that he had had numerous insect bites in recent weeks. I talked with the interventional cardiologist and asked for a delay in the planned procedure in order to administer a trial of doxycycline for a tick-borne illness. Within 24 hours he was afebrile and within 48 hours he was home.

Patients expect their doctors to be competent in making a diagnosis, choosing treatment, performing a procedure, and following up after the therapy. They can't evaluate practicing doctors on their competency. Only the professional society, peers, and the law can question an attending physician's judgment. However, there is a higher authority that we as practicing doctors must live up to: ourselves. We can do this by asking, "How can I be a better doctor?"

Communication

A busy and skilled surgeon came in to my elderly patient's room, undressed a wound on the left foot, and said, "We need to do an amputation."

This surgeon missed every opportunity to acknowledge the patient or to engage in any meaningful communication by bluntly announcing his assessment. Patients and the public often complain about the lack of communication skills -- not the lack of competency -- in their doctors. A 1998 British Medical Journal article notes that individuals who rated their doctors low on communication skills were more likely to change doctors.[1]

More important, a physician's good communication skills can improve health outcomes for the patient. According to a 1995 study in the Canadian Medical Association Journal[2]:

The quality of communication both in the history-taking segment of the visit and during discussion of the management plan was found to influence patient health outcomes. The outcomes affected were, in descending order of frequency, emotional health, symptom resolution, function, physiologic measures (i.e., blood pressure and blood sugar level) and pain control.

Compassion

Sweat covered my patient's scalp like dew, then coalesced and rolled down past his staring eyes. A specialist had just told him about his dire diagnosis of metastatic pancreatic cancer. To me, the patient reiterated the specialist's words: "'Well, this isn't very good. This is terminal.'"

The patient continued. "He didn't talk to me -- he talked to a piece of paper. I got a guy sitting here reading the piece of paper telling me I am going to die and then walking out the door. That was not well executed."

A few weeks later I recounted the story to medical students during a lecture. Patients want and need compassion, and compassion can be taught, I told them.

For example, researchers found that doctors in an intervention program, which combined experiential learning skills such as role modeling, with reflective exploration of values through writing narratives, were more compassionate or humanistic with their patients compared with controls.[3]

Compassion can also be lost. In a study of 419 medical students, researchers showed that scores for empathy declined significantly after the freshman year of medical school, when students began basic science lectures, and again after the junior year, when students began clinical rotations.[4]

Looking at the bleary-eyed students, some of whom had their textbooks open trying to prepare for their next exam during my talk, I knew why: Stress, anxiety, competitiveness, and sheer lack of time were likely reasons for the loss of empathy among medical students. Interesting to note is that even though women medical students had empathy scores twice as high as men's, they, too, decline in empathy during medical school training.

You can show compassion through the 3 T's: talk/listen, take time, and touch. Taking the time to talk and listen to patients comforts patients, as does a doctor's touch.

Convenience

When my mother developed itching and a rash, which I could not diagnose, she needed to see a dermatologist. The earliest appointment she could get was in 26 days.

My mother was fortunate. A 2009 survey showed that in major cities the average waiting time to see a dermatologist ranges from 11 to 50 days.

People often are in a compromised position when they are ill. If we can do our best not to inconvenience patients, they are ever more grateful. Early appointments, short wait times, open access to intensive care units, short NPO times before surgery, and pleasant nursing and support staff are what patients want.

The 4 C's aren't the commandments for being a good doctor; they are working guidelines for today's doctors. Some decades ago, another C -- confidentiality -- was paramount. As doctors, we learned to keep medical records secure and to not talk about our patients' medical information with nonessential personnel. Nearly every doctor understands and complies with this now.

In the future, my hope is that convenience, compassion, communication, and competence will all become ingrained traits among doctors. However, just as I did on my first day as a doctor, I will continue asking the question, "How I can be a better doctor?"

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