gms | German Medical Science

Claudia Witt

Der gute Arzt aus interdisziplinärer Sicht - Ergebnisse eines Expertentreffens

KVC Verlag (Karl und Veronica Carstens Foundation), Essen

year of publication: 2010, € 19,80, 257 pages

ISBN 978-3-86864-001-54

The question, what a good physician is, is as urgent as difficult. It is urgent because without an at least preliminary answer we cannot know how to educate a good physician. This aspect is especially important against the background of the ongoing discussion on the project of developing a national competence based catalogue of educational objectives for medical education in Germany. The question is difficult because the discussion about it continues unabatedly despite a number of proposals to define the construct of the good physician more clearly. Thus, one should not expect to find definite answers in the volume under review here. It documents a meeting of experts that was organized in 2009 by Claudia Witt, who holds the endowed chair (Carl and Veronika Carstens Foundation) of complementary medicine at the Charité in Berlin.

The volume embraces five chapters on different perspectives discussing the respective topic more or less comprehensively. This results for instance in a detailed contribution on physicians' empathy side by side with more general considerations e.g. on medical education. The introductory chapter, "perspectives", contains three papers dealing with medical education on a more general level. Especially interesting from a German perspective is the article by Paul Mueller, a medical teacher at the Mayo Clinic in Rochester (USA), because it builds a bridge to the ongoing intensive debate on medical professionalism in the Anglo-American countries. Professionalism in that sense is an umbrella term that refers to the attitudes, goals, behavior and conduct of members of the medical profession. Mueller portrays how the Mayo Clinic, as an institution committed to excellence not only in patient care but also with regard to the conduct of its employees, deals with the issue of professionalism. Here, professional behavior and conduct is defined, conveyed, expected and assessed on all levels of the medical hierarchy. However, without explicitly mentioning it, Mueller's contribution also points to some of the challenges surrounding the attempt to operationalize professionalism in order to make it teachable and assessable. Some of the elements he mentions such as clinical competence, communicative competence or a sound knowledge of the legal and ethical principles underlying medical care are straightforward to define and measure. More challenging in this regard are values such as altruism or humanism. The desire to define and assess these "components" of the good physician as clearly and unequivocally as the former faces a number of difficulties. Against the background of the necessity to balance individual values in a pluralistic society, the adequacy of a principle such as altruism might be assessed in different ways depending on the particular circumstances of the individual situation. For instance, the question to what extent beyond the fixed working hours a physician is expected to put the interest of his or her patients first is a matter of increasing controversy and affected by social change that has a specific dynamic depending on the respective society or culture.

In addition, the respective context of medical care influences to a great extent not only if but also how attitudes and values become relevant for individual action. This context dependency of professional behavior is highlighted in an (unfortunately very short) article by Wolfgang Klitzsch - managing director of the medical association Nordrhein - within the second chapter ("social context"). He depicts five fields of conflict that might hinder the physician to act as a good physician. For instance, inconsistencies in the framework that regulates medical care such as false financial incentives might counteract care in the patient's best interest. Patients, on the other hand, might have excessive expectations regarding the efficacy and scope of medical care instead of accepting responsibility for their own health. However, the patients' opinion on what a good physician is, might be very different depending on factors such as age, character of illness and other individual variables. This is further illuminated in an article by Bettina Berger, a researcher at the department for the theory of medicine, integrative and anthroposophic medicine at Witten/Herdecke University. According to her, patients do indeed have specific expectations but they also agree to a large extent on some more general characteristics of the good physician such as being humane and competent, engaging the patient in the process of decision making, having enough time, being available and accessible, providing comprehensive information, taking an interest in the patient's needs, being a good communicator and being responsive to the patient's wishes. Yet, due to the shift to more chronic medical conditions and the increasing importance of cooperation within the health care system, the patient's expectations are no longer directed exclusively to an individual physician but to the interprofessional health care team.

Against this background it is not surprising that communication constitutes one of the key competencies of the good physician. Accordingly, the papers within the chapters on communication and empathy constitute the main focus of this volume. This might also be caused by the fact, that the research literature on communicative competencies is much more comprehensive, making it easier to operationalize these competencies at least in comparison to some other qualities that come into mind. However, even here many questions are still open as is shown by the article of Melanie Neumann, also a researcher at the department for the theory of medicine at Witten/Herdecke University. She discusses the concept of empathy which is regarded as one of the most important components of communicative competence and also demanded as the fundamental attitude in the interaction with the patient. Despite this prominent role there are a number of definitions of empathy which are surprisingly vague and fuzzy resulting in a whole variety of instruments to measure it. Thus, there is an urgent need to clarify these definitional issues and to focus on some established and validated instruments in order to shed more light on the specific impact of empathy on the physician-patient-interaction. This might then result in effective and verifiable educational concepts that also take the influence of the respective learning or working environment into account.

Further contributions on communication deal with narrative approaches to the medical encounter or theoretical considerations. Yet, it would have been desirable if these contributions would have discussed the evidence especially from linguistic studies on the physician-patient-interactions more thoroughly instead of recapitulating well known concepts such as Watzlawick's theory on communication. This is especially true since these linguistic studies do not only produce multifaceted evidence that is indeed "unmanageable" but also frequently differ in aims and methodology from studies that are conducted "inside" the medical realm.

Finally, two contributions on the characteristics of complementary medicine constitute the fifth section of the volume. The results of a qualitative study by Gunnar Stollberg, professor for sociology at Bielefeld university, do not only shed some light on the motivation of physicians to adopt methods of complementary medicine but also on the concept of the good physician that these physicians and their patients have in mind. In doing so, some of the deficits of conventional medicine emerge quite sharply since the patients primarily depict attributes that might as well be fulfilled by physicians practicing conventional medicine: e.g. having enough time for the patient, approaching the patient as an individual in a holistic way, being reliable with regard to appointments, doing home visits, respecting patients' privacy. Interestingly, many of the patients in this study were not very much interested in shared decision making but rather trusted their physicians to decide. That patients who confine in physicians practicing complementary medicine hold a concept of the good physician that consists of such general attributes rather than of specific medical characteristics points once again to the actual flaws of conventional medicine (the exception proves the rule).

Overall, the reading of this volume leaves an ambivalent impression. This is caused by the heterogeneous quality of the respective contributions on the one hand and the fact that the volume falls short of its title on the other. Though the idea of the good physician is illuminated from different perspectives, an interdisciplinary dialogue does not arise. Assumingly, this dialogue took place during the conference following the presentations. Unfortunately it is not documented.

The author declares that he has no competing interests.