The making of a good doctor: a qualitative assessment of the views of a general practice manager
York Vocational Training Scheme (Postgraduate Department), York Hospital, YorkE-mail: neilmetcalfe{at}doctors.org.uk
 |
Abstract |
|---|
 TOP Abstract Box 1. General Medical...MethodsResultsDiscussionReferences |
|---|
‘One finger in the throat and one in the rectum’ produced a competent doctor in the 19th century but the ideal characteristics of modern doctors are not so easily defined. This topic is continually being mulled over in homes, waiting rooms, academic conferences, government think tanks and the nation's media, but determining what makes a good doctor is difficult. The General Medical Council's Good Medical Practice’ lists 14 specific duties of a doctor (Box 1) but in one survey, participants from 24 countries yielded 70 different responses about what makes a good doctor, ranging from the typical necessity for compassion and competence to the more unusual courage and creativity.
In all these matters, you must never discriminate unfairly against your patients or colleagues and you must always be prepared to justify your actions to them.
|
To date, the beliefs of general practice managers on the make-up of a good General Practitioner (GP) have not been explored. However, practice managers have unique insights into the range of skills and attributes that a GP needs not only to be a successful clinician but also to function long term in a practice and run a successful business. The aim of this study was to investigate the views and beliefs of a general practice manager about the ideal characteristics of a GP using qualitative methodology.
|
Methods |
|---|
|
TOPAbstractBox 1. General Medical...MethodsResultsDiscussionReferences |
|---|
Design
After piloting of the interview questions to be asked, one face-to-face semi-structured interview was undertaken with a practice manager. The practice manager was chosen from a pool of nine available on the basis of length of experience as a practice manager, breadth of experience from working with a large number of GPs, willingness to participate in the study and geographical location.
Procedure
The interview took place in an unused nursing room at the general practice where the practice manager works. Prior to the commencement of the interview, measures were taken to assure it would be uninterrupted. The interview was recorded for later transcription. Non-verbal actions were recorded at the time of the interview. Following the interview, the practice manager was given the transcript of the conversation to read and clarify points that were possibly over or underexpressed during the interview. No answers were altered.
Analysis
The interview was transcribed and analysed Thematically using grounded theory principles. In this way, themes and concepts that consistently emerged within the data were generated.
Ethical considerations
As the study did not involve NHS patients, ethical approval was not sought. Informed consent was obtained when the practice manager was initially invited to participate and on the morning of the interview. This included express consent for the interview to be recorded. The practice manager was not paid for any services and was assured of confidentiality.
|
Results |
|---|
|
TOPAbstractBox 1. General Medical...MethodsResultsDiscussionReferences |
|---|
Five main themes emerged. The themes are labelled using the words most frequently used to describe them in the interview transcript.
Theme 1: Communication skills
This theme was the most prominent theme identified during the interview (Box 2). This was mainly due to its affect on the doctor–patient relationship. Communication was viewed as a skill worth more than qualifications from the patient perspective. In the practice manager's experience, complaints about doctors were usually about poor communication skills. Good communication skills were also felt to be important for relationships with other members of the practice team including other doctors.
The practice manager's view was that communication skills were of such importance to a doctor that students applying for places at medical schools should be assessed on this skill at interview. Moreover communication skills were not purely inherent and could be developed during the course of medical school and doctor training through specific education. It was felt that doctors should have a range of communication skills at their disposal so that they could adopt different styles to meet the needs of different patients.
| Box 2. Reported views on communication skills in doctors (Theme 1) Practice manager (PM): Sometimes its (patient complaint) ‘I do not think they have heard what I wanted to say’. Interviewer (I): What should I look for in the students who are wanting to come into medical school? PM: The ability to communicate, how articulate they are, is important. PM: The whole style in which they open a consultation, inviting confidences and leading people through things. I think there is something that undoubtedly can be taught on that with communication skills. PM: As more recent doctors are trained, the communication skills have now got better and better. I think that young doctors are probably better than some of the older ones now’. PM: The downside about the communication thing is that there are more tendencies now for GPs to say ‘Well what do you think? What would you like me to do? What do you think is the problem?’ (I: laughs) and an older group cannot always cope with that best and so that does not sit comfortably with some patients. There is still the concept for them of ‘the doctor knows best’.
|
Theme 2: Coping mechanisms
The practice manager reported that doctors who can deal professionally with the pressures of the job are desired. GPs are subject to high amounts of stress during the course of their work. This is made worse by working for long hours in a consulting room alone. It had also been noted that some stress-related behaviours could cause offence to other team members and result in loss of team morale. The practice manager felt that doctors who had good coping mechanisms were best suited to life in general practice (Box 3) and that those who appreciated that others in the practice might be under stress and were supportive to others were an asset to a practice.
| Box 3. Coping mechanisms are needed (Theme 2) PM: I think you have got to have something in the practice that is an escape route from modern society. People do not find coping with stress easy ... Everybody is under pressure and it is about finding ways to deal with that.
|
Theme 3: Risk management
The practice manager expressed positive views about doctors who know when to take risks and when to play safe (Box 4).
| Box 4. Risk management in doctors (Theme 3) PM: Medicine is not an exact science. You cannot diagnose everything, you are not going to get everything right, and some of it is self-limiting. There is an element of risk management in there, you know, what is the risk of leaving this and see what happens in a week or where do I go from here. PM: You want somebody who is going to be thorough when they need to be thorough and is going to be prepared to take the risks, get the people through when they need to but can always be the expert communicator and to detect which it is and what the patient needs. So you are asking for, you know, something that is absolutely perfect.
|
Theme 4: Financial skills
The practice manager felt that doctors with financial skills were more likely to work in a successful practice and provide quality care themselves (Box 5). It was felt that there has always been a lack of awareness that general practice is a business. This situation continues today and is detrimental to the financial stability of a practice. The practice manager had noted that financial strain through bad financial management impacted adversely on clinical care through doctors becoming demotivated and vice versa. Not only the financial health of a practice but also clinical care could be improved by increasing time allocated to business skill acquisition while in training.
| Box 5. Financial skills (Theme 4) PM: You see what you want to see the career you are going into (in training). You do not actually learn about understanding, about what actually goes on and that sort of thing, understanding the business of health care. PM: People's jaws have dropped open and said ‘I have never ever thought about that. You just get funding in primary care’ (on teaching fifth year medical students about finances). So, I think everybody should have some insight into financial management. Basic things like how to read a budget, how to do budget forms and things like that. PM: Whether you are going into a sound financial partnership or entering a bad one is going to be one of your first questions (on being offered a GP partnership). It is not just about am I going to fit in here? Is the clinical workload going to be good? But am I going to be financially making sense?
|
Theme 5: Teamwork
The practice manager felt that being a GP was a constant tussle between being a practitioner working alone and a team member (Box 6). The ability to work as a team was important so that GPs understood the roles of other team members, valued their contribution, and could acknowledge the feelings and perspectives of other team members. It was felt that often communicating with other team members was of relatively low priority to GPs who had other things to do and that could cause difficulty. The practice manager also thought that it was important that GPs acknowledged the contribution of other team members and used their skills and experience as a learning resource for themselves. It was of particular importance that the whole team, including the GP, pulled together and helped and supported each other to achieve common aims effectively.
| Box 6. Teamwork (Theme 5) PM: I think you need somebody who understands the respective roles of the members of the team and I think that is about appreciating the worth of others and the efforts and the part they have (I: agrees) to play in the whole. PM: It is an interplay all the time between being an individual clinician and being a team player. PM: From a manager point of view specifically, it is trying to get time with GPs. It is particularly important that GPs can actually think about what we might be doing. It is the hardest thing with partners because they tend to have lots of different interests and we are often at the bottom of the order. PM: I do not know anybody in the practice that knows exactly the other person's job and you are just learning from each other. It does not matter what your role is or your academic ability, you can learn from somebody else in the team all the time. PM: I do not think you can operate as a partnership unless you are prepared to help each other. What makes for a successful partnership and a successful group is that they are prepared to accept that one of them has got skills in one area and one has got skills in the other area.
|
|
Discussion |
|---|
|
TOPAbstractBox 1. General Medical...MethodsResultsDiscussionReferences |
|---|
This study showed that practice managers have strong views about the desirable skills and attributes of a GP. Analysis of the interview transcript identified five themes that a practice manager felt were important in a GP: communication, risk management, coping skills, financial skills and teamwork.
The most frequently discussed skill was the ability to communicate. This is a topic that has been identified in other studies from both patient and doctor perspectives. Patients benefit from this skill by understanding care better, which in turn raises patient adherence to treatment. Doctors, on the other hand, can also identify the problems of patients more accurately and aid their own well-being by being good communicators. Teamwork, along with communication skills, already features heavily in the GMC's Good Medical Practice.
The views of the practice manager about the necessity of having good coping mechanisms, risk management and financial skills are, however, new to the debate. Although a need for these skills has not been specifically identified in other literature, several studies have suggested that education of professionals is often idealistic in nature and that, on entering the real world of their chosen profession, students in the nursing, police, law and medical professions often fall into the chasm between the ideal and the real. This can be avoided with more attention to realistic problems while the student is still within education. All three of the ‘new’ attributes identified by the practice manager interviewed for this study would fall under this heading.
Limitations of the study
This study sought the views of a single practice manager in a single practice. Although informative, they may be unique to that situation and not be in line with the views of other practice managers working elsewhere. In addition the interviewee was previously known to the interviewer. Although piloting of the interview questions ensured that they were easy to interpret and overtly unbiased, the practice manager involved knew the interviewer was a GP in training and may have modified the responses accordingly. In the same way, the interviewer had a vested interest in the responses and may have intonated the questions asked to illicit particular responses. Finally, interpretation of the data may have been influenced by the views of the researcher as a GP.
Key points
|
|
Acknowledgements |
|---|
The author would like to thank his colleagues for helping pilot the interview and especially the practice manager for their time and patience while being interviewed and for reading the transcript of the interview. This article was a winner of the RCGP/Roche GP Registrar Awards 2007.
|
References |
|---|
|
TOPAbstractBox 1. General Medical...MethodsResultsDiscussionReferences |
|---|
-
Babbie E. The practice of social research (1979) Belmot, CA: Wadsworth.
Baker R, Thompson J. Innovation in general practice: is the gap between training and non-training practices getting wider? British Journal of General Practice (1995) 45(395):297–300.[Web of Science][Medline]
Breakwell GM, Hammond S, Fife-Schaw CR. Research methods in psychology (1995) London: Sage.
Britten N. Qualitative research: qualitative interviews in medical research. British Medical Journal (1995) 311:251–253.
Burnard P. A method of analysing interview transcripts in qualitative research. Nurse Education Today (1991) 461–466.
Couchman W, Dawson J. Nursing and health-care research: the use and applications of research for nurses and other health care professionals (1990) London: Scutari.
Dornan M, Pringle M. The practice manager: a rising star. British Medical Journal (1991) 303:146–147.
Fox D. Fundamentals of research in nursing (1982) Norwalk, NJ: Appleton-Century-Crofts.
General Medical Council. Duties of a doctor (1995) London: GMC.
General Medical Council. Good medical practice (1998) London: GMC.
General Medical Council. Maintaining a good medical practice (1998) London: GMC.
Hurwitz B. What's a good doctor, and how can you make one? British Medical Journal (2002) 325:667–668.
Maguire P, Pitceathly C. Key communication skills and how to acquire them. British Medical Journal (2002) 325:697–700.
Maguire P, Fairbairn S, Fletcher C. Consultant skills of young doctors: benefits of feedback training in interviewing as students persist. British Medical Journal (1986) 292:1573–1578.
McManus I, Gordon D, Winder B. Duties of a doctor: UK doctors and good medical practice. Quality in Health Care (2000) 9:14–22.
Paice E, Heard S, Moss F. How important are role models in making good doctors? British Medical Journal (2002) 325:707–710.
Parle M, Jones B, Maguire P. Maladaptive coping and affective disorders in cancer patients. Psychological Medicine (1996) 26:735–744.[Web of Science][Medline]
Peters J, McManus I, Hutchinson A. Good medical practice: comparing the views of doctors and the general population. Medical Education (2001) 35:52.[Web of Science][Medline]
Pope C, Mays N. Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. British Medical Journal (1995) 311:42–45.
Pringle M, Wilson T, Grol R. Measuring "goodness" in individuals and healthcare systems. British Medical Journal (2002) 325:704–707.
Ramirez A, Graham J, Richards M, et al. Mental health of hospital consultants: the effects of stress and satisfaction of work. Lancet (1995) 16:724–728.
Roter D, Hall K, Kern D, et al. Improving physicians’ interviewing skills and reducing patients’ emotional distress. Archives of Internal Medicine (1995) 155:1877–1884.
Scambler G. Sociology as applied to medicine (1997) London: Saunders.
Silverman J, Kurtz S, Draper J. Skills for communicating with patients (1998) Oxford: Radcliffe Medical Press.
Strauss A. Qualitative data analysis for social scientists (1986) Cambridge: Cambridge University Press.
Tonks A. Summary of responses: what is a good doctor and how can we make one? British Medical Journal (2002) 325:711.
Toynbee P. Between aspiration and reality. British Medical Journal (2002) 325:718.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||