What is the most important quality of a doctor?

This is a common question asked at medical school interviews. According to Atul Gawande's international bestseller "Better", one of the most important qualities of a doctor is diligence

Atul Gawande's books are absolutely brilliant reads and I recommend them to all Applican students. His writing style is gripping and the way he bases his comments on clinical cases makes his words memorable and engaging. Over the next few weeks the Applican blog will be focusing on this book. We will discuss key interview questions and how to relate extra reading you do into your answers.  The most important point when preparing for interview is to consider exactly how each piece of extra reading you do relates to the key questions you are likely to be asked. Today we will be looking at Chapter 1 of his book - in this blog post I will summarise some of the points and cases he uses. For a more comprehensive view, I would recommend you read the chapter yourself. 

Gawande talks about how people underestimate the importance of diligence as a virtue. He claims it is something to do with how supremely mundane the word seems. I can see his point. There is nothing new or fresh about this term. Defined as "the constant and earnest effort to accomplish what is undertaken", Gawande says that if diligence was an individual's primary goal in life then that person's life would be narrow and unambitious. This is because diligence stands for commitment, dedication and relentlessness to the task at hand. The reason it seems mundane is that often sticking to the task at hand can be boring. We all know that new projects are the most exciting. Newly set goals seem attainable, regardless of how ambitious. However, maintaining high energy and effort input into a goal that is only slowly improving is far more trying. 

I am a current medical student and on my most recent placement, I began to realise the diligence required in hospitals for infection control. This is discussed in depth in the first chapter of Gawande's book where he quotes the US Centres for Disease Control that state,

"Each year, two million Americans acquire an infection while they are in hospital and 90,000 of them die from that infection."

Gawande goes on to explain how, when talking to an infectious disease specialist, the greatest difficulty the infection-control team has is getting clinicians to wash their hands. Everyone always assumes it is stronger pathogens (germs) or resistance to treatments that is responsible for infectious disease rates. In fact, it is simply washing hands. I can't say I am shocked. OSCE examinations are a common way that medical students are tested on their clinical skills in a station-like structure similar to MMI interviews set ups. Here, students fail a station if they forget to wash their hands. The aim of this is to really drill into students the importance of this procedure that consistently halts the spread of infections. Nevertheless,

"hospital statistics show that doctors and nurses wash their hands one-third to one-half as often as they are supposed to."

It is unsurprising, and as Gawande himself says "embarrassing", that this concept of diligent hand washing is far from novel. In fact, knowledge of the impact of hand washing dates back to 1847 where the Viennese obstetrician Ignac Semmelweis identified that the high rate of maternal death due to childbed fever was due to inconsistent hand washing. 

Childbed fever is also known as puerperal fever and was the leading cause of maternal death in the pre-antibiotic era. It is a bacterial infection most commonly caused by Streptococcus bacteria that ascends through the vagina to the uterus after childbirth. Back in the 1800s, about 20% of women who gave birth in hospital in a year died of this disease. However, of mothers that delivered their babies at home, only 1% died. This led to Semmelweis concluding that doctors themselves must be carrying the disease between patients. He mandated all doctors and nurses to scrub their hands with a nail brush and chlorine between patients. The death due to childbed fever reduced to 1% immediately. This was clear proof that he was right. 

However, even with this proof, Semmelweis really struggled to get his colleagues on board. In fact, many were offended and Semmelweis ended up being sacked! This was because of Semmelweis' approach. He would stand by the sink and "berate anyone who did not scrub or wash their hands". On the contrary, John Lister (another famous historical medical name), published a "much more respectful plea for antisepsis in surgery" in the Lancet (a British Medical Journal). In his book, Gwande discusses how "striking the difference is between the history of the operating room after Lister has been compared to that of the hospital ward after Semmelweis". He speaks the truth - consider an operating theatre where 100% compliance with scrubbing his only one intervention that occurs. Sterile gloves, gowns, masks, head caps, antiseptic wiping of the patient's skin - nearly every element of the operating theatre has been considered.

It is actually pretty crazy how even 140 years later this diligent approach to antisepsis in the operating theatre has not transferred to hospital wards. Well there are a few key reasons. The largest one is time. If for example, there are 20 patients on a ward and the team have to get round them within two hours on ward round. Washing hands would take up to a third of the staffing time. Moreover, washing hands that often commonly causes dermatitis - skin irritation. 

The introduction of antiseptic gel has been one of the greatest advancements, increasing complaint rates from about 40% to 70%. However, the most demoralising aspect of this statistic is that the rates of resistant bacteria such as MRSA (methicillin-resistant staph aureus) or VRE (vancomycin-resistant enterococcus) have not changed. This shows that the 30% of the time that doctors and nurses don't wash their hands is enough to maintain infection transmission. 

So what is the answer? If individual diligence cannot over come this then how what next? Diligence of the individuals in LEADERSHIP.

Gawande discusses how a surgeon, Jon Lloyd, came across a Save the Children programme used to reduce malnutrition in Vietnam. The programme discussed how getting outside sources to bring in solutions to villages with malnourished children failed time and time again. People were reluctant to change when simply told how to do so. Instead, the programme asked local villagers to identify what had helped bring about the best-nourished children. The villagers discovered that, of course, there were some well nourished children amongst them and found certain methods that these mothers were using that seemed to work. These ideas began to spread and took hold. 

Within two years malnutrition had dropped up to 85% in every village undertaking this programme.

This is referred to as "positive deviance". It works on the concept of building on capabilities people already have rather than simply telling them how to change. Lloyd decided to try this approach towards hospital infections. He held a series of 30 minute discussion groups with healthcare workers at every level: from food service to porters, nurses, doctors and even patients themselves. As Gawande discusses in detail, ideas began flowing. These people had been encouraged to use their own skills of innovation and creativity. When action was taken to solve the issues that had been discussed, the individuals that had brought up the problems took responsibility to ensure the action was carried out. The teams then began to carry out self surveillance. 

As these small group sessions were held they were very repetitive for Lloyd who was leading them - he wasn't learning anything new. But nevertheless he continued to hold them for every team. He realised that by empowering the teams, results would happen. And he was right.

"One year later, the entire hospital saw its MRSA wound infection rates drop to zero."

In conclusion, diligence is essential in a doctor. By using the first chapter of Gawande's book and the examples he uses regarding hand washing, we can see that diligence on an individual level is important. Individuals need to strive to 100% comply with washing their hands before and between patients. However, diligence as a team is required. Pushing for higher standards and working together to make this possible is required. That said, what I think is the most interesting consideration, is that diligence as leaders is essential. Leaders of healthcare systems need to realise that empowering change by listening to the opinion of those on the ground and actioning them, empowers the individuals and motivates the team.

In many ways, this parallels perfectly to the junior doctor contract dispute. As long as the healthcare team of doctors are pushed away, as long as they feel like nobody is listening to them and that their opinions are not valued, the more that the challenges facing medicine will put more and more pressure on the NHS. By listening to doctors and actioning what they are think are the solutions, real progress can be made. 

What is the most important quality of a doctor? Diligence is a good one to start with. 

Diligence as a school student to gain your place in medicine is also required. Keep updated on the blog about ways to prepare and to book your place on one of the Applican courses this summer go to www.applicancourses.com/book.