How You Become A Doctor, And Surgeon

By Gerrit Van Wyk.

Duck hunters.

I was trained in the British medical tradition. That means everyone must first become a family practitioner, do a family practice internship and practice as a family practitioner, before you can apply for a fellowship in a medical specialty. In North America, you go straight into a specialty, which, in theory, means family practice itself is a specialty.

The bar for entrance was a high enough high school grade, in other words, if you were smart enough, hardworking, and had the opportunity, anyone could become a doctor (it is more complicated than that in reality). Nowadays, in North America, you must pass a screening interview in which things like empathy, race, gender, disability, etc., also count, hence it is not enough to be just smart and hardworking. It assumes there is some sort of metric by which you can tell what a good doctor is, we know what that means, and you can project whether a candidate will become a good one, for which there is no evidence, which makes it problematic.

Towards the end of our undergraduate training, it became clearer who were likely to gravitate to which specialties based on their personality, aptitude, and interests, and, overall, it turned out that way. We all agreed one of us, who was very smart but lacked bedside manner and coordination, would become a pathologist, but he became a surgeon instead.

Not everyone can become a commercial airline pilot, you must complete a battery of personality and aptitude tests to determine if you will be a competent pilot, but everyone can become a surgeon. The only test is an interview with the head or heads of a department to determine whether you are likeable and will fit in, in other words, whether you are like one of us. Which is where things become complicated.

They tell a story of a group of doctors who went duck hunting. The flock first passed a psychiatrist, who saw these were ducks, but wondered: “do they experience themselves like ducks”, by which time it was too late. Next the ducks crossed an internist, who thought: “these look like ducks, but of course we’ll need to run tests to confirm that”, and the opportunity passed. When the ducks crossed a surgeon, he rapidly started firing until he had no more bullets, and as the ducks he shot started dropping on the ground, he turned to the pathologist and said: “just confirm these are ducks”. The point is, we know different specialties require different skill-sets, but there is no research telling us which they are, we pretend it doesn’t exist, the North American way of selection eliminates many of those types, and ending up in the wrong box can have disastrous results, as anyone who worked in medicine can attest.

David Kolb was interested in how we learn from experience, which became a staple in various forms at many management courses. Some color coded his 2×2 grid into yellows, who learn from experience by acting, greens, who use their imagination and feeling, reds, who problem solve and make decisions, and blues, who observe, think, and create abstract models. Which is where things become interesting.

There is preliminary evidence that about half of medical students are in the red column, which also represents most medical specialties, family practitioners tend to cluster in yellow, internists and psychiatrists yellow and green, and pathologists, blue. What that tells me, is there is differences in learning style, personality, aptitude, and life orientation between different specialty groups, but also that the way we currently select medical students may bias that somewhat towards problem solving types, and that may be one reason why more students migrate to the specialties as opposed to family practice.

As patients, how do we pick our doctors? What little research there is suggests people like doctors who are available, friendly, spends time with you, shows interest in you, listens to you, appears knowledgeable, and makes you feel comfortable, in other words, someone in the yellow or green category. Only around 8% of patients care whether they make an accurate diagnosis. The problem is those in the red and blue categories are not naturals on the emotional side, and many specialists are in the former column, which is where you want them to be. Some of the best surgeons I knew had the smallest practices because they weren’t universally liked, and some of the most liked with big practices were technically deficient and had poor outcomes.

How do family practitioners refer (I can’t find data for inter-specialist referral)? Things that matter are location, wait time, what the patient wants, the specialist you normally refer to, whether you like him or her, patients like them, and knowledge and skills. In other words, they pick someone like them. Competence doesn’t factor because the healthcare product is knowledge, and even physicians can’t tell with certainty who amongst them are competent and who not. I know of several instances where people practiced as physicians without being qualified; they received referrals from fellow physicians, and were well liked by their patients, which proves the point.

Someone once asked me how you identify a good doctor, and, without thinking, I started rattling off a list of desirable characteristics. I now know the answer is complex, and emerges from your perspective, are you a patient, nurse, physician, politician, etc., your needs, are you looking for a family doctor, psychiatrist, or surgeon for an acute problem, etc., and so on. The North American way of selection, and us as patients and the public, don’t take that into account.

I don’t know what color code commercial airline pilots are, and I pick on them because the World Health Organization compared them to surgeons, but I imagine when there is turbulence they don’t act on impulse (yellow), worry what the passengers are feeling (green), or try to form a theory of what is happening (blue), and I wouldn’t want them to.

The fact we don’t take these differences into account when selecting candidates for medical school or steering them into specialties is not a trivial matter. It is a crucial driver of medical outcomes. We need research on the subject, we need to select for the full variety of personality types, aptitudes, and learning styles, and match them to the fields where they will be most effective and efficient. Some may think I propose a form of eugenics, but human lives matter. We don’t call it that in selecting pilots, and, by eliminating a swathe of personality types and aptitudes, one may argue that is what the current selection process does.

I became a genitourinary surgeon, but only years later, at one of my leadership courses, discovered I’m a true blue. Like all blues, when things go wrong, I take it personally, which is unavoidable, because, as John Blandy said, surgeons not doing surgery don’t see problems. And, like blues, I obsessively kept records to reassure myself compared to my peers I was doing a decent job. Like all blues, the emotional side of human relationships never came naturally, I had to work at it, and I never excelled at being a fake yellow. Looking back over my career, I wonder if I could have been better at my profession and a more comfortable fit, had someone steered me into a different specialty better suited to my style fit early on.