The Bad Doctor

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No one goes into medicine hoping to be a bad doctor. No one even aims to be “just OK.” But not all of us will be the best. So, what makes a doctor “good?” And what condemns one as “bad?”

It can’t be grades because some of the most arrogant, least trusted physicians I’ve met were top of the class. It’s not strictly skills, either. I’ve been thanked profusely after admitting a mistake and received complaints minutes after saving a life.

Truthfully, I have no idea where I fall on the scale of good and bad. My identity as a physician swings wildly between extremes, rarely landing at “enough.” One minor patient complaint or a passing comment from a colleague can send my sense of self crumbling like a paper castle, only to be rebuilt with more paper…or whatever else brittle stuff ego is made of. And I’m far from alone.

But I didn’t write this newsletter to talk about doctors’ fragile egos.

Well, not quite.

Katie

When I sent my patient Katie to the ER for severe back pain, we were desperate. I’d tried for weeks to help her in our rural clinic, hoping to keep her out of the hospital. I called ahead, explained the urgency, and asked for an MRI and a neurosurgery consult, which I couldn’t access myself. But the ER doc’s tone told me he wasn’t convinced.

I had been Katie’s doctor for years, and she had never had back issues before. Now, she was in excruciating pain, with sudden leg weakness. Worried, after I sent Katie to the ER, I called her.

“Hi, Dr. Zha,” Jose, Katie’s husband, answered, “They sent us home.”

“Did they get the MRI or consult neurosurgery?” I asked.

“No…”

“Did you remind them I called?”

“Yes…but he kind of implied…um…” Jose trailed off. In the background, Katie groaned in pain.

“What did he say?” I had no idea what to expect, but I knew it wasn’t good.

“He said…basically…that you don’t know what you are doing. And that got Katie really upset, which aggravated her pain.”

I was stunned.

“But we told him you are a good doctor,” Jose added quickly, as if trying to patch something broken.

Inside me, the paper castle began to curl and smolder in the heat of anger, the wind of indignation, and the rain of self-doubt. Then, I heard Katie’s moans in the background again. This isn’t about me. At all. I reminded myself. And Katie’s expression of pain pulled me back to reality, one where the patient comes first, as they should.

“Jose, I’m sorry you had to hear that,” I said, “and thank you for standing up for me. But please don’t worry about it. It’s not your job to defend your doctor. Let’s focus on getting Katie what she needs.”

Tim

“The only thing that has worked for me is X, so my doctor’s been prescribing it to me,” my new patient, Tim, told me.

Tim’s record confirmed that he had indeed been on X for years. X was a good initial treatment for what Tim had, but it was not meant as a long-term solution. Most patients would have transitioned to Y long ago.

“How come—” I started to say, fully intending to question the clinical decision of keeping Tim on X for much longer than the gold standard.

“I love my doctor,” Tim interrupted, leaning forward, as if he knew what I was about to say, “he’s the only one who listens. I told him he’d better not retire anytime soon!”

But your doctor doesn’t know what he’s doing, were the words I wanted to say. But something told me to swallow them. I looked up curiously and saw Tim’s eyes, which radiated loyalty to his family physician, who had taken care of him for a long time. Who had made his patient feel heard from the start.

And now, it was my turn to listen and hear what was said: He is a good doctor.

And he was in every sense of the word. He listened to Tim’s concerns and treated Tim with X, which helped him tremendously. And he followed up to make sure Tim was doing well. And when X wasn’t enough, he referred Tim to me so I could prescribe Y. Even though the “standard” was not followed, no harm had been done.

Quite the opposite, actually.

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The Good Medicine

When the ER doctor doubted me, Katie and Jose rushed to defend me. But their defense came at a cost. Katie, already in pain, was made to carry the emotional burden of protecting her therapeutic relationship with her doctor. And that is not a burden any patient should bear.

We are not the only ones building paper castles. Our patients construct an image of who we are, too — one built on trust, mutual respect, and above all, one that is the foundation for healing.

Research consistently shows that a better therapeutic relationship, characterized by trust, respect, and empathy, leads to improved health outcomes. The more patients trust their doctors, the better they feel, both physically and mentally. With the exact same treatment, patients who like their clinicians have lower blood pressures, less pain, and better health status overall.

And I suspect the opposite is true, too: break that relationship, and patients suffer, even if the treatment is perfect.

Remember how Katie’s pain worsened while having to defend me? And imagine, would Tim continue to benefit from X treatment if I had shaken his trust in his doctor? Or, worse, would Tim accept or get better with Y, aka, the gold standard, if I never gained his trust by doing what the ER doctor did to Katie?

I think we already know the answers.

In other words, a good doctor (according to patients) is good medicine (with or without a prescription). Clinical standards matter, but the patient’s standard is gold.

The Bad Medicine

So, why are we so quick to smear one another, insisting we’re the only ones who know what we are doing?

Because medicine has long been built on a culture of shame and blame. From the first day of training, we’re taught that uncertainty is weakness, and that doing anything less than everything is laziness. The implicit message is clear: to be a good doctor, you must know more, do more, give more, and never admit you don’t.

In this relentless grind, the paper castle of who we are collapses and reinvents itself, over and over, each time bigger and stronger than the one before. Only it’s still made of paper, overtaken the next time we are publicly shamed or quietly humiliated for not knowing what we are doing.

Gradually, we learn to sustain an unsustainable construction by pointing fingers. We call other clinicians careless, clueless, or not thorough enough. By making others look small, we can look big. In reality, no one does it all. And no one knows nearly enough. “I don’t know” shouldn’t be an admission of failure, but an invitation that opens doors for “tell me more” and “let’s learn,” so that curiosity and humility can become the cornerstones of our professional identities.

This blame reflex bleeds into patient care. We blame patients for being too sick, for not being sick enough, for showing up too late or too often. While in reality, we hide behind labels so we don’t have to confront our own discomfort: the patient is difficult, noncompliant, poor historian, ob*se, drug-seeking, etc. We forget that the gold standard doesn’t fit everyone, and the textbook doesn’t represent all. The textbook was written with certain bodies in mind, and for many people, especially those with rare diseases, complex trauma, or identities medicine has long ignored, it hasn’t been written at all.

So here is a radical idea: when we undermine a patient’s trust in another clinician, we don’t become more trustworthy, we just leave them in the wreckage of a relationship that once held the potential to heal. When we blame patients for their suffering, we don’t become more competent, we become participants in medical gaslighting.

Sure, our paper castle might still be standing. But it stands alone. And it sways in the storm.

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“Your doctor sounds pretty awesome,” I said to Tim, softening my tone, “I hope he doesn’t retire anytime soon, either. I’d love to share more patients with him. And I have a treatment I think will help a lot, too. Want to hear about it?”

Tim smiled warmly, finally settling back into his chair.

Later, I wrote a note to his doctor: Thank you for the referral. This patient really trusts you.

A few months went by. Tim’s symptoms improved significantly on Y. His doctor forwarded me the follow-up note and wrote one word in response: Teamwork!

A team of two bad doctors practicing the kind of medicine that heals, it was.

Paper castles and all.

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Disclaimer: All patient stories have been significantly altered to protect the privacy of individuals involved. Identifying details related to patients and staff have been changed. This newsletter is not intended as medical advice and does not represent the views of my employer.

*In solidarity with Size Acceptance activists such as Ragen Chastain, the term “obese” is written with an asterisk to protest its stigmatizing and dehumanizing usage in medical discourse.