Article Text

Original research
What are the characteristics of excellent physicians and residents in the clinical workplace? A systematic review
  1. Abdullah Khawar1,2,
  2. Femke Frederiks1,
  3. Mana Nasori1,2,
  4. Marianne Mak1,3,
  5. Mechteld Visser1,2,
  6. Faridi van Etten-Jamaludin4,
  7. Agnes Diemers5,
  8. Nynke Van Dijk1,2,6
  1. 1Department of General Practice, Amsterdam UMC, Locatie AMC, Amsterdam, the Netherlands
  2. 2Amsterdam Public Health, Personalized Medicine and Quality of Care, Amsterdam, the Netherlands
  3. 3Amsterdam Public Health, Personalized Medicine and Methodology, Amsterdam, the Netherlands
  4. 4Research Support; Medical Library, Amsterdam UMC, Amsterdam, the Netherlands
  5. 5Faculty of Medical Sciences, Lifelong learning, Education & Assessment Research Network (LEARN), University Medical Centre Groningen, Groningen, Netherlands
  6. 6Amsterdam University of Applied Sciences, Faculty of Health and Faculty of Sports and Nutrition, Center of Expertise Urban Vitality, Amsterdam, Netherlands
  1. Correspondence to Abdullah Khawar; a.a.j.khawar{at}amsterdamumc.nl

Abstract

Objectives In order to recognise and facilitate the development of excellent medical doctors (physicians and residents), it is important to first identify the characteristics of excellence. Failure to recognising excellence causes loss of talent, loss of role models and it lowers work ethos. This causes less than excellent patient care and lack of commitment to improve the healthcare system.

Design Systematic review performed according to the Association for Medical Education in Europe guideline.

Information sources We searched Medline, Embase, Psycinfo, ERIC and CINAHL until 14 March 2022.

Eligibility criteria We included original studies describing characteristics of excellent medical doctors, using a broad approach as to what is considered excellence. Assuming that excellence will be viewed differently depending on the interplay, and that different perspectives (peers, supervisors and patients) will add to a complete picture of the excellent medical doctor, we did not limit this review to a specific perspective.

Data extraction and synthesis Data extraction and quality assessment were performed independently by two researchers. We used the Quality Assessment Tool for Different Designs for quality assessment.

Results Eleven articles were eligible and described the characteristics from different perspectives: (1) physicians on physicians, (2) physicians on residents, (3) patients on physicians and (4) mixed group (diverse sample of participants on physicians). The included studies showed a wide range of characteristics, which could be grouped into competencies (communication, professionalism and knowledge), motivation (directed to learning and to patient care) and personality (flexibility, empathy).

Conclusions In order to define excellence of medical doctors three clusters seem important: competence, motivation and personality. This is in line with Renzulli’s model of gifted behaviour. Our work adds to this model by specifying the content of these clusters, and as such provides a basis for definition and recognition of medical excellence.

  • education & training (see medical education & training)
  • medical education & training
  • human resource management

Data availability statement

Data are available upon reasonable request. All necessary data are provided in this manuscript or available in the supplementary data.

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This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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Strengths and limitations of this study

  • Inclusion of studies with multiple designs and different perspectives to give a complete view on characteristics of excellence in medical doctors.

  • Renzulli’s model of giftedness appears to be a suitable framework for our results using an existing model of giftedness.

  • The term ‘excellence’ has a wide semantic variance, and as a result, excellence can be differently expressed by different individuals, and assessors may assign different gradients or thresholds to it.

Introduction

Some medical doctors (physicians and residents) are identified as being excellent by their peers, supervisors, teachers or patients. Studying these excellent medical doctors is important as it can help in recognising and suitably challenging them throughout their professional development. Failure to recognise excellence is known to cause low morale and prestige among clinicians, suboptimal clinical care, loss of talented clinicians, lack of commitment to improve patient care systems and fewer excellent clinician role models to inspire others.1 Knowing how excellence is characterised, supervisors and teachers could promote the development of excellent medical doctors, for example, by optimising their learning strategies using the characteristics of excellence.

There is no explicit definition of an ‘excellent doctor’ in the literature.2 3 The existing theories on excellence seem primarily aimed at describing excellent (or ‘gifted’) children and young adolescents.4 5 Although these theories seem broadly applicable, we do not know whether they also apply to the medical field. However, these models indicate there is more to ‘being excellent’, as excellence depends on ‘above average ability’, ‘creativity’ and ‘task commitment’ according to Renzulli. Therefore, as a first step to define excellence of medical doctors, we performed a systematic review to identify characteristics of excellence of medical. Assuming that, excellence may be viewed differently depending on the interplay one has with the clinician, and that these different perspectives will add to a complete picture of the excellent clinician, we included different perspectives in this review. We aimed to identify building blocks for a definition on excellence of medical doctors.

Methods

This systematic review was performed according to the Association for Medical Education in Europe (AMEE) guide to approach systematic reviews and was aligned to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 checklist.6 7 This review was not registered prior to its start. However, the protocol is available as a supplementary document (see online supplemental appendix 1).

Data sources and searches

We searched Medline (Ovid), Embase (Ovid), Psycinfo (Ovid), ERIC (Ovid) and CINAHL (Ebscohost) for possible eligible studies from the earliest available date for each database. The search strategy was developed in collaboration with an information specialist (FvE-J) and was conducted on 14 March 2022. For the search strategy per database see online supplemental appendix 2.

Terminology

We consider the term ‘medical doctors’ to encompass ‘physicians’ and ‘residents’. Physicians are all who ‘are qualified by education and authorised by law to practice medicine’.8 Residents, or postgraduate medical trainees, are those who finished medical school, obtained their undergraduate medical degree and practice medicine in any setting (eg, a hospital or primary care setting).9

We did not use a definition of excellence, and instead chose to search broadly in the literature.

Study selection

No restrictions were applied concerning publication date, language or geography. Eligibility criteria are listed in table 1.

Table 1

Inclusion and exclusion criteria

After deduplication, the studies were uploaded in Rayyan for title and abstract screening,10 by two independent teams (FF/NVD and AK/MN) labelling each article as either ‘include’, ‘exclude’ or ‘undecided’. Results were discussed within the two teams. If disagreements in judgement persisted, a third reviewer was consulted. Articles still labelled as ‘undecided’ would proceed for full text screening. Full texts were obtained to decide on final inclusion. Again, the full texts were screened by two teams (FF/AD/MV and AK/MM) following the same aforementioned procedure.

Data extraction, quality assessment and synthesis

Data extraction was performed by two researchers (FF and AK), using a coding sheet designed for this systematic review, including: (1) author, year, (2) study design, (3) country of origin, (4) participants (specialism), (5) research sample, (6) perspective and (7) characteristics of excellence (see table 2).

Table 2

General characteristics and data extraction

Two researchers (AK and MM) independently assessed the quality of the included studies using the Quality Assessment Tool for Different Designs (QATSDD).11 This tool can be used appraising diverse study designs.12 It contains a total of 16 items rated on a 4-point scale (0–3) ranging from a total of 0 to 42 for qualitative or quantitative studies, and from 0 to 48 for mixed-methods design. Disagreements were discussed, and if necessary a third reviewer (MV) was consulted.

We produced a synthesis of the characteristics of excellent medical doctors from different perspectives (table 2). This process was iterative and included continuous discussions within our research group. We decided to present the characteristics that stood out most in our results and provide all other characteristics extracted from the studies in table 2.

Patient and public involvement

No patient involvement.

Results

The search yielded 7135 articles: 29 were identified as relevant after initial screening of titles and abstracts and 11 were included after reviewing the full texts (figure 1).13–23 The included articles were published between 2004 and 2017 with different designs (survey, interview, Delphi method) and from different countries (table 2). We found four different perspectives on excellent medical doctors; (1) physicians on physicians,13–17 (2) physicians on residents,18–20 (3) patients on physicians21 22 and (4) mixed group (diverse sample of participants on physicians).23 We will describe the characteristics per perspective. The mean QATSDD scores for qualitative studies were 29.8/42,13 15–20 22 23 for the quantitative study 25/4221 and for the mixed-method study 35/48.14 Studies scored low (0 or 1 point) on ‘explicit theoretical framework’,13 15 16 18–22 ‘sample size considered in terms of analysis’14 16 19 22 23 and ‘user involvement in design’13 16–23 (online supplemental appendix 3).

Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of systematic review selection process.

Many studies described excellence through competencies. And some of these competencies were mentioned across all included studies. We considered some competencies mentioned by the different studies, for example ‘Patient communication’18 and ‘communicating effectively’17 as the same and placed them under the umbrella of ‘Communication’ according to the CanMEDS framework. In table 2 we provide all data extracted per study.

Physicians on physicians

Christmas et al,13 Mahant et al15 and Kotwal et al17 interviewed physicians who were identified by their peers as being excellent, to identify their characteristics. Eva et al14 distributed a survey with closed and open-ended questions to identify characteristics of outstanding practitioners. Sprung et al16 administered a survey in different parts of the world, and subsequently ranked the identified attributes of excellent practitioners.

All studies mentioned competencies as an important characteristic of excellence. The most prominent competencies described in the aforementioned studies were knowledge,13 14 16 17 communication,13 16 17 professionalism13 16 17 and leadership skills.13 15 16 Less prominently mentioned competencies were related to research (research success14 or research skills,16 and scholarship or scholarly approach13 15), being an outstanding teacher16 and reputation among peers.13 All articles mentioned a form of motivation (eg, high level of intrinsic motivation,15 dedication,14 commitment16 17 and enthusiasm16) as a characteristic of excellence. Besides motivation in general, motivation to learn was specifically mentioned (committed to continued growth and development17) as well as motivation for patient care (passion for clinical medicine13 and passion for patient care15). Mahant et al15 and Sprung16 et al also mentioned personality characteristics related to excellence: humility,15 flexibility15 and empathy.16

Physicians on residents

Ginsburg et al18 interviewed 19 experienced physicians to identify characteristics of excellent residents. Regehr et al19 created 16 narrative profiles, based on the interviews conducted by Ginsburg et al,18 and subsequently rated them in multiple phases. The final ranking showed two profiles (profile A and H) categorised as ‘outstanding/excellent/exemplary’. Oerlemans et al20 conducted interviews with supervisors to identify consistent behaviours of trainees during consultations. Their aim was to develop a framework to describe narrative profiles of perceived behavioural patterns in excellent and underperforming General Practice trainees, to guide future learning and assessment of clinical performance. Two dimensions emerged from these interviews: (1) ‘doctor–patient interaction’ and (2) ‘medical expertise’.

Competencies such as communication,18–20 knowledge,18–20 professionalism18–20 and leadership18 were important in order to be considered as an excellent resident. Residents were also considered excellent based on their personality characteristics: impact on staff (how the resident affected the staff supervisor, sense of humour and a resident who is fun to work with),18 a warm personality or exudes warmth19 and possesses a great deal of empathy.20 Physicians also mentioned characteristics related to motivation, such as work ethics,18 genuine interest,20 appearing excited19 20 and enthusiastic.19 Finally, we found aspects related to motivation to learn such as ‘wants to develop his/her understanding of what is going on’,19 being inquisitive20 and being curious.19 20

Patients on physicians

Schattner et al21 asked hospitalised and day clinic patients to select those attributes from a list that they considered the most important and most wanted to see in their own physician. In a qualitative study by Anderson et al,22 almost 3000 patients rated their physician on several dimensions of healthcare experiences and provided specific comments about aspects of care that were excellent or most in need of improvement.

Both studies mentioned competencies as important characteristics of excellent physicians: medical expert (being an experienced physician21 and up-to-date21) and professionalism (physician’s attentiveness,21 communication,21 22 demeanour,22 being truthful,21 respecting patients preferences21 and being patient21). Schattner et al21 also specifically mentioned behaviour related to organising care and characteristics of excellence (access, follow-up, referrals and care continuity).

Mixed group (diverse sample of participants on physicians)

Based on a two-round modified Delphi study with medical consultants and trainees, Smith et al described a ranking list of characteristics of an excellent anaesthetist.23 They identified characteristics of excellent medical doctors related to competencies (clinical skills, knowledge, good communication, show leadership, good judgement) and personality characteristics (being liked, respected, flexible, innovative and original).23 Finally, the authors mentioned motivation, such as a ‘can do’ attitude, and striving for excellence.

Discussion

The aim of this systematic review was to identify building blocks for a definition of excellence in medical doctors. The included studies showed a wide range of characteristics of excellent physicians from four different perspectives. Irrespective of the perspective, characteristics related to competencies were mentioned (medical knowledge,13–17 19–23 communication13–20 22 23 and professionalism13 16 19). Also, according to the reviewed studies, excellent physicians are motivated, as they are engaged,15 committed16 and enthusiastic.16 Specifically, we found two aspects related to motivation, namely motivation to learn (being able to continuously reflect on the practice of medicine with efforts to improve clinical care13 15 17 20 and having a high intrinsic motivation15) and motivation related to patient care (passion for clinical medicine13 and for patient care15). Also, our results indicate that personality characteristics seem important, such as humility,15 being empathic,16 19 20 having a sense of humour19 and being flexible.15 20 23

Our findings feature building blocks for a definition of excellence. Many models exist for defining excellence,5 24 25 of which Renzulli’s is most prominently used.24 However, these models were directed at defining excellence or gifted behaviour in children. Renzulli defines giftedness, or rather gifted behaviour, as the outcome of the interaction between three clusters of traits: (1) above average abilities, (2) task commitment and (3) creativity. The first cluster is ‘above average ability’. Within this first cluster Renzulli distinguishes general abilities (process information, integrate experiences and abstract thinking) and specific abilities (acquire knowledge or perform in an activity). The second cluster is ‘task commitment’, which he defines as a motivational energy including perseverance, endurance, hard work, self-confidence, perceptiveness and special fascination for a subject. The last cluster is ‘creativity’, which means fluency, flexibility, originality of thought, openness to experience, sensitivity to stimulations and willingness to take risks. Our findings indicate three clusters of excellence, namely competencies, motivation and personality characteristics, thus our findings have common ground with Renzulli’s model.15 20 23 Additionally, our results seem to be an extension and specification of Renzulli’s model, by giving a focused direction towards defining excellence in the medical field. The first cluster, ‘competencies in the medical field’ is often described using the CanMEDS framework.26 We did not find new elements or competencies to add to the CanMEDS framework concerning excellent physicians and residents. Our findings show that all competencies were mentioned at least in one of the perspectives. However, some competencies were mentioned most across all studies, and it seems these are considered important competencies belonging to excellent physicians and residents, these included medical knowledge, communication and professionalism. Also leadership (the leader), scientific quality (the innovator) and organisational qualities (the collaborator) were mentioned across different studies. From our data, however, it does not become clear to what extent one has to perform within a certain competency, in order to be considered excellent. Only Oerlemans et al,20 who studied trainees, mentioned that there should be room for growth within competencies. We also found motivation in general (engaged,15 committed16 and enthusiastic16), and motivation specifically related to learning (eg, being able to continuously reflect on their practice of medicine with efforts to improve clinical care13 15 17 20) and related to patient care (eg, passion for clinical medicine13). Lastly, also flexibility was recurrently named as a characteristic in the included studies and we also found that medical doctors are judged based on other personality characteristics of which empathy and flexibility15 20 23 seems a particular interesting one related to patient care. We found personality characteristics, motivation to learn and motivation for patient care. Motivation to learn is an important characteristic in the medical field, as physicians undertake life-long learning activities, also known as continuous professional development, in order to maintain, update or develop their knowledge, skills and attitudes in everyday clinical practice.27

Perspectives on excellent medical doctors

There are similarities between the four different perspectives. Patients and physicians both value medical expertise, communication and professionalism. This finding is in line with previous research performed by Price et al,28 who showed that several qualities such as clinical judgement, being up-to date, communication and professionalism were mentioned by medical and non-medical respondents. There are, however, also differences between the perspectives, as patients mentioned only organisational skills, while physicians also mentioned leadership, scientific qualities and teachings skills to judge the excellence of other physicians. Furthermore, physicians mentioned motivation to learn (eg, reflection on clinical practice, scholarship, engagement and commitment to continued growth and development), which was not mentioned by patients. Another difference between the patient and physician perspective is that medical specialists considered residents to be excellent based on their impact on staff (how the resident affected the staff supervisor, sense of humour, being fun to work with)18 and their warm personality. These differences arise because it can be argued that one is only able to recognise and mention characteristics of excellence that are visible from one’s position. Thus, when trying to identify excellent professionals, opinions should be sought from multiple stakeholders as different assessors can identify different characteristics and contribute to a holistic view.

Strength and limitations

The strength of our review is the inclusion of studies with multiple designs and different perspectives to give a complete view on excellence in medical doctors. Furthermore, we tried to explain our finding by using an existing model of excellence. However, this review also has limitations.

The term ‘excellence’ has a wide semantic variance and as a result excellence can be differently expressed by different individuals, and assessors may assign different gradients or thresholds to it. Because of the wide semantic variance, we may have missed articles in our review. Also because of the wide semantic variance, some of the articles found through the search described clinical excellence as an outcome related to patient care, rather than excellence related to the performance of a physician. While this could be a limitation, in view of our broad search strategy, however, we consider this unlikely. It is remarkable, however, that we did not find studies from the nursing perspective. As multiple perspectives can identify different characteristics and contribute to holistic view on excellence. Another limitation of this study is the variable quality of the included studies. Two studies had less than half of the total amount of points on the QATSDD. Even though we found many characteristics attributed to excellence, from this work it does not become clear to what extent a physician should perform within a certain characteristic. For instance, within a competency, whether it is sufficient to be above average, good or really excellent. Neither is it clear if you should possess all competencies to a high extent or if a selection would be sufficient. This also applies to the other characteristics, and asks for further research. Finally, we did not look at the grey literature in this systematic review.

Recommendations and future research

Our work indicates that excellence of medical doctors is related to competencies, motivation and personality. Interestingly, a few of the included studies mentioned motivation to learn when describing excellent medical doctors. Perhaps, excellent medical doctors may be more adapted to optimally benefit from the clinical workplace as learning environment29 and also engage in deliberate training for practice,30 thus being ‘active learners’. Future research should shed light on the learning characteristics and (environmental) preconditions of excellence, which might result in the development of methods for optimising learning in the clinical setting, talent recognition and facilitate the development of excellent physicians. This understanding might give us insight in the barriers and facilitators of talent development, for those who do possess certain talent(s), but have not yet been stimulated to further develop it. Also, studying to what extent a medical doctor should perform within a certain competency and whether some competencies are more important than others, seems an interesting aspect for further research. Finally, future research should shed light on which didactical improvements and possible recommendations for training excellent medical doctors are suitable, in order to help supervisors (teachers and trainers) to suitably challenging excellent medical doctors in their professional development.

Conclusion

We tentatively conclude that in order to define excellence of medical doctors, the competencies ‘knowledge’, ‘communication’ and ‘professionalism’ are crucial. Furthermore, motivation related to patient care and learning, with an emphasis on motivation to learn as physicians engage in life-long learning activities. Also, personality characteristics seem important, such as flexibility and empathy. These findings are in line with Renzulli’s ‘three-ring model of giftedness’ and add to his work by specifying it for the excellent medical doctors. By providing building blocks for a definition of excellence we took a step towards talent recognition and facilitating the development of excellent physicians.

Data availability statement

Data are available upon reasonable request. All necessary data are provided in this manuscript or available in the supplementary data.

Ethics statements

Patient consent for publication

References

Supplementary materials

Footnotes

  • Contributors AK, FF, MV, AD and NvD designed the study. FvE-J developed and performed the search. AK, FF, NvD, ADD, MN and MM screened the search results. AK, FF, NvD and MN extracted the data. AK and MM assessed the quality of the articles. AK drafted the manuscript with input from FF, MM, MV, AD and NvD. All authors critically assessed and contributed to the manuscript revisions, approved this version of the manuscript to be submitted for publication and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work is appropriately investigated and resolved. NvD is guarantor for the content of this systematic review.

  • Funding This work is funded by ZonMw grant number 839130008.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.