Of all impaired physician issues, incompetence is the toughest to manage. The "dry lab" component of competence is obvious; required didactic certifications must be maintained, CME's must be completed, licenses must be active, minimum case numbers must be documented. The problem arises in the crucible of clinical practice. Like everything in life, physician competence resides on a continuum, from inspiring to notorious. Competence changes with time; sickness or senescence, improvement with experience or intercurrent training, and importantly, shifting standard of care. To make matters more difficult, competence can be contextual; I might be an outstanding neuro-vascular anesthesiologist, but weak with liver transplantation. So, how to judge?
The answer is outcomes. As in evidence based medicine, good outcomes are the proof of good practice. Competence is generally considered adequate from an institutional and leadership perspective if bad outcomes don't "fall out" in Quality Assurance activity. There are sentinel events (major complications) or patterns of lesser complications that serve to focus leadership scrutiny on the affected practitioner. Here is a situation where once again, insight is key.
An insightful, concerned practitioner will welcome other colleagues' suggestions and ideas, and the discussion that ensues as they jointly review the case will illuminate the affected practitioner's cognitive capacity with respect to the clinical situation at hand. A certain defensiveness is to be expected, but insight-impaired clinicians show a shocking inclination to point fingers rather than engage in introspection, which is obvious to even beginning physician leaders. Incidentally, I try to include as many junior leaders in these processes as possible; like everything else, medical staff leadership is a learned skill.
I have sometimes been asked by affected practitioners to review allegations against them at outside institutions. In most of those instances, it has been possible to define where the problem lies, and most usually, it involves mis-judgments in situations where the practitioner is over-reaching his experiential base. At some point in practice, judgment becomes primarily emotional. As a journeyman, I am not likely to get in trouble if I don't do procedures that make me uncomfortable or nervous-that may seem obvious, but anxiety and stress are common characteristics of the hospital environment, and ego (and professional fees!) can sometimes lead a clinician to stretch past his competence level. Too, in training, discomfort and anxiety are the rule, but that is a supervised situation. Once out in practice, these emotional cues are good signals that competence boundaries are being breached.
This is also true of aging practitioners. Most physicians' self image in large part revolves around their professional role; you can't be called "doctor" all your life and give it up easily. Complex cases which were once a journeyman clinician's daily fare become problematic for some aging doctors, as they lose touch with current practice and lose track of criticial details.On more than one occasion MECs with which I have been involved have gradually transitioned aging practitioners to retirement over years by progressively limiting the scope of their practice to less technically demanding cases, and to require consultant "participation" in their inpatient care.
Competence standards can shift seismically underneath the feet of an otherwise competent physician in two ways; first, technique can change, and second, higher level practitioners can enter the market. Two decades ago, the introduction of laparoscopic general surgical techniques resulted in stress for a whole generation of very senior surgeons, as they were progressively pushed to demonstrate competence in laparoscopy. Despite the obvious improvements in post-op pulmonary function and length of stay, a few surgeons held out for years rather than learn the techniques. One threatened to sue if his privileges to do open cholecystectomies were taken away; a difficult situation, since all general surgeons have privileges to do open "choles"; they just don't do them as first line surgical therapy. In the meantime, there were pockets of trusting patients who consented to, and underwent, elective open cholecystectomies and the relative increased morbidity, knowing no better. To make matters more confused, there was a transition time when having an experienced surgeon perform an open chole was probably preferable to having a recently trained surgeon perform his first or second lap chole. Aggravated docsurg has discussed competence and credentialing, and Sid Schwab frequently muses on these issues in the excellent Surgeonsblog as well.
Competence standards shift when new subspecialists move into town; thirty years ago, general surgeons displaced family practitioners in the operating room. Fifteen years ago, pediatric surgeons displaced general surgeons. (and pediatric and cardiac anesthesiologists displaced generalists) None of these transitions was accomplished gracefully. Kicking and screaming was the general rule, with the trump card being played by...the medical-legal system.
I am especially interested in National Transportation Board disaster investigations; even single pilot/single engine plane crashes rate a visit from an NTSB investigator to review and assess. I was raised as an anesthesia resident to use NTSB crash reports in a metaphorical way to inform anesthesia practice; I wonder why (besides cost) such oversight does not exist for true sentinel events in hospital care. Perhaps it is because they are considered to be individual errors; experience suggests otherwise; sentinel events almost always involve failures of the care system. Aggravated docsurg mildly disparaged the commercial air transport metaphor for the OR, but I'm not so sure the comparison is inapt, at least from the anesthesia end. Both involve complex systems and multiple participants, each of whom must do their job correctly and communicate effectively for the enterprise to be successful.
Amazingly, no regulatory oversight exists for hospital outcomes; we barely make outcomes publicly available so that the market can "decide." Having no oversight is like not investigating commercial aviation accidents, arguing that it should be up to consumers to simply not fly on United or Delta if they didn't think it was safe based on media reports! (which are not available anyway!) When I say there is no outcomes based regulatory oversight, I mean it; the Joint commission comes to make sure histories and physicals are signed, and that fire extinguishers are inspected, but a hospital could receive accreditation with a 30% surgical infection rate, as long as it was properly documented!
Psychiatric impairment is a knotty issue. While there is a legal requirement to accommodate persons with disabilities, I don't believe anybody (save the occasional affected practitioner) believes that this applies to accommodating behaviors that threaten patient well being. The question of when a psychiatrically afflicted practitioner is fit to practice is another matter. In my experience, a physician's personal therapist or psychiatrist is an advocate for his patient/client, and not the hospital and its patients. In these cases, I have always recommended that the hospital retain the services of paid outside consultants to evaluate and advise. (Likewise when there are only one or two qualified practitioners in a given specialty, and the question of competitive bias is raised) Sometimes the hospital administration has taken this advice; sometimes not. In my experience, when the hospitals don't do this, outcomes have not proven satisfactory (penny wise and pound foolish, I'd say.)
I have yet to cover administrative issues pertaining to affected practitioners; I'll do so in a near-future post.