June 1988 IX/10
PHYSICIAN COMPETENCY: WHOSE RESPONSIBILITY?
A few weeks ago a conference entitled "Physician Competency: Whose Responsibility?" was held in Houston, Texas. The fact that three prestigious groups, the AHA, the AMA, and the Association of American Medical Colleges sponsored the conference, indicates that physician competency is a serious issue. Because the conference seemed to focus upon educational methods and federal monitoring of physician activity, there were few useful conclusions. Yet the question is vitally important. What is physician competency and who is responsible for it?
Principles
In order to evaluate competency, one must have a clear concept of the purpose of the endeavor to be evaluated. What is the purpose of being a physician? Medicine aims at maintaining human health and preventing illness and disease. While medicine is directly concerned with the physiological and psychological functions of the human person, it never abstracts from the social and spiritual functions of the person. Rather, it orders the healing and restoration of the physiological functions in accord with the patient's social and spiritual values. Of course, the competent physician does not make decisions about the patient's social and spiritual values, those decisions pertain to the person/patient. But insofar as making decisions about the physiological and psychological functions of the patient are concerned, the physician retains a responsibility which is not shared with the patient. The physician is not the slave of the patient, but rather a co-worker, supplying a very important service which enables the patient to strive more adequately for an integral experience of humanity. From this concept of the purpose of medicine an important corollary follows:
Medicine of its very nature is a moral enterprise. That is, because of the intimate relationship which medicine has to the value area of the patient's life, the social and spiritual function, the physician must be consistently concerned with the morality of his or her actions: Is what I am doing morally good for this person? Clearly, the patient or proxy must be heard before the physician reaches a conclusion in this regard.
Discussion
Given this short exposition of the purpose of medicine, who is responsible for developing the competencies which enable the physician to perform aptly the profession of medicine? First and foremost, the physician himself or herself is responsible. Being a professional is different than being a technician. A technician can be trained and tested to perform a mechanical task. Teaching a person to be a plumber or an electrician involves a definite body of information and a definite set of procedures to apply the information. Moreover, the testing of the competency of a plumber or an electrician is rather easy: Does the faucet work! Does the light go on! Insofar as the profession of medicine is concerned, however, the preparation and evaluation is much more complex. There is a definite body of knowledge concerning health disease, and illness which must be acquired by the physician, but the application of this knowledge will vary from patient to patient. Even if the knowledge is applied accurately, there is no guarantee that the technical results will be successful: No one lives forever. Moreover, the competent physician will assure that the social and spiritual values of the patient are respected and govern the application of the knowledge proper to the medical profession. To put it another way, competency in medicine requires not only knowledge and the ability to apply it but also the capacity to "get inside" the person being cared for: To know the patient's value system. This ability cannot be taught in the way one is taught plumbing or electricity. Rather, medicine requires personal dedication to helping people to a better life. It demands respect for persons, empathy and compassion; competencies which develop over time and as a result of personal dedication to the goals of medicine. Clearly, physician competency requires affective as well as intellectual development.
Because no one becomes an accomplished professional as a result of solitary endeavor, the various medical communities are also responsible for developing competency within their members. Because achieving and maintaining competency is a life-long endeavor, medical communities are necessary at all stages of professional life. Thus a medical school will have responsibility to help individuals develop the initial view of the medical profession and to acquire the basic knowledge necessary for fulfilling the purpose of the profession. Equally important are the attitudes and effective dispositions which are an integral part of medical competency which should also be initiated in these formative years, Thus, the importance of having role models of total medical competency as members of the medical communities engaged in initial formation of physicians.
The various medical societies within the medical profession (e.g., internal medicine, surgery, obstetrics/gynecology) should realize that their goals are to help members to develop overall competency, not merely to keep members up to date on latest scientific knowledge or state of the art equipment. The convention agendas of various speciality groups might be analyzed with this more integral responsibility in mind.
Even if individuals assume responsibility for their professional development and even if the various medical societies are conscious of their responsibility to enable members to develop the necessary attitudes and knowledge, evaluation of competency will still be required. Accountability is an integral factor in developing competency. To date, most evaluations of physician competency has been by physicians, The argument is offered that "lay people don't know enough about medicine to evaluate physicians." Current dissatisfaction with this system, however, has led the federal and state governments to intervene in evaluation as the aforementioned conference reported. If the purpose of medicine set forth above has merit, it seems that evaluation should be offered by boards composed of both physicians and "lay people." The purpose of medicine is not speculative; it is practical and practical results require an analysis of the people who are affected by those results. Once again, the board composed of physicians and "lay people" will be interested in evaluating more than speculative knowledge. It will also have the challenge of determining whether the social end spiritual goals of the patient were prominent in the formation of practical medical decisions. No small order, this.
Conclusion
While some may challenge the foregoing concept of medical competency and the plan to evaluate it, let us realize that concepts of competency offered in the recent past have proven inadequate, as have the methods utilized to evaluate competency. Otherwise prestigious societies would not be sponsoring a conference entitled "Physician Competency. Whose Responsibility?"
Kevin O'Rourke, OP
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