Tag: competency

Medical Competency: An Unfortunate Truth

There is an unspoken truth throughout the medical field. It affects every specialty of medicine along with every hospital; nowhere is immune. This truth? It’s that not all doctors are competent.

“What?! But they passed boards! They went to school! They are supposed to be smart! How do you know which one? OMG should I go naturopathic?”

It is a fact that every practicing physician in the United States has completed the conditioning program known as medical school, jumped through the hoops known as their “Steps”, managed through their existential crisis known as residency, and then topped it off with their boards to finally reach the status of full-fledged pill dispenser / knife jockey. It is also true that all of these people are undoubtedly smarter than your high school friends who were unable to read a paragraph aloud in under five minutes. But none of this equates to that physician being competent.

“So why are they incompetent?”

Well, I’m glad you asked, voice-in-my-head. Let me try to explain.

Lack of Appeal

First and foremost, one of the biggest issues with maintaining a competent physician work force is to recruit people who are actually capable of being competent. It is an understatement to say that the medical profession has an “image problem”. Physician suicide remains high, the reasons for which remain vast and ever-increasing, satisfaction with career choice is poor, and the large majority of our time consists of paperwork and other bureaucratic bullshit. I remember when I was a pre-med student and shadowing a family physician in my home town. I remember, in between his morning and afternoon clinic blocks, him rushing to eat lunch in his office, checking his own blood pressure, and asking me if I really wanted to pursue a career in the slow-death known as the medical profession. I remember answering in the affirmative, willfully ignorant to the obvious, and naively hopeful that not all of medicine was like this. The joke was on me, I guess. I know for a fact that many, if not the majority of, physicians would not recommend going down this road. Many of our recommendations go unheeded, often for the same reasons we ignored prior pleas, but I get the sense that is changing.

Despite the ever-increasing number of boxes that require checking and hoops necessitating jumping for medical school admissions, I would wager that the overall quality of medical student is degrading. I do not mean that the scores are dropping or the academic focus is fading. In fact, I would argue that the requirements for medical school continue to become more stringent. But I would argue that the “well-balanced” medical student is becoming a thing of the past. At least anecdotally, I have noticed that the ability for critical thinking, deductive reasoning, intellectual flexibility, conversational fluency, perspective, and the ability to “read” people have been severely deficient in many medical students. Conditioned to be nothing more than high-scoring automatons willing to consume and regurgitate specific sets of data repeatedly over a span of years, I understand how their other faculties could suffer. But it also seems that most medical schools are purposefully selecting for those individuals who are most adept at generating high board scores usually at the cost of social intelligence. To put it into primetime TV terms, medical schools are searching for The Good Doctor .

“But The Good Doctor is super smart and saves people all the time! He’s like so amazing!”

Sure, if I ever had a TV-medical problem I may be inclined to put him on the case since House is no longer available. But this is not TV. Medicine is rarely curative and I am willing to bet you would be unable to last ten minutes conversing with someone of similar social deficiencies before clawing your eyes out. Furthermore, the intellectual rigidity most often associated with the real-life proxies of The Good Doctor make them at best questionably hygienic encyclopedias. But, if medical school admission committees get their way, you may have no other choice. Everyone else, equally intelligent but able to maintain eye contact, has already heeded the advice of their depressed and possibly medicated predecessors and veered away from the medical profession.

Lack of Thought

There appears to be a paucity of critical thinking throughout the medical profession. To be clear, research is still on-going, new treatments for diseases (primarily cancer) are being manufactured, and academia is still thriving. But all of that is largely irrelevant to the patient sitting in the waiting room; the big question is whether or not your clinician is still capable of critical thought.

There is a lot to know in medicine these days. And outside of “The Good Doctor” and “Dr. House”, it is unlikely that any physician will know it all. And even if they did, it would be irrelevant within five years. With this deluge of knowledge, the cult of Evidence-Based Medicine (EBM) was conjured forth into existence. Like all cults, EBM promised real answers to troubling questions; it promised to apply scientific knowledge (trial data) to the problems of our times in order to ascertain the best treatment option. No longer would we need to live in the dark ages of “expert opinion”; we were bound for enlightenment! But sadly, like most cults, it generated more confusion than clarity and focused on control of information but without the benefit of crazy sex parties.

Through the utilization of EBM, hundreds if not thousands of guidelines were generated spanning nearly every medical problem in existence scattered throughout hundreds of different journals and medical societies. What once was supposed to serve as a guideline for practitioners, presumably based off trial data (but more often still based off expert opinion), slowly morphed into a mandatory “standard of care”. Never mind the fact that not all trials study all patients afflicted with a specific disease. If you have Disease A then you better get treatment X or risk possible malpractice. Praise be to EBM!

I imagine it was this development, along with several others, that led to further specialist referrals. Problems that once may have been managed by a primary care doctor were now referred out because it was impossible to keep up with the ever-changing recommendations by the “Powers-That-Be” for each group of specialists.

Following this even further, the only way to effectively treat a patient now would to become a specialist. Yeah, you could still work in primary care, but no one wants to do that anymore. It’s way too much work. Instead, you should specialize and get the privilege of focusing on a specific area of the body. However, now that specific area of the body has about ten different medical advisory groups, each focused on their unique disease, and each with their own body of recommendations which can span hundreds of pages long. Shit. What do? I know! Sub-specialize! Now you can focus primarily on diseases affecting the lower third left ventricle of the heart, be an expert on relevant recommendations, and never have to concern yourself with anything involving any other part of the body! And the best part? Templated notes ensuring that you never miss any detail needed for patient questioning or billing purposes.

This is why many Americans have the luxury of seeing eight different specialist a year for a handful of different problems, each specialist prescribing their own treatments, each specialist providing their own recommendations, and each specialist wholly ignorant to the workings of their colleagues. Occasionally, the primary care provider may be able to intervene, if they have the capabilities of doing so. But for the most part, the wheels of the machine continue to turn unabated until an inevitable complication lands the patient into the hospital. This allows the patient to see all of their specialists at once for a fun Battle Royale of competing ideas. Although each specialist is likely well-versed in their specific field, they have willfully abjugated themselves from the whole of medicine. Generalized competency is lost and so is the patient. But those boxes are checked!

Lack of Control

If it has not become obvious by now, physicians appear to have far less control over their occupation than they did in the past. As mentioned already, most of their work revolves around glorified secretarial work in order to prove their worth to their respective M.B.A overlords whose job is to quantify productivity and exert bureaucratic control. This is not to say that we do not deserve this treatment. We most certainly do. We gave up our control willingly to avoid the hassle of worrying about finances and other “non-medical” issues and in turn we allowed ourselves to be pushed into a pseudo-slavery propagated solely by our collective cowardice. Ask any physician, in private, about their thoughts regarding kicking the system down, striking, or refusing to comply to the insane regulatory requirements (IE: MOCs) and they will grab their pitchfork and torches. Suggest the same in a public setting, and be met with a collective brow raise, platitudes ending with “…for the patient”, and recommendations to instead appeal to our masters for more control over our lives which is invariably denied. Eventually, another physician will kill themselves in the interim and physician burnout will be the hot topic of the day. Victim blaming often ensues during these discussions which reinforces further to the physician that the system is here to stay and that the best they can do is try and learn yoga. It is usually easier just to keep drinking until the next cycle begins though. This happens ad nauseam to the point where the medical community as a whole would be viewed as having poor insight and judgement during a psychiatric exam. Again, this is why so many physicians want out of the field and are slated to be replaced by the box-clicking, questionably autistic, automatons currently matriculating through our medical schools.

 

I’m not a genius by any stretch of the imagination. I highly doubt I will ever change the face of medical knowledge. But I can at least see that which is in front of me. This is why I have a hard time interacting with my “peers” without openly questioning their sanity. This is why “outside hospital” sends me patients that are billed as “too complex” because they have three or more chronic conditions and the transferring physician has no idea how to logically approach it. This is why I have to dictate to may different outside ED physicians how to appropriately evaluate a patient on BiPAP to determine if they need to be intubated. It is scary just how many physicians in critical care settings don’t get it. This is why cases of iatrogenic salt water drownings are so common in hospitals that are hyper-focused on guideline driven protocols, such as for sepsis. Soon they plan to roll out a protocol to initiate antibiotics and fluids on patients who MIGHT be septic in my hospital. To the three people who may read this, and have no medical background, they want to give 2-3L of fluids to people who have no business getting fluid (heart failure, kidney failure, liver failure patients). This will invariably result in respiratory failure, further complications, and likely ICU transfer. So why do it? Because CMS has changed guidelines into mandates. Because bureaucrats and spreadsheet jockies are never challenged. Because critical thinking is irrelevant. And because competency is all but dead and the patients are not far behind.

“….So how do I determine if my doctor is competent?”

Trial and Error. Good luck!