Sorting Through the Diagnosis of Physician Dyscompetence

William Norcross, MD

Disclosures

November 23, 2009

Case Description

Dr. W is a 42-year-old, white, male physician. He graduated cum laude from an Ivy League college and received the doctor of medicine (MD) degree from his state's university medical school. He describes his performance in medical school and residency as "average, but solid." He successfully completed a residency program in family medicine in California and is certified by the American Board of Family Medicine. Although he is now a member of a relatively large medical group, he is the sole physician in a semirural town where agriculture is the main business of most of his patients. He is bilingual in Spanish and describes a large, busy primary care practice, in which he routinely sees 35 to as many as 50 patients daily -- Monday through Friday. He shares call with 4 family physicians in his group. His average workday goes from 7:00 am to 7:30 pm, and he works at an urgent care clinic for 12 hours on most Saturdays. He takes an average of 2 weeks' vacation each year. He averages 7 hours of sleep per night, and takes call every third to fourth night. On nights on call, he averages about 5-6 hours of sleep. His typical daily food intake includes coffee and a pastry for breakfast, a tuna salad sandwich and sugar-free soft drink for lunch, and a large supper -- usually with meat, rice or potatoes, and a vegetable. He has been happily married for 10 years and has 2 healthy children ages 5 and 7 years. He values his leisure time and spends as much time as possible with his family, often related to his children's activities, which include youth soccer, ballet, and piano lessons. He participates in aerobic exercise at least 3 times weekly (jogging, racquetball, or brisk walking) for at least 90 minutes each time. He reports only light social alcohol intake and no recreational, illicit, or prescription medications.

His presenting problem, brought to Dr. W's attention by the leadership of his group, is poor medical record keeping that reflects disorganized care, noncompliance with nationally accepted clinical guidelines, and lapses of clinical care -- most notably in his patients with multiple chronic diseases. Dr. W reports no prior episodes of discipline, legal troubles, or academic difficulties during his premedical or medical training. He says that he always was a "poor charter," but believes that he is fundamentally a good doctor. He describes his clinical strengths as centering on his relationships with his patients.

At the suggestion of his medical group, Dr. W voluntarily presents to the University of California, San Diego (UCSD) Physician Assessment and Clinical Education (PACE) Program for a customized assessment of his health and clinical competence. Dr. W is relaxed, open, and has a good attitude about participating in this program's assessment. He understands why the leaders of his medical group want him to attend and does not dispute most of their assertions.

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