Sorting Through the Diagnosis of Physician Dyscompetence

William Norcross, MD


November 23, 2009


The US FSMB in the Essentials of a Modern Medical Practice Act, Eleventh Edition, defines physician impairment as follows:

"Impairment should be defined as the inability of a licensee to practice medicine with reasonable skill and safety by reason of:

  • mental illness;

  • physical illness or condition, including, but not limited to, those illnesses or conditions that would adversely affect cognitive, motor or perceptive skills; or

  • habitual or excessive use or abuse of drugs defined by law as controlled substances, of alcohol or of other substances that impair ability."

Although in day-to-day parlance "impairment" is generally used to refer to physicians whose practice is compromised through abuse or addiction to drugs or alcohol and/or who suffer from mental illness, the definition allows for a broader interpretation and should include physicians whose clinical behaviors and mental habits, over time, place their patients in jeopardy of receiving suboptimal care.

Prevalence of Dyscompetence

The prevalence of physicians who chronically manifest deficient clinical performance in the absence of significant physical or mental illness is unknown. The operant word is chronically. It is likely that all physicians, at one time or another, perhaps even unknowingly, fail to perform at an optimum level. The problem under discussion is that of chronic, persistent, daily clinical behaviors that are not commensurate with quality patient care and may present risks to the health of the patient. One experienced assessor estimates the prevalence of "dyscompetence" among US physicians to range between 6% and 12%.

Impact of Dyscompetence

The impact of dyscompetence and chronic clinical underperformance is unknown, but it is beyond doubt a significant cause of patient morbidity and mortality. We know that deficiencies in physician clinical performance commonly are either not identified or, if they are identified, no intervention is conducted. Studies have shown that physicians are notoriously unwilling to point a finger at a colleague, even when the problem with clinical performance is severe.

Strategies to Address Impairment due to Deficient Clinical Performance

Minor and moderate deficiencies in clinical performance have historically been, and should be, handled at the local level. Hospital or medical group quality improvement activities, quality continuing medical education programs, and colleague mentors are effective sources of remedial education. However, referral to a formal clinical competence assessment program is sometimes helpful for recalcitrant cases in order to define the specific dysfunctional behaviors and tailor a specific program of remediation.