Sorting Through the Diagnosis of Physician Dyscompetence

William Norcross, MD


November 23, 2009

Case Conclusion

Evaluation of Performance

The PACE assessment team evaluated Dr. W's performance using the 6 Accreditation Council for Graduate Medical Education (ACGME) core competencies.

Patient care. Dr. W demonstrated significant problems in the realm of patient care, evidencing hasty clinical decision making and "rushing" to make the most likely diagnosis, rather than developing and exploring a wider differential diagnosis. His medical records also reflected haste, paucity of information, illegible handwriting, gross disorganization, and failure to follow through appropriately on critical diagnoses. However, when examined in the setting of the PACE Program, he was able to demonstrate quite acceptable clinical performance, including a thorough, complete, quite legible documentation of a complete history and physical examination. This can be explained with Miller's pyramid of levels of competence (Figure).


Miller's pyramid of levels of competence.

Applying this diagram to Dr. W shows the following:

  • He has the knowledge ("knows") to provide good care to complex patients;

  • He "knows how" to employ that knowledge;

  • He was able to show the assessors during Phase II that he had solid knowledge and was able to create high-quality, organized charts when he was asked to ("show how"); but

  • In his own practice, he was not applying this knowledge ("does").

Medical knowledge. Although his performance on some of the NBME tests was not at the highest levels, the team judged his level of medical knowledge more than adequate for safe medical practice. Medical knowledge was not a deficiency responsible for his poor clinical performance.

Practice-based learning and improvement. Dr. W's practices for obtaining continued education and professional growth seemed adequate, although it was unclear that he was applying this knowledge and learning in his practice. His solo practice seemed to create a somewhat isolated environment, depriving him of the day-to-day feedback from colleagues that physicians in group practices enjoy.

Communication and interpersonal skills. He seemed personable and warm, demonstrating good communication skills while with the PACE team. They had no reason to suspect that his communication with patients, staff, or colleagues was anything less than adequate. His communication through his medical records was very poor and required immediate improvement.

Professionalism. Although there were no obvious, egregious deficiencies in professionalism reflecting fraud, boundaries violations, or the like, it seemed that some of his clinical behaviors could reasonably be attributed to lapses of professionalism. Professionalism has been characterized as "the behavior one manifests when nobody is looking," and given that Dr. W was able to demonstrate to the team that he had an adequate fund of medical knowledge and was able to document his clinical performance in a medical record very competently, we deduced that he chose to exhibit a hasty, risky approach to patient care. This can be understood by way of Miller's pyramid of physician behavior (Figure).

Systems-based practice. Because the PACE team did not perform an on-site, in-practice assessment of his clinical environment, they were unable to completely assess Dr. W's competency, but they strongly suspected that deficiencies in his systems contributed to the poor performance that they observed in his clinical performance.

Recommendations for Improving Performance

The PACE participating physician is asked to create and complete a Commitment to Change document, which is reviewed with the physician at 6 and 12 months. Dr. W chose to commit to:

  • Improve the legibility, thoroughness, and organization of his medical records;

  • With the approval of the leadership of his medical group, meet with at least 2 electronic health record (EHR) vendors to explore their wares; and

  • Consider a differential diagnosis of at least 3 entities for every new undifferentiated symptom or sign that he encounters in practice.

The PACE assessment team recommended an on-site, in-practice evaluation of Dr. W's clinical facility, including an assessment of his clinical systems. Although the UCSD PACE Program does offer such a program, the team believed that such an assessment could also be performed by a motivated colleague in his community. Such a person could also serve as a mentor (a term that the PACE team prefers to the more austere monitor) over the next year or so.

They determined that Dr. W needed to work on his clinical practice style: thinking problems through more thoroughly, expanding his differential diagnosis, and developing systems to help him adhere to clinical guidelines for chronic diseases and preventive care.

The team also suggested that Dr. W explore the possibility of obtaining educational support from his county medical society and the California Medical Association.

They recommended that Dr. W limit the number of patients seen daily to no more than 25. Although they did not have precise data, on the basis of their chart review, it appeared that a generous percentage of his practice is a geriatric population with multiple chronic diseases, and they believed that he needed to allow appropriate time to provide quality care to such a complicated patient population.

The PACE group believed that Dr. W's practice (in fact, any practice) could benefit from an EHR. They advised Dr. W to attend either the Case Western Reserve School of Medicine, Cleveland, Ohio, program Medical Record Keeping With Individual Preceptorships or the PACE Medical Record Keeping Course. Both are intensive 2-day programs that would help him create better medical records and educate him on EHRs. There are several quality, inexpensive EHR options for solo practices. They also recommended that he begin to develop facility with speech recognition technology because he has a problem with his handwriting. Using a transcription service would be an alternative.

In the final analysis the PACE team determined that Dr. W must improve the quality of care that he renders, not only as it is reflected in his charts, but how it is reflected in the clinical outcomes of his patients. He must be monitored and mentored to be certain that improvement is attained and sustained.