The Good Doctor: What Patients Want
Auckland University Press, $40.00,
Neither title nor subtitle accurately reflects the thrust of this book. It is less about how we might distinguish the good doctor (and define what we mean by that), than about how the underperforming or incompetent doctor might be identified.
After his 10-year role as Health and Disability Commissioner, engaging with patient complaints and assimilating information about the functioning of medical regulatory systems internationally, Ron Paterson’s views are worth reading. In contrast to Mark Henaghan, Dean of Otago University’s Law Faculty, who states “If care, empathy and respect are not internally embedded, then external moderation and auditing will make no difference”, Paterson emphasises the role of regulators, professional colleges and employers in protecting the public from the incompetent doctor. He is careful to discriminate between the idealised doctor and the “good enough” doctor. Even by these generous criteria it is estimated that one to five per cent of practitioners are incompetent. In New Zealand there is no central database to keep track of those poorly performing doctors who cause concern to their patients, colleagues, employers, professional bodies or the Health and Disability Commission. Although the Medical Council is charged with maintaining standards and protecting the public, its response to evident practice deficiencies can be suboptimal and tending toward rehabilitation rather than discipline. The author recounts alerting the Medical Council to a series of 16 complaints against an Auckland GP only to have the council take no disciplinary action and allow the doctor to continue practising.
The book is subdivided into four sections: “The Ideal”, “The Reality”, “The Roadblocks”, and “The Prescription for Change”. It is the latter which receives the most attention and will provoke the most reaction. At present, most professional bodies such as the colleges of physicians or surgeons or GPs require their members to submit a summary of their continuing professional education annually, but do not require evidence that such activity actually translates into responsible medical practice. Knowledge is not the same as competence.
In arriving at his prescription for the analysis of doctors’ competence, Paterson has reviewed regulatory systems in place in the US, UK, Australia and Canada. Of these, the systems in Quebec, Ontario and Alberta are the most successful in assessing physician practice. The difficulty lies in the amount of time and effort required to assess all doctors comprehensively and regularly. This can be diminished by targeting those who are known to be at risk, but that process does not ensure that every doctor is a safe doctor. (Those at risk include those more than 35 years out of medical school, specialists solely in private practice, international graduates with restricted permits and those who have been subject to complaints.)
To help us select a doctor, the author advocates that accessible information concerning doctors’ professional qualifications, track record and any published disciplinary proceedings be readily available through the Medical Council or employer (such as hospital) website. Similarly, specialist societies should be encouraged to provide robust data comparing procedure outcomes in different hospitals or different units. Currently there is almost no locally available data to help one select a GP, let alone a specialist. Not only is the only list of GPs in the White Pages, but it is not at all easy to find out which are accepting new patients, not to mention which have been subject to justified scrutiny by the Medical Council.
To help ascertain whether the selected doctor is fit for purpose, Paterson recommends various changes to the current recertification practice. These include: 1. A clear commitment to a public protective function from the Medical Council with proper standards advocated and enforced, although there remains a role for remediation or retraining where appropriate. 2. Expanding recertification to include at least a clinical audit and peer review. These new processes should be developed by professional bodies. He states “at some point in the future Australasian doctors will need to overcome their aversion to periodic exams, given the evidence that they clearly add value in testing cognitive and clinical problem solving skills.” 3. In the absence of periodic performance reviews, medical regulators need to implement targeted screening of “at risk” doctors.
To improve the functioning of the medical regulators themselves, particularly the Medical Council, he urges a change from the current dominant medical presence to equal numbers of lay and professional members, the impetus being that “the job of a regulator must be clearly seen to be to regulate the profession in the public interest not on behalf of the profession”. Similarly, he suggests that the law be changed to make medical regulators subject to freedom of information laws, also in the public interest. This would need to include appropriate protection of patient and doctor privacy. Finally, he recommends that regulators be required to work together more closely so as to share information and expertise. Paterson’s conclusions are based on carefully argued and documented evidence from New Zealand and overseas. There are nearly 500 end notes.
Although the need for protection of the patient from the incompetent or malevolent doctor is clear, the mechanisms for achieving this in the total doctor population are at present hard to imagine. For instance: should I, as a clinical haematologist, sit regular exams in general medicine? In general haematology? In malignant haematology? Or in my practice specialities of leukaemia and lymphoma? Who could set such exams for such tiny minorities and who could determine the minimum standard of competence? Should such exams be national or international? And how does one allow for variations in resources and environment worldwide?
Regular 360 degrees feedback would be welcomed by most practitioners, but the process is enormously time-consuming and expensive, and will therefore meet with resistance at this time of resource constraint. Would any personal scrutiny have detected Doctor Shipman’s activities earlier? He is said to have been assiduous in maintaining his continuing education and in fulfilling his professional requirements. Fortunately such active doctor malevolence is extremely rare, but given his capacity for forging false details in patient notes, it would have been very difficult to detect his crimes.
Clearly we do need our doctors to be sensibly audited in the years following graduation. Such a process will require the energetic cooperation of the medical profession and also their employers. Paterson’s book provides an intelligent, informed and courageous beginning to major discussion and then action. It should be read by doctors, medical administrators, policy makers, legislators, medical defence insurers and coroners. While Henaghan’s sentiments concerning embedded empathy do strike a chord, and have implications for medical student selection, Paterson’s argument for regular post-graduate assessment of doctor performance is compelling.
Rae Varcoe is a Nelson physician and poet.