How should doctors be assessed? And how should they assess themselves?
Christmas Day, early morning, and I’m walking deserted streets to my PO box to collect a few weeks of mail. I was in my first year as a fully qualified specialist, working in a large city hospital, and I was neither on call nor responsible for any patient on any ward. So unburdened did I feel at that moment that I may have been humming an off-key carol. The first year is the toughest: eye-squinting anxiety by day, phone calls at midnight kicking your heart up into your throat. But here was a day off, my only responsibility to boil the hell out of a drunken pudding. I flicked through the envelopes. Among the pile was a letter – Important Confidential – from the medical board. Maybe I’d forgotten to pay my registration. I opened it and kissed goodbye to any peace, joy or pudding the sunny day had promised.
The medical board had received a complaint from a patient’s mother, about me. They enclosed the complaint: three pages of hysterical accusations that I had mistreated her 22-year-old son. They advised me to contact my medical defence organisation before I lodged my response, which would be reviewed by a panel that would decide what action, if any, to pursue. I walked home without blinking, closed my study door and pressed my face into a cushion so I didn’t wake my family. All those years of study, worry and sacrifice and now I’d be sacked, struck off. When I thought I could talk, I called my mentor and friend Mike, a physician in his 60s. Then I called the hospital’s lawyer, then my boss, then my best friend. Everyone told me not to worry.
They say “impostor syndrome” (the belief you have your position by mistake and will eventually be found out) is more common among women. Among physicians, it’s almost universal to feel it now and then. Once you’ve crammed your way through the hoops early in your career, there’s no clear way to measure your competence and absolutely no way to know everything, to never miss anything, to never make a mistake. How do you judge yourself? By your cure rate? Most modern diseases – chronic, non-communicable, lifestyle – aren’t curable. Your death rate? It’s actually quite difficult to bump someone off, and everyone experiences the very occasional close call. Bedside manner? Who’s to be the judge of that?
Self-perception aside, ensuring a doctor’s ongoing competency is clearly important for the community. Internationally, governments, insurance companies, institutions and specialist colleges all wield various assessment tools. Like any set of performance indicators, they narrowly define the clinical work as a collection of measurable, lowest-common-denominator actions. It’s not hard to teach (and work) to a test. But if that’s the best we can do and those markers keep patients safe, then I suppose that’s tolerable.
Doctors can also be assessed via patient surveys, with varying results. In the US it turned out that some of the doctors with the highest ratings were the ones handing out opiates and benzodiazepines like they were party favours. Multiple studies show that many GPs are reluctant to discuss their patients’ weight – even if it’s the cause of their diseases – for fear they’ll offend. Is this perhaps because there are searchable websites now that allow you to post reviews of your doctor as if she’s a restaurant?
Recently, one of my friends was erroneously listed as a “sure thing” to get you on the Disability Support Pension. He only found out after a rash of patients showed up with Centrelink forms at the ready. Imagine if he cared about ratings? Imagine if his job depended on them?
Despite all talk to the contrary, the consumer model of medicine is a disaster. If you know what you want and you’re willing to pay for it, then the person to call is your dealer. Patients aren’t customers, consumers or clients. It’s a relationship, not a service. The beauty of Medicare is that it enables the transaction to remain purely ethical. Who’d ever pay for tough love?
I was terrified and then ashamed about that complaint. I knew the mother’s claims were false and vindictive, but they hit me at the peak of my insecurity. Maybe I had inadvertently mistreated this young man, missed something, hurt him.
I’d seen the patient and his mother four times. For years they’d seen – and continued to see – numerous other doctors. The young man had been investigated since childhood for symptoms that were consistently, eventually, determined to be “out of keeping”, “mysterious” or “not clearly organic”. He’d been tested and re-tested. I was initially tempted to do the same but instead brought a senior colleague in to review him. At our last appointment he was finally seeing a psychologist and a personal trainer, and had enrolled in university. Soon after, the mother emailed me, requesting that I declare him permanently unfit for work. It was there in my early notes: “Mother: Munchausen by proxy??”
As a doctor you must retain the ability and the right to refuse a patient’s demand, or the demands of their loved ones, or the demands of the institutions that pay your wages. To do so you have to keep your anxiety in check, act only in your patient’s best interests, read your reviews like a novelist might (that is, noting who wrote them), and trust that the board, your peers, your quadruple-checking fear of missing something will keep you on the safe side of sorry.
As I reviewed and re-reviewed my notes like a cop, as I wrote and rewrote my response, my terror and shame turned to righteous anger, then to deep sadness for the mother and her son. They let the aggrieved party read your response. A kind of closing clinical intervention. Please, I wanted to write, please let him be. In the final exonerating draft, I summarised the case gently but without ambiguity. “I’m so sorry,” I wrote, “and I truly hope you find someone who can help.”