Physician Accountability and Taking Responsibility for Ourselves: Washing the Dirty White Coat, One at a Time

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Excerpt

Personal physician accountability lies at the core of medical professionalism. The last few years have brought into focus the need for assessing and documenting competency by the Liaison Committee for Medical Education in medical schools and the Accreditation Council for Graduate Medical Education (ACGME) for residency programs. Practicing physicians work under 50 separate jurisdictions which are, by and large, ineffective to deal with all but the most egregious behaviors, so that it takes felony acts, multiple malpractice occurrences, or both to place an individual in the National Practicioner Data Bank. State Board actions thus become the end point of poor professional behavior rather than the guardian of the public good through continual assessment of professionalism. In turn, this should generate the need for much more thorough assessment of professionalism begun much earlier (in medical school and through residency) and with more consequence attached, such as failures in coursework, nonpromotion, lack of certification, and limited licensure or even non-licensure. States then will need to take a hard look at a physician's record of professionalism, which will, in turn, have begun in medical school, continued through residency and into practice, eventuating with a strict Maintenance of Licensure.
This is a difficult scenario to envision as numerous barriers will need to be overcome, not the least of which are imposed by a economically driven health care system embracing profits over principle coupled with a stifling legal climate in which the aggrieved can disappear amid volumes of legal gibberish. Oversight officials cave in to less expensive settlements while poor professional behavior goes unchecked.
Educational institutions are now challenged with providing evidence that programs are making data-driven improvements by documenting learner performance. Of the six prescribed competency domains including patient care, medical knowledge, practice base learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice, the most difficult to document are those involving interpersonal and communication skills and professionalism. Historically, the heart of the medical education system for measuring physician achievement has been in the assessment of medical knowledge, the most easily documented aspect of physician achievement through standardized testing. As such, medical knowledge has been taken as a surrogate for defining competent physicians and educational institutional excellence by those responsible for accreditation, licensure, certification, and recertification. Although medical knowledge is important to provide good patient care, equally important are professionalism and communication skills necessary to be good doctors. An earlier article discussed aspects of professionalism, quality care, and professional self-regulation.1 The authors made reference to professional liability issues revolving around high-claim physicians and their failure to communicate to or show lack of respect for patients and their families. While assessing quality outcomes and meeting expected academic standards are important, additional areas related to the selection and assessment of individual behaviors are also important as a matter of risk management as they relate to professionalism and ethical behavior.
Various models of accountability in health care have been developed to include the professional model that guides the physician–patient relationship, the political model that operates within managed care plans and other integrated health delivery networks, and the economic model that brings to light market influences and consumer choice.2 The root of some of the failures in our health care system lie in the confusion of these models encouraged within a for-profit health care system, which attempts to portray physicians as caring professionals while forcing them to act like economic producers. The purpose of this article is to deal with aspects of individual professional accountability while acknowledging that to do so, one needs to accept the larger context in which the individual physician works.
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