Competence, litigation, and limitations on training
These interlocked areas cannot easily be untangled. I have already offered some thoughts on the subject of litigation, and mention it here only in relationship to the training of pathologists and because it deserves to be noted in a roundup of external factors acting upon the practice of pathology.
Determining the actual competence of newly graduated residents is a challenge that has received increasing attention over the last decade. On the one hand, competence is a matter of natural importance to the training institutions, which have an obvious interest in sending qualified pathologists into the community. Conversely, the community has an equally compelling interest in the capabilities of pathologists sent out to serve it. Largely in response to pressures from a public worried about medical error in general (hence the link to litigation), the ACGME has put forward competence, with a capital C, as a central component of its charge to all training programs, clinical and otherwise. Instead of allowing program directors to issue vague statements when certifying that a resident has satisfactorily completed a residency, the ACGME in 1999 initiated the General Competencies, a much more complex approach to the display of residents' evolving ability as they proceed through training. Implementation of the Competencies is now a central tenet, involving the preparation and adjudication of all residents in six discrete areas: patient care, medical knowledge, professionalism, interpersonal skills and communication, practice-based learning, systems-based practice.
The ACGME website, under "Glossary of Terms", describes the Competencies as "specific knowledge, skills, behaviors and attitudes and the appropriate educational experiences required of residents to complete GME programs." In practical terms, the measurement of the Competencies involves a re-alignment of the way in which the resident is judged. In order to maintain their accreditation, training programs must show that they are applying the Competencies as intended. There has thus been a fundamental overhaul in the way in which resident performance is formally documented and judged in the United States.
To apply the Competencies in anatomic pathology, one must find ways in which the activities of the resident can be pinned to each of the six categories listed above. In what way, for example, does a surgical pathologist exercise "Patient Care"? One might imagine that just because the pathologist usually never sees a patient, the question is moot. However, it should be apparent that a resident (and, by the way, a pathology assistant) attending to a gross specimen is very closely connected to the care of the patient from whom the specimen was taken. Activity during the performance of frozen sections is also a good example of involvement in Patient Care. Another Competency, Medical Knowledge, could be examined from various angles, such as through one-on-one interactions between resident and pathologist, the performance of the resident at conferences, and the results of the annual Resident In-Service Examination (RISE), administered by the American Society of Clinical Pathologists. Academic pathology departments across the country, in plotting links to the six Competencies, have developed assessment schemes, many of which are available on the Web. The strategy of the Competencies has exposed an entirely new way of analyzing precisely what is going on at grass roots in a residency program. For example, faculty will now ask questions about "Systems-Based Practice", referring to whether the resident is able to (1) draw on the availability of resources in the larger community of pathology; (2) work with hospital management and interdisciplinary teams to improve patient care; (3) work within a framework of cost effectiveness. Under "Practice-Based Learning and Improvement", we will enquire into whether the resident can analyze her own performance and make improvements, or whether she can critically appraise the scientific literature, or use a computer to support learning and patient care. Through the 360º evaluation, further input into resident performance may be derived from remarks gathered from individuals with whom the resident may have regular contact, such as secretaries, histotechnologists, laboratory assistants, etc.
Arising from all of this, it is fair to ask a few questions. (1) Is a resident, in full possession, on paper, of the Competencies, necessarily and actually competent? (2) Has implementation of the Competencies generated a major, slight or minor improvement in actual competence, or not? (3) Would faculty come to the same or similar conclusions about a resident's competence without specifying the six Cs? (4) Has documentation of the big Cs become so institutionalized that busy faculty members end up paying lip service to the process, without having undergone really fundamental shifts in their analysis of trainees? (5) Is the public now safer because of the big Cs?
Those who have the greatest intrinsic interest in promoting adherence to the Competencies are the program directors, who are directly accountable to their institutional graduate office and to the ACGME. In order to make the assessment of the Competencies for every resident meaningful, one would expect the gathered information to be detailed, consistent, reliable, and thoroughly examined. Measurements arising from specific test results are likely to be most helpful, but many Competency-related questions are not always easy to answer in quantitative terms. Suppose that the faculty members do their evaluations as a group, and are asked for their opinions on a resident. Unless the members have been paying close attention to the resident, unless they have been making specific notes along the way, unless the evaluation is performed immediately after the rotation, and unless enough of them have encountered the resident that month, they may not really know or remember too much about the performance level in the specified categories. Unless they are careful, deliberate, and have sufficient Time to pay attention to the details, they may loosely agree that she is doing all right, and evaluate her as satisfactory, which, in effect, means acquisition of the Competency. The months pass quickly, and before long, the resident is pronounced ready for the American people. The Competencies, meant to assure the public that the medical profession is at last doing something to create doctors (here pathologists) who are less likely to make errors that generate malpractice suits, have given us additional talking points and longer meetings. They insert yet another bureaucratic layer into an overworked environment already top-heavy and pregnant with paperwork and regulations. In my opinion, we have reached the point of diminishing returns for our efforts. The imposition of additional structures to evaluate residents will not accomplish anything new in satisfying the expectations of the public. Academic pathology departments are hard enough pressed without having to micro-dissect the performance of its grownups. After some time, perhaps a decade or more, additional data will emerge, and we may then know more.
Finally, a little gem from Starr's "The Social Transformation of American Medicine." In a discussion on the precarious economic and social status of physicians in the 1800s, he criticizes the attitude expressed by D.W. Cathell in Cathell's 1881 manual, The Physician Himself, as follows: "All people"... are obliged not only to carry out their tasks and routines, but also to express their competence in doing so. Only in some cases, however, does the expression become more important than the activity itself... Cathell advises the physician to concern himself first with expressing his competence and only secondarily with actually being competent." (My emphasis)