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The nature of clinical competenceJames McCormickIntroductionWhile there are many qualities that we might desire our doctors to display, none can be so important as clinical competence. That is the ability to find out what is wrong and to make an appropriate response. How does the ‘clinically competent’ doctor find out what is wrong, and how does that doctor ensure that response is appropriate? KnowledgeIn this century, knowledge relevant to medicine has increased by geometric progression and shows no sign of slowing. By knowledge I mean those refutable statements that are the best available approximation to reality. It has been said that half of what one learns at medical school turns out to be wrong but that one does not know which half. This popular jibe is nonsense. In reality two things happen: old knowledge becomes refined and almost always more complex and new knowledge is acquired. Little of the old knowledge is completely replaced, although useless therapeutic fashions may be discarded. The main problem with the knowledge we acquire during education is its short half-life, which seldom exceeds 12 months. Only the knowledge which is reinforced or used remains. Most new knowledge is only relevant to the margins of the discipline and rarely affects our proper day-to-day practice. The common conditions seen either in general or specialist practice can be completely managed without recourse to the most recent apparent advances. The volume of new knowledge threatens generalists who are aware that there are others whose in-depth knowledge in certain areas is much greater than their own. This carries real dangers to the well being of patients because their care may become increasingly fragmented between super specialists at the expense of consideration of the unique human being who has the misfortune to be, for the time being, a patient. All practising doctors rely on their experience: a fallacious guide which usually results in continuing to make the same mistakes with increasing confidence. Experience is of two kinds - experience of diseases, which leads to statements such as ‘in my experience this sort of case does well with (a statement which is untenable in the age of the randomised controlled trial), and experience of individual patients. This second sort of experience is characteristic of general practice where continuity of care is still, despite threats to its survival, a not infrequent reality. This sort of knowledge is valuable and can lead to an understanding of anxiety which might, in other circumstances, be seen as inappropriate. It can also lead to a more accurate appraisal of the significance of symptoms. Some people are fearful and easily worried by symptoms while others can be stoical to the point of danger. However, the hypochondriacal are not immune from serious disease and all symptoms deserve proper consideration. Experience, despite its dangers, can often identify the discordant, the ‘funny peculiar’, which should counsel caution. Listening to peopleThe important evidence base of medicine is what people tell you and what we find by examination and investigation. This is the evidence that leads to sound diagnosis and the possibility of appropriate therapy. Of course, many decisions we make in clinical practice, such as starting a statin or hormone replacement therapy or considering whether a patient should be encouraged to opt for measurement of his prostate specific antigen, require us to consider evidence gathered from points far beyond our consulting room. Nevertheless, if we forget the primacy of what that individual patient tells us and what we find on examination, then we flirt with incompetence. A ‘good history’ is unobtainable by asking questions. It may only be obtained by encouraging the patient to talk and by careful and attentive listening. It is not necessary to have attended a course in ‘communication skills’ to know that encouraging people to talk depends upon the ambience of the encounter and a body language which signals commitment and attention. Information that is volunteered is gold dust by comparison with that which is extracted. All clinicians with experience recognise the characteristic use of words, accompanied by certain tones of voice and body language that predict with high probability the presence or absence of certain diseases. Sadly, there has been almost no research into the positive and negative predictive value of the use of language. General practice is in a position to rectify this deficiency, although it has to be recognised that the findings will be culturally and locally specific. Looking at peopleWhile there are diseases and disorders that are obvious at first sight (Down’s syndrome and many dermatological conditions, for example), looking at people generally involves some form of examination. There are, however, other kinds of looking at the whole person that are important. The body language of apprehension and anxiety, of sadness, that slight moistness of the eye which anticipates weeping. Medical students used to be encouraged to do ‘a complete physical’ and, I suspect, sometimes still are. This is an impossible task. Examination must be driven by at least some notion of diagnostic possibility. It should be used to confirm, or better still to refute, diagnostic hypotheses. Approaching the abdomen with an open mind is a recipe for disaster and leads to false negatives and sometimes false positives. The search for tenderness or splenomegaly must be relevant to that which has gone before, specific, and thorough. The emphasis on skills in eliciting physical signs characteristic of examinations is in many ways appropriate but ignores the extent of intra- and inter-observer variability. Very few signs are so easy to elicit and so definite that agreement is universal. While it may happen that one stumbles upon an unsuspected and real sign of disease - a breast lump, a melanoma on the back - findings that are unrelated to diagnostic sense should be viewed with great suspicion. Many important signs are difficult for most of us: popliteal pulses, raised venous jugular pressure; others, such as crepitations at the bases, are useless. By comparison with the substantial body of research on observer variability in the interpretation of x-rays, cardiographs, and histological specimens, there is a relative dearth of enquiry into the ability of doctors to agree about physical findings. Yet these very physical findings are the basis of many diagnoses. TestsThe commonest test in medicine is the attempt to measure blood pressure, and it is appallingly badly done. Digit preference, especially zero preference, is universal; little account is taken of arm thickness or arm difference; Osler’s phenomenon is ignored; anaeroid machines remain uncalibrated; and mercury sphygmomanometers uncleaned. Other tests, especially those involving the laboratory, are abused. There is a general failure to realise that when the prior probability of abnormality is low, false positives outnumber true positives by a large margin. There is also failure to recognise that many biological variables are not stable (serum cholesterol, for example) and we underestimate the extent of laboratory error. Mindless investigation, like mindless examination, produces misinformation. There is proper concern about the’ cost of high technology imaging but the cost of unnecessary and wasteful common laboratory and microbiological tests is many times greater. In addition, inappropriate tests and false positives harm the health of our patients. CommitmentClinical competence is impossible unless there is a commitment to put the patient first despite other competing claims on time and energy. The lack of such commitment is the chief cause of patient dissatisfaction, complaints and recourse to the courts. On the other hand, the provision of such commitment is the chief cause of doctor unhappiness and stress in personal and family life. Unfortunately, this may be a problem without a solution. The best that can be hoped for is damage limitation. Such limitation begins with recognition that the practice of medicine is primarily a social function and that those who are, or believe themselves, to be sick have always needed the possibility of seeking help from someone whom they can trust to mediate between themselves and misfortune. Thus the nature of the relationship is intrinsically different from that which exists between ourselves and our plumbers, accountants, or bank managers. Illness is accompanied by a degree of regression towards childhood and dependence. People come to their doctors with their begging bowl and only become aggressive when it is not filled. The problem of commitment is made more tolerable if it is appreciated that its rewards are more than money. Other professions receive much less in the way of gratitude, which no matter how little justified, is one of the major recompenses of being a doctor. Damage limitation may also be reduced by difficult decisions to set some limit to outside involvements. Outside involvements that are often connected with professional life - to committees, to Royal Colleges, to medical associations, to good causes. Saying ‘no’ can only he learned with difficulty. An essential component of commitment is enjoyment of the job. Once work becomes a burden, a task to be completed as soon as possible and with minimum stress, any commitment to patients is eroded beyond recovery. Few of us can maintain commitment throughout our professional life without some method of recharging our enthusiasm. For some this may be achieved through involvement in teaching, for a smaller number by undertaking research. Perhaps the most valuable protection is the opportunity to share concerns with supportive colleagues. ‘Me too-ing’ provides valuable comfort. ScepticismScepticism is the scalpel that frees accessible truth from the dead tissue of unfounded belief and wishful thinking. It is not a synonym for cynicism. It always seems strange that the word is so often accompanied by the tautologous addition of ‘healthy’ - it is always healthy. It may be that those who favour this usage also recognise ‘unhealthy’ scepticism, which presumably casts doubt upon the validity of their cherished beliefs. Clinical competence must include recognition of ignorance. ‘I don’t know’ tends to reassure rather than appal those who seek our help. Recognising ignorance is an important prompt to appropriate referral. It is also the best spur to individually tailored continuing education. Scepticism recognises that all treatments alleviate symptoms, whereas only some affect diseases. By being aware that the faith and enthusiasm of the therapist are major determinants of therapeutic success, the clinically competent are unlikely to be seduced by the apparent successes of absurd placebo therapies. Continuing medical educationWhile it is self-evidently true that to practice medicine with nothing more than whatever one acquired in medical school is a recipe for disaster, mechanisms for continuing growth are many and varied. The best antidote to fossilisation is not quasi-compulsory attendance at lectures and courses but fascination with the tasks of medicine; fascination, which is a subset of commitment to patients and the enjoyment of our profession. ConclusionClinical competence depends upon a quantum of knowledge, the ability to listen to the patient, and to elicit physical signs while recognising their limitations, and the intelligent use of investigations. There are two other essential and relatively neglected preconditions: scepticism and commitment.
Source: The British Journal of General Practice, November 2000 |
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