Dr. H was a promising young surgeon who enjoyed teaching and was known for his quick wit and charisma. He was well known in his community, operated at multiple institutions, and spearheaded initiatives ranging from improving hospital infection control to hands-on education of trainees. Dr. H took a position at a major academic medical institution, where he implemented a variety of changes to the medical staff. He enjoyed a storied career, during which he pioneered multiple surgical techniques and received numerous accolades. As Dr. H aged, his operating style became progressively more cautious, with unexplained absences and other lapses in his clinical practice earning him censure from his institution’s board of trustees and a referral to the medical board. Despite concerns regarding Dr. H’s performance, he continued to practice with minimal restriction.
Dr. H, or William Stewart Halsted, as he is better known, is remembered today as the father of surgical residency and a pioneer in the field. In the pantheon of American medical giants, few have shaped medical training and practice more. His dependence on cocaine and morphine defined and shaped his career, though his focus on development of the surgical residency largely prevented any harm to patients that might have come as a result of it. Halsted was, in many ways, beautifully human — a contradiction of excellence and impairment that is not uncommon in many people, though in most not to his degree.
As physicians, many of us see and understand how a person like Halsted might exist and still perform well in the “real world.” Yet, in a world where physicians are tasked with the care of human lives, the demand for an objective, ongoing singular measurement for “competency” is as tantalizing as it is illusory. This, I think, is the crux of the issue of the recent American Board of Internal Medicine (ABIM) certification lawsuit. For those not familiar, the plaintiffs claim that ABIM acts as a monopoly, essentially freezing out those who refuse to pay a fee to maintain certification that they claim does not meaningfully correlate with improved patient outcomes. The defendants claim that certification is voluntary and that voluntary certification bodies like ABIM act within the public interest to protect them from impaired or incompetent physician practice. What is at stake is the question posed by the life of Dr. Halsted: How do we determine or measure physician competency?
Unfortunately, board certification has become the proxy measure of choice that hospitals and insurers use to denote competency, a point that ABIM notes is the choice of hospitals and insurers, not the ABIM. As a medical director in a medium-sized group practice, I am sympathetic to the desire for a singular measure that would indicate physician competency. I have never dealt with a Dr. Halsted, but I have dealt with colleagues whose practice is out of step with modernity, those who don’t return pages, and those who simply don’t lock their notes. I have physicians who struggle with productivity metrics but excel at patient satisfaction, as well as physicians whose patient satisfaction is unmatched but to the detriment of accepted clinical practice and quality metrics. While each of these supposed markers of competency — maintenance of certification status, RVUs, quality and performance metrics, and patient satisfaction ratings — is somewhat useful in isolation, I frequently find myself in need of a fuller picture when it comes to measuring the competency of a clinician. Fortunately, the answer is usually found with the human who is increasingly micronized to a number on a spreadsheet. While metrics, numbers, and status can indicate a need to investigate further, ultimately, it is in conversation with that complex human that the answer to whether the physician is “competent” can be found.
Interestingly, though perhaps not surprisingly, I think Halsted himself would agree. In HL Mencken’s review of Halsted’s 1930 biography, he summed up the sentiment that defined Halsted’s character as a physician:
"Antisepsis and asepsis … had turned the attention of surgeons to external and often extraneous things. Fighting germs, they tended to forget the concrete sick man on the table. Dr. Halsted changed all that. He showed that manhandled tissues, though they could not yell, could yet suffer and die. He studied the natural recuperative powers of the body, and showed how they could be made to help the patient. He stood against reckless slashing, and taught that a surgeon must walk very warily."
Although I am not a surgeon, I think the principle that humanity must be treated humanely is one that I share with Dr. Halsted and that many of us do when it comes to the practice of medicine. In a sense, this is what I think the plaintiffs are asking for in the ABIM lawsuit: a chance for competency to be determined not by metrics, or numbers, or board certification (or lack thereof), but by careful consideration of the human individual who has dedicated their life to the practice of the art. Unfortunately, that is not the case when it comes to hospitals and insurers that use board certification as the proxy credential for the hard work of evaluating the individual clinician's competence. Day to day, the standard of the whole person is the standard I try to hold people to in my job as a medical director — considering them as more than someone “board certified,” but also by their demeanor, their reputation in the community and with patients, their outcomes, and yes, sometimes even their metrics, productivity, or otherwise. It is a standard that I hope others hold me to as well when they look at my “competency” as a clinician — because, like the plaintiffs, I hope to be treated as a person, not simply a cog in the machine of corporate medicine.
