Defining the Successful Physician
Over the past 30 years recognition that academic skills, book learning to use a colloquialism, is only one aspect of intelligence and only one predictor of success has grown. Other skills are important, too. Presently, though, there is no standardized definition of these skills. Anya Kamenetz reviewed this issue in an article called “Social and Emotional Skills: Everybody Loves Them, But Still Can’t Define Them.” Older words such as character are commingled with other old words given new meaning like grit, agency, and resilience. After reviewing developments for each of these words, she concludes there is a drift toward a default phrase: “social and emotional learning.”
I have followed this debate with interest, because my experience has taught me that to be truly successful physicians need both academic and “social and emotional” intelligence. Some years ago, our group hired a medical specialist who was technically able, but who had been the subject of many nurse and patient complaints. One condition of his employment was that he had to meet with me on a regular basis. His parents were both PhD physicists, and he was a very intelligent man, but had not developed any “people skills.” I concluded he had to upload “software” every morning reminding him that he had to talk to staff, patients, and family members. Naturally, this was easier to do when he was rested, but if he was tired or had a bad night on call the upload did not take place. Although he kept his bargain with the group, his partners eventually got tired of going behind him and explaining things to his patients and he moved on. This doctor, then, had plenty of intellectual capacity, and was technically competent, but was unable to succeed in practice because he lacked basic social skills.
I also recall another physician who was quite amiable and outgoing and viewed himself as a politician. Once, when I had to talk to him about a behavioral problem with one of his partners, I discovered that he had almost no ability to abstract from the concrete to the general, and thus could not understand the social context of the issue that were clear to others in his group. I got frustrated and told him that the issues were as clear to others as the desk he was sitting behind and that he just needed to accept this. Naturally he didn’t do either believe it. In his case, his personal skills were not linked to any special social intelligence.
I have known many physicians who were successful—that is, who had the professional respect of physicians and staff as well as the respect and affection of their patients and families. Some were generalists, some were specialists. Some were gregarious, others not so much. What they have in common was a genuine emotional and social connection with the people they encountered, which they demonstrated repeatedly. To be truly outstanding, they coupled their social and emotional skills with intellectual knowledge. But are these skills given or do they change over time?
In the 1980’s, the notion developed that physician knowledge bases eroded with time, and that older physicians needed to be goaded to “keep up.” Out of this developed the notion of “maintenance of certification.” Lipner and associates have now reported a study of the impact of an “open book” format on certification “practice exam.”  Physicians were randomly assigned to a standard, closed book, time-limited exam, compared to other formats, including time unlimited exams where the physician was given access to an online reference, (Up to Date ®). The statistics used in this paper were beyond me, but the authors concluded having access to online data does not negate the utility of the standard test format to discriminate among the skill levels of different physicians.
For many years, being a physician meant one had specialized knowledge, and those who could retain and recall the most data were thought to be particularly gifted. This experiment, though, deals with the reality that no one can retain all available medical knowledge. The skill needed seems to be the ability to skillfully locate and apply selected bits of information to the problem at hand. It is still intellectual work, but of a different type.
Improved testing, though, is not likely to calm the rising resistance to maintenance of certification examinations. It seems to me there are several issues which have become entwined in the debate. First, physicians now practice, for the most part, in groups. The impaired, demented, or otherwise ineffective practitioner cannot hide ineptness easily. Unfortunately, members of the group are usually loath to act on this information and many organizations “solve” the problem by sending the disabled practitioner somewhere else. Exams are not going to solve the problem of self-discipline.
Second, those who have been in practice awhile become increasingly aware that medical practice is subject to fads. Many of today’s guidelines will be replaced or changed as currently popular assumptions are disproved. Only a small number of guidelines are supported by “A” level data—the majority are “C” level, meaning expert opinion recommendations. Most physicians eventually decide they are experts, too, but having your own opinion can reduce the chance of doing well on the recertifying exam, where the “school solution” is the only correct one.
Third, experienced practitioners come to realize making the correct diagnosis or starting the correct treatment is a necessary, but not sufficient, grounds for appropriate medical care. To be appropriate each decision must be grounded in the facts of the patient’s other ailments and must account for the patient’s goals and wishes. The best physicians seem able to incorporate the A level “best practices” most of the time, but make exceptions when it is “best for the patient.”
Weinberger has suggested the real issue is making the periodic assessment the determinant of success, rather than using the periodic test to determine if there are opportunities to improve problem-solving skills. At a time when the demand for services outpaces the supply of physicians, do we want to disable effective clinicians with decent problem-solving skills who may not be fully up-to-date? Do we want to do a test that lets us find those who get a D or and F, and get them into more personal assessments designed to bring them up to speed? (And who would do this or pay for this?) And in the end, no computerized test currently available can measure the emotional and social skills that are the also necessary to be a successful physician.
12 September 2017
 Kamenetz A. Social and Emotional Skills: Everybody Loves Them, But Still Can’t Define Them. 14 August 2017. http://www.npr.org/sections/ed/2017/08/14/542070550/social-and-emotional-skills-everybody-loves-them-but-still-cant-define-them.html.
 Lipner RS, Brossman BG, Samonte KM, Durning SJ. Effect of Access to an Electronic Medical Resource on Performance Characteristics of a Certification Examination: A Randomized Controlled Trial. Ann Intern Med 2017;167;302-310, 5 September 2017. Doi.:10.7326/M16-2843.
 Weinberger SE. Opening the Book on Maintenance of Certification. Ann Intern Med 2017;167:353-354, 5 September 2017. doi: 10.7326/M17-1853.
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