I On Being a Physician

Elizabeth G. Nabel, MD, FACP

Being a healer holds a special place in our society. Almost all human societies, in fact, have persons who act in the role of healer. A common thread throughout many societies is the combination of the science and art of medicine. In some societies, the function had only a minimal basis in science, and the practice of healing was an art, highly dependent on a confident, personal relationship between the patient and the healer. In today’s society, medicine combines a progressively enriched science base with an unequaled social connectedness between physician and patient.

The role of a physician as healer has grown more complex in recent years. Health care reform will improve access to medical care for many millions of Americans. Over time, we anticipate payment reform, as well, where payment will shift to global or bundled reimbursement for outcomes based on value, quality, and safety, rather than a fee-for-service emphasis on volume. The emphasis will increasingly be on patient and family-centric care. The phrase „right treatment for the right person in the right setting at the right time” is often used. The medical team is also expanding. Physicians will increasingly share care responsibilities with nurses, physician assistants, pharmacists, technicians, therapists, and family members of patients. Many of us will practice within the setting of a medical home. The physician, however, will continue to bear most of the responsibility for the care of the patient.

Being a patient’s physician requires a number of attributes. The Accreditation Council for Graduate Medical Education (ACGME) has outlined six „core” competencies for all physician trainees, regardless of discipline: (1) medical knowledge; (2) patient care; (3) interpersonal and communication skills; (4) professionalism; (5) practice-based learning and improvement; and (6) systems-based practice < http://www.acgme.org/outcome/comp/compmin.asp >. These core competencies have also been embraced by the Joint Commission for Accreditation of Hospital Organizations (JCAHO) and are used to benchmark ongoing physician practice for all physicians subject to JCAHO accreditation. The Institute of Medicine has endorsed these core competencies in its ongoing discussions of value- and evidence-based medicine.

Competency-based education focuses on learner performance (learning outcomes) in reaching specific objectives (goals and objectives). It shifts the focus away from process-oriented measures of resident education (i.e., how many procedures a resident completed) to outcome-oriented measures (i.e., how well the resident completed the procedure). The goals of the ACGME Outcome Project are twofold. First, residents must develop competencies to complete their training and practice as independent physicians. Second, resident and practicing physician education should be a potent vehicle to improve patient care. Most patients would agree that they want physicians who have strong medical knowledge, demonstrate good communication skills, are professional, know the literature, are reflective about their practice, and act as the patient’s advocate within the health care system.

Medical Knowledge

Physicians should demonstrate knowledge about established and evolving biomedical, clinical, and cognate (i.e., epidemiologic, social, and behavioral) sciences and the application of this knowledge to patient care. Residents should demonstrate investigatory and analytical thinking to clinical situations and apply basic and clinically supportive sciences appropriate to their discipline. Medical knowledge is the foundation of our profession, is ever evolving, and requires us, as physicians, to engage in lifelong learning.

Patient Care

Physicians are engaged in a privileged relationship with patients, which is built on trust, empathy, and advocacy. Physicians should provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Physicians in training and in practice should be competent in the following eight attributes: (1) communicate effectively and demonstrate caring and respectful behavior toward patients and their families; (2) gather accurate and essential information about patients; (3) make informed diagnostic and therapeutic decisions based on patient information and preferences, up-to-date scientific information, and clinical judgment; (4) develop and carry out patient management plans; (5) counsel and educate patients and their families; (6) use information technology to support decision making and patient education; (7) competently conduct procedures appropriate for the area of practice; and (8) work effectively with other health care professionals to achieve beneficial patient outcomes. These attributes are essential to a successful medical practice.

Practice-Based Learning and Improvement

Physicians should embrace a lifelong learning approach whereby they continuously appraise and assimilate scientific evidence to evaluate and improve their practice. Practice-based learning is essential to the success of a medical home, which focuses on value, quality, and safety. Physicians should have the skill set to analyze how well they are following standard clinical guidelines for their specialty, and should reflect on their care of patients, using this self-reflection to drive their learning and improvement. Engagement in quality improvement and patient safety experiences and the use of information technology to support their practice are also essential. Physicians should be comfortable being effective teachers of multiple groups of learners. Finally, physicians should understand the health disparities that exist in their patient population, including their disease epidemiology and potential differences from other populations.

Professionalism

Professionalism encompasses multiple attributes. We recognize physicians who consistently demonstrate professional behavior by showing respect and compassion for others, managing conflict, and behaving in a manner consistent with their values. Professionalism also includes the knowledge and ability to act in an ethical manner and to be sensitive to those whose culture, age, or gender is different from their own. Residents in training should demonstrate a commitment to carry out professional responsibilities, to adhere to ethical principles, and to be sensitive to diverse patient populations.

Interpersonal and Communication Skills

Interpersonal and communication skills go beyond medical interviewing and history taking. Effective communication skills are at the heart of quality patient care. Our patients and their families expect that physicians and their care team will communicate clearly with them, will ask them for informed consent, and will deliver unfortunate news with empathy and compassion. Communication skills are especially important when medical teams must communicate with one another during hand-offs to avoid medical errors. Residents in training should seek to listen to their patient’s story, extract the important details from the history taking, and provide information to patients and their families in an understandable manner. Most important, physicians should establish relationships with their patients that will promote the delivery of good patient care. As physicians, we are our patients’ advocate.

Systems-Based Practice

Physicians are increasingly part of a larger health care team where the ability to negotiate through this system is essential to function as a patient’s advocate. We must have an appreciation for billing and coding systems, the operations of different insurers, the cost-effective determination of ancillary imaging or laboratory studies, and the cost-effective prescribing of medications. Systems-based practice competency also includes patient safety. Physicians need to understand how the system as a whole might contribute to medical error. Finally, physicians partner with other individuals within the system, such as nurses, discharge planners, social workers, chaplains, and pharmacists, to provide quality care. Residents in training should demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.

Summary

We undoubtedly will have many opportunities and challenges ahead of us as we navigate health care reform. Many more Americans will have health insurance and, it is hoped, access to health care. We will likely be challenged with bringing the costs of health care down while preserving value, quality, and safety. Although this is our current landscape, being a physician carries many of the same roles and responsibilities as it did in previous times. Physicians, indeed, have an unparalleled opportunity to combine scientific knowledge with the traditions of an ancient and honored profession in serving and helping humankind.