Are You an Obsolete M.D.?: Some Clues to Self-Recognition

ARE YOU AN OBSOLETE M.D.? SOME CLUES TO SELF-RECOGNITION CAMPBELL MOSES* Professional baseball players live in a world that permits ready recognition of obsolescence. Averaged to the hundredth decimal place, daily batting, earned-run averages, and fielding records provide a continuing, systematic record ofthe athletes' performance. When their performance improves or begins to slip, these figures provide a cold appraisal available to the athletes, other professionals, and the public. Based on these data the player moves from amateur to the minor leagues to the majors, and then back to the minor leagues. A few players are diverted for varying periods of time to become coaches before they return to the inevitable and permanent role of spectator. Although native ability, training, practice, and luck (especially injuries ) influence how fast athletes move through this sequence, the common denominator is age. After achieving peak performance, as the athlete ages, his or her performance tends to decline. For swimmers this peak may occur in the late teens, but most other athletes peak in their twenties and thirties. By the time they reach their forties and early fifties, most are well past their prime performance. No such neat records as baseball statistics permit appraisal of physicians and surgeons. Starting later in life after long periods of training and apprenticeship and after passing various licensing and specialization hurdles, most M.D.'s achieve their peak performance in their thirties and early forties. Researchers and laboratory scientists, whose achievements depend so largely on a fertile imagination coupled with disciplined analytical skills, may hit their peak in their twenties and early thirties. In the clinical areas, medical and surgical years of experience tend to improve clinical acumen, but sharper skills do not guarantee professional growth in the practitioner. Deterioration of mental and physical skills, failure to incorporate newer techniques in solving clinical *Address: 165 East 72nd Street, New York, New York 10021.© 1994 by The University of Chicago. AU rights reserved. 0031-5982/94/3702-0858$01.00 Perspectives in Biology and Medicine, 37, 2 ¦ Winter 1994 233 problems, and the tendency of familiarity to lead to careless performance can mean that ten or twenty or thirty years after hitting one's clinical peak, the slide to obsolescence begins. Most of the specialty societies have begun to move toward requiring recertification of their diplomates after ten or more years. Unfortunately , certification and recertification exams determine if the examinee knows what the examiner knows, but they cannot evaluate the examinee 's skills at the bedside, in the office, or at the operating table. And there is no way to identify and weigh what the examinee knows within his or her special area of expertise. Examinations almost never give appropriate weight to the most important decision the clinician ever has to make—the stark admission "I don't know!" The New York State Department of Health has in recent years publicized patient mortality records from coronary bypass surgery for all cardiac surgeons in the state. This remarkable achievement in record keeping has made many hospital staffs look more carefully at the performance skills of their surgeons and has caused some hospitals with low numbers of cardiac surgical patients to drop coronary artery surgery altogether. Yet it in no way ensures that the team with the lowest mortality rate has the highest clinical skill. The slide from peak performance toward medical obsolescence can begin very slowly and can easily escape recognition by the M.D. One reason is that doctors are constantly involved with patients who believe in and trust them. Patients who have not developed or sustained this trust have almost certainly drifted off to another practitioner. In some cases, where the doctor's judgment has been seriously faulty, patients may have died. When most of those you see in daily contact think you are wonderful, self-doubt is not likely to flourish. Fortunately, patients' friends and families may be much more willing to suspect when the doctor's skills are outdated or obsolete. While most recent surveys suggested that the profession of medicine has slipped in its public approbation, the individual's own doctor is generally excepted from this criticism. As buyers, we necessarily trust automobile and...