evolution

I've been a practicing oncologist for all of seven months, and so was surprised when my chief asked that I take part in our quality review panel. The quality review panel is an internal group that is tasked with the responsibility of looking into allegations that a patient's care was not in keeping with best practice or what is generally considered the standard of care. Cases (often in the form of a complaint) can be submitted by patients or the nursing staff, but more frequently come from other physicians.

Cases are reviewed and scored individually by each member of the panel, and the composite score is used to determine whether corrective action should be taken. Although physicians whose cases are repeated scored "P2" - in which the standard of care was clearly violated - can be forced into remediation, the purpose of the review panel is didactic, not putative. And to that end, the standard is different than that of a legal proceeding - there need not be a bad outcome in order to determine a case P2, only that the expected level of care was not that which was delivered.

Obviously I can't go into the specifics of the cases or the physicians, but what I've been impressed by so far is the recurrent sin of omission. The incidences in question didn't involve the wrong therapy, intended deception, or malice, but the accumulation of small omissions - documentation, timely follow up, etc that morphed into a larger problem. Data management and communication also came up as frequent offenders. 

In one or two cases I felt the problem was that the physician - a few of whom had been practicing medicine while I was still in grade school - couldn't or weren't able to evolve with changing expectations. We are expected to be transparent, thorough, and accountable for what the patient does and does not understand. There's an astounding amount of information to be managed, including but not limited to the electronic medical record, patient email, open notes, and the near-entirely of uptodate and pubmed.  I can speak better to what is happening in my own field - where fifteen years ago there were about that many different types of chemotherapy. Now there's fifteen new drugs coming out every year. 

I started thinking about what it means to evolve and what its going to look like for me over the course of my career. I've found the review experience hugely instructive in that I understand better how physicians get themselves in trouble, but I've also found it unnerving. Twenty years from now the central tenets of"being a good doctor" might be entirely unrecognizable when compared to today. 

I wish I had a note of conclusion on which I could end this post, but I don't. I am just beginning to see how important professional evolution will be, but I have no idea what that really means.