Book Review

American Medicine: The quest for competence

N Engl J Med 1996; 334:1274-1275May 9, 1996

Article

American Medicine: The quest for competence
By Mary-Jo DelVecchio Good. 265 pp. Berkeley, University of California Press, 1995. $35. ISBN: 0-520-08896-4

The current health care debate has focused on the classic triad of cost, access, and quality. Although there has been a substantial debate over cost and a growing debate over access, there has been minimal discourse on the question of quality. Central to the debate over quality is the question of what it means to be a good doctor. How do we define, assess, and promote medical competence? This is the topic of American Medicine: The Quest for Competence by Mary-Jo DelVecchio Good, who is an associate professor of medical sociology at Harvard Medical School.

Professor Good uses competence as a paradigm to study the knowledge, skills, judgment, power, and moral character of the medical profession. The book is an exploration of the way physicians speak about competence. This discourse takes place among members of the profession, between the profession and the public, and at a more reflective level that seeks to understand the experiential and symbolic nature of competence. To accomplish her task Professor Good uses the narrative approach of a sociologist-ethnographer to analyze three case studies. Each case addresses a different perspective on the nature of competence.

As a grounding for her narrative cases, Professor Good begins with an analysis of medical malpractice. Clearly, the issue of negligence provides a classic forum for the exploration of questions of incompetence. What is fascinating is how medicine has shifted the focus of the debate from medical mistakes and malpractice to concern about liability and trust.

The first case study concerns obstetrical practices in a rural northern California community, where newly trained board-certified internists, family practitioners, and obstetricians moved in on older general practitioners. On the surface these groups debated what qualified one as competent to deliver babies. But the chapter describes several more or less hidden agendas, including turf battles between general practitioners, specialists, and the community and between physicians and midwives, as well as underlying tensions based on sex, hierarchy, and power.

The second case study, which I found to be the most interesting, focuses on the establishment of curricular innovations such as the New Pathways program at Harvard Medical School. This case study comes closest to capturing the idea of what it means to be a good doctor as opposed to the policy implications of being deemed competent. The organizational changes in medical education serve as a backdrop to the question of how medical students learn to be good doctors. Here, medical faculties determine competence. As the curriculum moves away from lectures to more tutorial- and problem-based clinical teaching, there is anxiety among the faculty about what to teach and there is anxiety among the students about what they should know. Quotes from students reveal the complex strategies used as they become accustomed to the clinical hierarchy of house staff and attending physicians.

The third, much less developed, case study focuses on the competence of research oncologists at an academic medical center and the point at which science and experimentation meet therapeutics and patient care. Here, physicians must struggle not only with clinical competence but also with the politics and economics of research medicine.

What does this book have to tell us? Although we have the most sophisticated and advanced system of medicine in the world, those in the profession continue to grapple with who and what they are. The careful descriptions of medical ethnography can serve as a rich way to explore the evolution of competence in health care. American Medicine: The Quest for Competence will be of interest to policy makers, educators, sociologists, and physicians or students in search of greater insight into the practice of medicine. To quote Professor Good, “ `competence' provides a medium for articulating relations of power and competition for resources (prestige, money, control over knowledge) in clinical practice, training, and research.”

Michael A. Grodin, M.D.
Boston University School of Public Health, Boston, MA 02118