PHYSICIAN ASSESSMENT OF PATIENT COMPETENCE

OBJECTIVE: To determine if physicians know and can apply the legal sta ndard for determining competence; to determine if physician assessment of competence varies by physician age or specialty. DESIGN: Mail surv ey with specific questions about a patient scenario and general questi ons about the law. PARTICIPANTS: 2100 randomly selected Massachusetts internists, surgeons, and psychiatrists. MEASUREMENTS: In Part I, the survey presented a scenario adapted from a court case that involved an elderly woman's refusing lifesaving surgery. The scenario was divided into three sections: the medical history, the patient's rationale, an d a psychiatrist's opinion that the patient was incompetent. Responden ts were not told that an appellate court later decided the psychiatris t applied the wrong standard of competence and the patient was indeed competent. Respondents were asked whether the patient was competent, w hom they would consult, and how they would respond. Part II posed a se ries of theoretical questions about competence. Group differences were tested by chi-square. MAIN RESULTS: Surveys were returned by 823 (41% ) of the sample. In Part I, before the psychiatrist's opinion, 58% tho ught the patient was competent, 92% would consult a psychiatrist to he lp assess competence, and only 17% would to go to court. After the psy chiatrist's opinion, only 30% thought she was competent and 55% would go to court. In Part II, 89% knew the correct standard for competence; however, most incorrectly responded that conditions such as dementia and psychosis establish incompetence. Psychiatrists performed signific antly better on theoretical, but frequently worse on scenario, questio ns. CONCLUSIONS: Physicians in general, and psychiatrists in particula r, know the standard for competence but may apply it incorrectly. This suggests that the common clinical practice of relying on expert medic al opinion may introduce bias and produce inaccurate results that unde rmine patient autonomy.