Changing physicians' competence and performance: finding the balance between the individual and the organization.

There are serious problems associated with the underuse, overuse, and misuse of health care. Part of the solution involves changing practicing physicians' competence and performance, but this proves to be a difficult task. People differ widely in their views of how the behavior of physicians can be effectively changed. Some approaches focus on improving the knowledge, skills, or attitudes of professionals, whereas others believe in changing the social interaction and collaboration within teams or changing the organizational or political context. Some believe in self-motivation and regulation by those who need to change, whereas others emphasize external stimuli, pressure, or control. However, systematic reviews show that no current approach is superior for all purposes and target groups and that we may need them all, well integrated, to achieve effective improvements in patient care. Educational activities for professionals are not sufficient and should be combined with activities and measures at other levels. Those wishing to improve the competence and performance of physicians must be aware of the limitations of educational approaches and know how to integrate these with approaches that focus on teams, organizations, or the political or economic context. Teachers of physicians need to develop their knowledge and skills in these areas to be successful.