If you suspect that a colleague&s aberrant behavior may endanger patients, here are ways you can intercede.
If you suspect that a colleague's aberrant behavior may endanger patients, here are ways you can intercede.
No doctor wants to report a colleague for possibly endangering patients. But when you took the Hippocratic oath, you tacitly agreed to do just that.
"Ten to 15 percent of physicians will have a problem affecting their ability to practice medicine at some point in their careers," says internist Mike Wilkerson, medical director of the North Carolina Physicians Health Program. The most common problemsalcoholism and drug addictionmirror those in the general population. Other problems include sexual improprieties, uncontrolled psychiatric disorders, behavioral problems, senility, and incompetence.
And yet the colleagues of a problem doctor often refuse to acknowledge that something is wrong, even when faced with evidence that should arouse suspicion: alcohol on the doctor's breath, disheveled appearance, an explosive temper, repeated failure to return patient calls, or consistent tardiness.
Why are so many doctors loath to act?
Doctors are groomed to think of themselves as a breed apart. This notion can lead to a dangerous arrogance. "Only in recent years have doctors been able to say, 'I have a problem,' " observes psychiatrist Luis T. Sanchez, director of the Massachusetts Medical Society's Physician Health Services. "We've always been expectedand expected ourselvesto be one step below God. We're only now starting to accept that we're not godlike. Despite our MDs, we're subject to the same frailties and illnesses as our patients."
Doctors are conditioned to believe they're infallible, says addiction medicine specialist Lynn R. Hankes, president of the Federation of State Physician Health Programs. Even when they have strong reason to suspect a colleague is impaired, they find ways to deny it: He's one of us. It can't be true. We don't get sick.
Denial isn't lying. It's an unconscious defense mechanism used to avoid facing a fearful truth. "For a doctor to acknowledge that a colleague has a problem means the entire profession is vulnerable to that problem," says Hankes. "That's threatening. The public places us on pedestals. There's no room to be imperfect, let alone impaired."
Add to that the professional and legal vulnerability doctors feel, which fosters a protective bond among them. "Medicine is so full of uncertainty," explains University of Michigan medical sociologist Marilynn M. Rosenthal. "The boundary between avoidable and unavoidable mistakes can be very thin. It's often hard for physicians themselves to assess, let alone laypeople."
What the public is quick to call a medical blunder, to doctors is often a regrettable but unpreventable adverse event. As such, the doctor who reports a colleague today knows he himself could be reported tomorrow. And if he's reported, the last thing he needs is a history of turning in colleagues.
Then there's the burden-of-proof problem. What if your suspicions about a colleague are wrong? You could destroy someone's career. So you're forced to play detective. But is that realistic? Notes FP Regina M. Benjamin, a member of the Alabama State Board of Medical Examiners: "Most physicians are way too busy to stop and investigate a colleague."
Even when a doctor's suspicion is well-founded, he still might remain uncertain about the nature of a colleague's impairment. For example, a 1998 survey found that only 7 percent of doctors had extensive training in recognizing and treating alcoholics. In contrast, 32 percent characterized their training as adequate, and 61 percent admitted theirs was inadequate or nonexistent. "Because many doctors don't understand alcoholic behavior patterns, they wonder whether they're overreacting, especially when aberrant behavior is followed by normal activity, which is usual in early-stage alcoholic disease," says Hankes. "So doctors conclude that they need more data before acting."
A few ingrained myths also hinder reporting. For instance, it's untrue that an addict must want help or hit bottom before an intervention can succeed. On the contrary, procrastination may seal a chemically dependent colleague's fate. "By the time aberrant behavior surfaces at work, the disease is already well-developed," says Hankes, "and a once salvageable career may be ruined."
So what can you do? You can have what Rosenthal calls a "terribly quiet chat" to let the doctor know there are concerns about him. Such an off-the-record session also enables you to gather more information, assess whether the doctor realizes he has a problem, and, if appropriate, urge him to seek help.
Another tack, which Rosenthal says British doctors in group practices sometimes employ, is protective support. "Colleagues and nurses quietly shift work away from the doctor and do it themselves," she explains. In a variation, a nurse or receptionist who handles appointments reroutes a problem doctor's patients to colleagues, and other doctors simply stop referring to him.
This strategy may protect patients, but it's of no help to the physician, who should be regarded as a patient himselfespecially if he has a chemical dependency. As North Carolina's Mike Wilkerson puts it: "Ignoring an addiction problem is a death sentence."
If the doctor has hospital privileges, you might alert a department head or the chief of staff and pass the responsibility on to him. However, sociologist Rosenthal finds that doctors in authority are often no better equippedemotionally or in terms of interpersonal skillsto deal with problem colleagues in their charge than are doctors on the front lines.
If you don't want to confront a colleague or report him to a hospital or state licensing board, alert your area's physician health program. Begun in 1978, PHPs exist in every state except Arizona, Nebraska, South Dakota, and West Virginia. (The Federation of State Physician Health Programs has a central office at AMA headquarters in Chicago. For information on individual programs, call 312-464-4574.) While the situation in each state is a bit different, most PHPs allow for anonymity, and, with some legally defined exceptions, the details of the troubled doctor are kept confidential.
PHPs diagnose physicians, treat them or refer them to treatment programs, and monitor them. While chemical dependency and mental illness account for most cases, a growing number of doctors are referred to PHPs for interpersonal and behavioral problemssuch things as using profanity, throwing instruments, or intimidating people with verbal or physical threats. "Usually," notes Mike Wilkerson, "these are good doctors with poor communication skills, and they aren't team players."
According to PHP directors, many doctors misconstrue the goal of these programs. It's rehabilitation, not witch-hunting. "PHPs are not Big Brother-like organizations," explains PHP federation president Lynn Hankes. "Once we receive a report on a potentially impaired doctor, we begin a discreet inquiry. We assess the reliability of the reporting sources. We gather corroborating data. We have to reach a critical mass of information before we have reasonable cause to suspect impairment and take action."
Unfortunately, PHPs vary in scope of services. Only about a third of the programs, such as North Carolina's, Massachusetts', and Washington state's, are "independent, adequately funded, and statutorily defined," says Hankes. "They have credibility with medical boards, medical societies, organized medicine, and the medical community at largeand they are financed by those entities, as well. They have full-time physician directors and ancillary support staff. Some PHPs even have immunity from lawsuits by physicians whom they investigate."
Another third of the programs are only paper operations, with a volunteer staff and maybe an answering service, Hankes says. "These are halfhearted efforts that get mixed results." The remaining PHPs fall somewhere in between.
While most programs are affiliated with either their state medical board or state medical association, the best PHPs are independent. The distinctions are crucial. The two major obstacles that PHPs face now are delayed reporting and underreporting. Independent programs promote reporting. Those attached to a licensing board discourage it inadvertently, because doctors fear that turning in an impaired colleague will result in disciplinary sanctions, not recuperative help.
In 2000, for example, only some 300 physicians out of 75,000 licensed to practice in California (0.4 percent) were monitored by the state PHP, which is attached to the state licensing board. In contrast, in Washington, where the program is independent, 184 physicians were enrolled, out of 15,000 licensed in the state (1.2 percent).
PHPs affiliated with state medical associations are also less popular than independent counterparts. "There's still a lot of paranoia surrounding this," Hankes says. "Moreover, not every physician belongs to a state medical association; a significant segment have major issues with organized medicine. If they view a program as part of the medical establishment, it's perceived to be tainted."
North Carolina's PHP is independent. In 12 years, it has handled more than 1,000 caseshalf referred by the state medical board and most of the rest by hospitals. A minority were referred by other physicians. Ten percent were self-referrals.
Sixty-five percent of the doctors treated were chemically dependentalmost half of those (45 percent) were alcoholic, while many of the rest were addicted to prescription drugs as well as alcohol. One hundred twenty doctors were psychiatric referrals. The two biggest mental health problems: bipolar disorder and, surprisingly, ADHD.
The best PHPs have been remarkably successful in remediating impaired physicians, on the order of 85 to 90 percentincluding alcoholics, whose relapse rates are otherwise notoriously high. (Of those Alcoholics Anonymous members who continue to attend meetings, so that they can be surveyed on their lengths of sobriety, more than half report relapsing after five or more years.)
What's the secret of the most effective PHPs? "Monitoring, monitoring, monitoring," says Hankes. Well funded and staffed PHPs monitor their charges for five years; random drug testing is frequent. Doctors who relapse either are retreated, subject to intensive monitoring, or reported to their licensing boards for disciplinary action in order to protect patients.
If it's proved that you kept mum about a doctor who was potentially endangering patients, you could be sanctioned, as well. You risk social repercussions, too. Says the Alabama State Board's Regina Benjamin: "In our community, silence carries a greater stigma than speaking up."
Reporting a colleague to a board won't necessarily spell his professional doom. "Doctors get due process," says FP Charles N. Aswad, executive vice president of the Medical Society of the State of New York. "While the health commissioner can suspend a doctor's license, there must be an investigation within 30 days."
Increasingly, a board is apt to refer an impaired physician to that state's PHP rather than immediately discipline him. "The tone of our board members, who are political appointees, is changing to support our PHP and the idea of identifying problems early and correcting behavior before it becomes a real problem," says attorney Helen Diane Meelheim, assistant executive director of the North Carolina Medical Board.
Despite what doctors may fear, board actions, especially concerning impaired physicians, aren't just rubber-stamped. According to attorney Bruce A. Levy, a former anesthesiologist who is now deputy executive vice president for leadership support services of the Federation of State Medical Boards, "Not all complaints result in investigations, not all investigations result in discipline, and not all discipline leads to licensing restrictions."
See "Was I doing my dutyor ratting on a colleague?" in this issue.
Neil Chesanow. Why is it so hard to report a problem doctor?. Medical Economics 2001;7:94.