Doctor, lawyer say disruptive physician article falls short. (Reader Feedback Dear Editor).

The article, "The Disruptive Physician: Diagnosis and Therapy" by Niranjan Kissoon, MD, Susan Lapenta, JD, and George Armstrong, MD, (The Physician Executive, January/February, 2002,) was a welcome addition to the much-too-scarce debate of disruptive physician behavior in the literature, but is troubling in its assumptions.

Despite the authors' assertions to the contrary, there are generally agreed upon definitions of disruptive behavior that can be found in the "AMA Policy H - 140.918 Disruptive Physician," and the "JACHO Medical Staff Chapter, Physician Health, MS.2.6."

Also contrary to the article, the "classic symptoms" of the disruptive practitioner are notoriously difficult to recognize in the absence of such guidelines. They are often confused with legitimate behavior that happens to be disruptive.

As stated in my article in Click, (Feb. 2001, "Dr. Jekyll/Dr. Hyde: Managing The Disruptive Physician") a large percentage (upwards of 80 percent) of newly onset disruptive behavior reflects a significant alcohol, drug or psychiatric problem.

Further, given the nature of denial and the history of enabling of such problems within the medical profession (the so-called "conspiracy of silence"), such soft intervention strategies may drive the physician underground to deal with his problem only to have it surface later in life or in a career-threatening crisis.

While, at first blush, collegial interaction might seem appropriate, in reality this approach is tantamount to "curbside consultation" in the face of what is, in all likelihood, a chronic, progressive mental health issue.

Given the nature of the denial processes, and the notoriously low index of suspicion of physicians for such problems among their peers, the offending individual is as likely to win converts to his/her position (It's not me, it's them!), than to really address the problem.

It is a well accepted principle in clinical medicine that a given symptom is examined in light of the most serious health problems to be ruled out. Then, once all parties are satisfied that a life or career is not in immediate jeopardy, the problem can be addressed in a less urgent (yet formal) manner.

Only the most unreasonable (or ill) physician would resist being the subject of such a coherent intervention process. For this reason, the seemingly compassionate step of collegial intervention is ill advised.

A high index of suspicion for the presence of a serious mental health problem is necessary for any policy to be effective; it also must provide for immediate specialized medical referral, evaluation, and, if necessary, treatment.

Living as we do in the epoch of scientifically based treatment, our approach to even the most potential mental health problem in a colleague must be definitive. The initial annoyance of the individual aside, a more formal process is a small price to pay for the great benefits to the life of the affected physician (who is often grateful in the end), the medical staff and to the society that invested so much in his training.

Joseph Molea, MD, CAP, MRO, CHE Timothy J. Sweeney, JD, CCJAP