Impaired physician scenario draws large response.

MANAGEMENT GROUND ROUNDS

In the January-February 1992 issue of the journal, we presented a case study involving an older surgeon whose waning skills and knowledge presented a serious problem for a hospital. In this issue, we briefly summarize the case study and present some of the solutions that readers sent. To the readers represented on the following pages, as well as all the others who responded after our deadline passed, we offer our thanks. We hope that many of you will provide some solutions to the new case study at the end of this column. Please share your views with Wesley Curry, Editorial Director, ACPE, Suite 200, 4890 W. Kennedy Blvd., Tampa, Fla. 33609, FAX [phone].

Dr. Cayle, Medical Director of Memorial Medical Center, has a problem. Dr. Drell, an old and respected member of the medical center's surgical staff, has begun to show serious signs of deteriorated skills and knowledge. Resident physicians and some attending physicians have expressed concern about Dr. Drell's abilities. However, Dr. Drell's many years of service to the hospital and the community have made him a favorite of patients, nurses, and most physicians. Although the findings are clearly preliminary, Dr. Cayle believes he must take some steps in response to evidence that Dr. Drell is no longer up to standards professionally. What, in your view, should he do?

READERS RESPOND

...Dr. Cayle needs to seek the support of the hospital's chief of surgery. Dr. Cayle and the chief of surgery need to have the "soft evidence" augmented with data from the current year and the past 3 years regarding Dr. Drell's complication rate, with surgical notes that detail his technique, with recent literature reviews that detail change in techniques, and with evidence on his surgical colleagues' techniques for the same procedures. It has to be obvious that Dr. Cayle is not singling out Dr. Drell, but that Dr. Drell is practicing a style of surgery different from that of the majority of his colleagues.

Having done all the necessary supporting "homework," Dr. Cayle and the chief of surgery have to sit down with Dr. Drell and have a chat. The conversation should be on a one-to-one basis and should include the following elements:

* Thank Dr. Drell for his past contributions and loyalty.

* Acknowledge that medicine is a fast-changing field and

that it is sometimes difficult to keep up with the latest

advances.

* Indicate to Dr. Drell that the hospital is there to help

him with some perceived difficulties and ask him to

keep an open mind in the conversation that will follow.

* Delineate all the problems that have been occurring

and back them up with the evidence.

* Wait for Dr. Drell's response. If he denies all the evidence,

indicate that the perception exists and that the

both of them will have to work out a solution to

improve that perception.

* Ask Dr. Drell for suggestions on how to deal with the

issues raised. One suggestion might be to have Dr.

Drell upgrade his surgical techniques.

* Address the possible side effects of any medication he

may be taking and encourage him to talk this over with

his personal physician.

* End the conversation with a summary and clear

understanding of any agreement and with a time when

they will meet again to assess what progress has been

made.

* In the extreme case that Dr. Drell storms out of the

room at any time during the conversation, Dr. Cayle

should write a letter to Dr. Drell indicating what

changes are needed and a specific period in which to

make them. If no improvement is perceived, Dr. Cayle

should discuss the situation with the chief of surgery

and proceed to generate some disciplinary action and/or

have Dr. Drell perform surgery only under the direction

of another surgeon on staff.--Victor A. Diaz, MD,

MPH, MPA, Chief of Staff, CIGNA Healthplan of

California, Orange.

...The obvious first step is to fully investigate all of the allegations to find out if there is significant substance to the complaints. Dr. Cayle should review the charts personally or sit down with his Surgery Case Review Committee and satisfy himself that a serious quality issue exists. Dr. Cayle should also have an informal discussion with the surgery residents, bringing up various issues and listening for concerns of quality. I feel this should be done in a questioning, nonconfrontational mode that would not key the residents to the fact that Dr. Cayle is specifically asking about Dr. Drell.

Once Dr. Cayle has established the extent and the nature of quality concerns, he must then move to discuss the concerns with Dr. Drell. I am fortunate in that I can always depend upon the "Gray Berets" at my hospital. This organization was developed in 1987, and the membership is limited to members of our medical staff for five years or longer who are 60 years of age or older, or widows of physicians who meet those requirements. Their purpose is to promote the dignified and timely retirement of physicians. They also seek out or create locum tenens or parttime salaried positions for those who desire to "wind down" for a year or two before retirement. They assist in disposal of office equipment, collection of accounts receivable, and relocation of patients. They also provide medical care and advice as well as emotional support for each other. If I had the issue that was described in this case, I would contact the President of the Gray Berets and could rest assured that they would handle it from there.

If Dr. Cayle doesn't have a resource such as the Gray Berets available, he would need to address the issues with Dr. Drell accompanied by one or two older members of the Surgical Case Review Committee. I always insist on having at least one neutral, highly regarded medical staff member with me when sensitive issues are discussed. It's very easy to have a misunderstanding when only two people are involved in a conversation. Should Dr. Drell deny the problem and continue to practice, Dr. Cayle would have no choice but to follow the by-laws through the quality process.--W. Richard Stubbs, MD, MBA, FACPE, FAAFP, Medical Director, McKay-Dee Hospital Center, Ogden, Utah.

...There is a second problem here--a patient care assessment committee that is not doing its job. With today's legal and JCAHO monitoring, a hospital cannot afford to let a physician's failing skills to be swept under the rug.

* Pressure the patient care assessment committees at

both hospitals to do their jobs. I would suspect that a

few of the same physicians may serve on both committees.

The entire medical community must recognize

there will be accurate identification and follow-through

regarding concerns about quality of practice.

* Use a senior peer/friend/retiree to contact Dr. Drell

regarding concerns. The patient care assessment committees

must then invite Dr. Drell to go over well-documented

concerns before the credentials committee is

required to act.

* Seek an emeritus position for Dr. Drell to maintain his

dignity. The doctors' lounge could be named in his

honor or he could be honored with a dinner and a permanent

wall decoration. We also tend to forget the doctor's

family, especially the wife. You may find that

Mrs. Drell has wanted him to retire for years!--James

E. O'Dea, MD, Medical Chief of Staff and Chair of

Risk Management Committee, Irwin Army

Community Hospital, Fort Riley, Kan.

...I feel it is necessary to share the concerns directly with Dr. Drell. In a large hospital, we would assume that the medical staff is departmentalized and that there is a department of surgery and a bevy of quality assurance activities. It is the chair of that department who has primary responsibility for the professional work of members of the department. Dr. Cayle should ask the chair of surgery to review the materials in hand very carefully and present them privately to Dr. Drell. If this does not work, there would be ample courses of action spelled out in the medical staff bylaws to take it from there. When working with the more "mature" physician, the direct, personal, and private approach by the appropriate authority figure (who may be a long-time friend and colleague) generally works wonders.--Ronald E. Cohn, MD, FACPE, Executive Vice President and Medical Director, Mercy Hospital, Buffalo, N.Y.

...My approach as medical director would be to talk with Dr. and Mrs. Drell in a very informal meeting, preferably over lunch, where I would mention to Dr. Drell, very clearly in the presence of Mrs. Drell, the problems that have been brought to my attention, express my concern, and suggest that he see his physician immediately for the possibility that the anti-asthmatic medications are affecting his performance. I would give him a month's time to get his treatment adjusted. I would set up another appointment with either the two of them or Dr. Drell alone in about four weeks to follow-up. In the meantime, I would continue to monitor his performance closely. At the end of four weeks, if there is no improvement in his performance, I would suggest to him that it is probably in his best interest to phase out his practice and consider retiring during the next 12 months. I would present it as a problem that he needs to address for his own benefit. If Dr. Drell refuses to cooperate, I would drastically reduce his privileges at the time of the next two-year credentialing process and thus reduce the risk of a malpractice suit against the hospital. I would definitely seek the cooperation of the elected chief of the medical staff in accomplishing this goal.--Mahendr S. Kochar, MD, MS, MBA, Executive Director, Medical College of Wisconsin Affiliated Hospitals, Inc., Milwaukee, Wis.

...Dr. Cayle is fortunate to have the resources of a large, university-affiliated, teaching hospital at his disposal. These management assets will be indispensable in dealing with this problem, as the actions to be taken must be broadly based, not only institutionally but within the medical staff structure. He is also fortunate to have some time in which to implement his solution, because the problem of Dr. Drell is not yet a crisis.

Dr. Cayle must immediately begin to work with the chair of the department of surgery to use departmental information and reports generated on all staff surgeons to demonstrate that Dr. Drell is in fact an outlier. These data can be the surgical case review reports, the written resident faculty feed back and evaluation reports, and results from the departmental quality assurance process and its committee reports. Presuming that Dr. Drell shows up with substandard performance, he and any others likewise identified should be required to meet with the surgery chair to discuss these findings. These discussions should focus on the problem areas identified, should be collegial in nature, and should be aimed at obtaining physician recognition of the problems and at mutual efforts to resolve them. The involved staff, including Dr. Drell, should be informed that the results of this review and of the agreed upon resolutions will be reported to the medical director and placed in the practice profile portion of the physicians' credentials files for future review and removal from the file if appropriate. They must understand that the information may be used in accordance with the credentialing portion of the staff bylaws if the problems persist.

If Dr. Drell continues to be delinquent in the completion of his medical records, simple suspension may be required. Suspension of increasing length may be required if the problem persists. The adverse effects on the billing process, on medicolegal status, and on accreditation surveys must be made clear to him, and the medical records committee must recommend further action by hospital administration if the matter remains a problem.

If all of the above steps fail to cause Dr. Drell to willingly change the quality of his performance or to voluntarily restrict his activities, the medical director must convince the executive committee of the medical staff to institute restriction of privileges action before a real crisis occurs. With the actions coming from the staff as well as the medical director, political problems will have been prevented.--Tracey Strevey Jr., MD, FACS, FACPE, Executive Director, Nassau County Medical Center, East Meadow, N.Y.

...Having been through this a couple of times, I know what I suggest can work; I just don't know if it's the best way.

* Develop a file of hard evidence that includes QM

reports, incident reports, and written statements by

residents, nurses and other physicians.

* Do an intense retrospective review of a sampling of Dr.

Drell's cases.

* Present the facts to the Medical Executive Committee

for discussion to include the concerns, the data, and

recommendations.

* If the committee members agree there is a problem, invite

Dr. Drell to meet with them to discuss the concerns.

This meeting should not be adversarial, but it also

should not end until a plan of action is agreed upon,

with a clear date for reconsideration. The action could

range from a warning with follow-up to 100 percent

chart review and mandatory preceptoring in surgery.

* Implement the plan of action, with the plan clearly

communicated to Dr. Drell.

* On the agreed-upon date, meet and reassess the situation

and take whatever is then the appropriate action.

* If the committee thinks medication is imparing his

function, Dr. Drell should be required to submit two

affidavits to the contrary.--William Z. McLear III,

MD, FACPE, Director of Medical Affairs, Baptist

Medical Center, Jacksonville, Fla.

...I would take advantage of the fact that Dr. Drell is taking a prescription that may cause emotional instability. I would sit down with him and discuss complaints in light of the influence this medication could have. I would suggest to Dr. Drell that he may be impaired by the medication. This would serve two purposes. First, it would make Dr. Drell less defensive about the subject of the complaints. Second, he may be able to save face by acknowledging that the medication is part of the reason for his decline. I might then recommend to Dr. Drell that he have another surgeon, ideally someone on staff for a long period so he does not feel threatened, assist on some cases with him in order to help if he runs into problems. This "doctor" would then serve as an observer who could objectively document if the problems alluded to are real and are the result of waning skills or impairment caused by medication or if they are unfounded.--Faustino Gonzalez, MD, Medical Director, Salva Medical Management, Inc., West Palm Beach, Fla.

...There is enormous variation among physicians, which requires sensitivity on the part of the Medical Director. The question, "What, in short, should he do?" must be addressed on an individual basis, considering the personalities of the individuals involved. It may be appropriate to approach some physicians individually with specific instances (as listed in the case study). An introspective and self-aware Doctor Drell would clearly recognize the assistance he is being offered by Doctor Cayle and would seek further help in terms of advice as to what to do or seek personal medical evaluation.

If, on the other hand, Dr. Drell is an arrogant, demanding, basically noncooperative individual (which is not how he was presented in the case study), some sort of consensus building among medical staff leaders through either the Medical Executive Committee, Department Chairs, or other members of Doctor Drell's group might be advantageous in approaching the problem. This would be similar to the basic approach of overwhelming an impaired physician suffering from alcohol abuse into seeking care.--John C. Huus, MD, Chairman, Board of Trustees, Wellborn Clinic, Evansville, Ind.

...The first step is to begin to gather hard data to document the verbal information being received from the residents and attending physicians. If the data reflect a significant problem, the next step is to have the Department Chief and Medical Executive Committee review it. If data review warrants it:

* The Medical Director should meet one-on-one with Dr.

Drell, reveal the concerns diplomatically, and get feedback

from Dr. Drell about how he views the concerns.

A complete physical exam and evaluation of medication

should be encouraged.

* Consider recommending to the Medical Executive

Committee to have concurrent review of Dr. Drell's

patients to provide protection to patients and minimize

risk to the hospital and medical staff.

* Consider recommending stringent educational requirements

for Dr. Drell, with specific time limits for completion

and possible personal reporting to the Medical

Executive Committee to evaluate the results of the

CME.

* Explore areas where Dr. Drell's medical expertise and

experience might be valuable without exposing patients

to harm and the physician would continue to be useful.

* Consider using medical staff members for an intervention

similar to the type used for a chemically impaired

physician.

One might also consider having Dr. Drell sign a release for information from the other hospital in the community to evaluate the extent of the problem at that institution. A concurrent intervention of some type might be fashioned, regarding CME, etc.--John P. Haun, MD, ABFP, ABMM, Vice President of Medical Affairs, St. Joseph Hospital, Lancaster, Pa.

NEW SCENARIO

Profit Motive Raises Conflict-of-Interest Issues

Doctors' Clinic is a multispecialty group practice in a medium sized city. It has grown steadily over the 40 years since its founding and offers a wide range of medical services. An important part of its growth has been the addition of services as volume permitted. It now finds it necessary to refer outside the group for very few services, and new services are added through planning each year.

In the past year or so, the clinic has been under intense price-cost pressure, largely because of a large Medicare load but also because of general changes in health care financing. Profits have slimmed, and members of the group have begun to complain. Dr. Conch, the group's CEO and medical director, has worked closely with the group's Executive Committee and with the general membership to contain costs and expand the group's market, but the pressures have continued unabated.

Recently, the group has faced a new source of competition--members of the group. Several internists have been persuaded to invest in the establishment of a local home I.V. therapy company. A national company operates the service and provides the bulk of the financing. The investing physicians contributed minimal capital financing and share in the local profits. The return on investment promises to be substantial. Other members of the group have expressed an interest in making similar investments.

While Doctor's Clinic currently has no formal program for home I.V. therapy, Dr. Conch is concerned. The existence of the outside services effectively blocks the clinic's entrance into the market. This is one of two new services that the clinic was considering for implementation in the coming year, the other being radiation therapy. He has learned that three members of the group are discussing an investment in the outside establishment of that service. Like home I.V. therapy, the outside radiation service would divert planned revenues from the group, even if some of the group's members would benefit from the arrangement.

Members of the group not involved in either venture have expressed concern about the further loss of income, raising conflict of interest charges. In informal talks with the investing physicians, Dr. Conch has been told flatly that the investments are personal business and have nothing to do with the clinic. He now fears that these and other possible ventures have the potential to seriously divide the membership. If the issue is addressed, he thinks, further growth of the clinic could be stunted. What, he wonders, should be his first step in bringing the issue forward for group discussion?