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 sum·ma·rize
intr. & tr.v. sum·ma·rized, sum·ma·riz·ing, sum·ma·riz·es
To make a summary or make a summary of.
sum 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 ACPE Accreditation Council for Pharmacy Education
ACPE American Council on Pharmaceutical Education
ACPE American College of Physician Executives
ACPE Association for Clinical Pastoral Education, Inc. , Suite 200, 4890 W. Kennedy Blvd., Tampa, Fla. 33609, FAX 813/287-8993.
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?
...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
* 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 Side effects
Effects of a proposed project on other parts of the firm. 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
* 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 MPA
medroxyprogesterone acetate. , Chief of Staff, CIGNA CIGNA CG (Connecticut General Life Insurance Company) INA (Insurance Company of North America) Healthplan of
...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 dig·ni·fied
Having or expressing dignity.
digni·fiedly adv. and timely retirement of physicians. They also seek out or create locum tenens LOCUM TENENS. He who holds the place of another, a deputy; as A B, locum tenens of C D, mayor of the city of Philadelphia. 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 accounts receivable n. the amounts of money due or owed to a business or professional by customers or clients. Generally, accounts receivable refers to the total amount due and is considered in calculating the value of a business or the business' problems in paying , 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 Richard Stubbs (born 1958 in Brighton, Victoria) is an Australian comedian.
Stubbs started his career in radio in the early 1980s on 3XY as part of the XYZoo team. Early in his television career, Stubbs appeared as a performer and a writer on , MD, MBA MBA
Master of Business Administration
Noun 1. MBA - a master's degree in business
Master in Business, Master in Business Administration , FACPE FACPE Fellow of the American College of Physician Executives , FAAFP FAAFP Fellow, American Academy of Family Physicians , Medical Director, McKay-Dee Hospital Center, Ogden, Utah Ogden is the county seat of Weber County,GR6 Utah, United States. A 2006 estimate placed its population at 78,086. The city served as a major railway hub through much of its history, and still handles a great deal of freight rail traffic which makes it a .
...There is a second problem here--a patient care assessment committee that is not doing its job. With today's legal and JCAHO JCAHO Joint Commission on Accreditation of Healthcare Organizations, see there 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 e·mer·i·tus
Retired but retaining an honorary title corresponding to that held immediately before retirement: a professor emeritus.
n. pl. 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 Fort Riley, U.S. military post, 5,760 acres (2,331 hectares), NE Kans., on the Kansas River; est. 1852 to protect travelers on the Santa Fe Trail from attack by Native Americans. , 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 bevy
a flock of birds. 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 The rules and regulations enacted by an association or a corporation to provide a framework for its operation and management.
Bylaws may specify the qualifications, rights, and liabilities of membership, and the powers, duties, and grounds for the dissolution of an 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 Mercy Hospital or Mercy Medical Center could refer to the following hospitals in:
...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 Adv. 1. in the meantime - during the intervening time; "meanwhile I will not think about the problem"; "meantime he was attentive to his other interests"; "in the meantime the police were notified"
meantime, meanwhile , 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 malpractice, failure to provide professional services with the skill usually exhibited by responsible and careful members of the profession, resulting in injury, loss, or damage to the party contracting those services. 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 outlier /out·li·er/ (out´li-er) an observation so distant from the central mass of the data that it noticeably influences results.
an extremely high or low value lying beyond the range of the bulk of the data. . 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 pre·sum·ing
Having or showing excessive and arrogant self-confidence; presumptuous.
pre·suming·ly adv. that Dr. Drell shows up with substandard substandard,
adj below an acceptable level of performance. 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 col·le·gi·al
a. Characterized by or having power and authority vested equally among colleagues: "He . . . 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 Adj. 1. agreed upon - constituted or contracted by stipulation or agreement; "stipulatory obligations"
noncontroversial, uncontroversial - not likely to arouse controversy 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 medicolegal /med·i·co·le·gal/ (med?i-ko-le´g'l) pertaining to medical jurisprudence.
Of, relating to, or concerned with medicine and law. 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 FACS Fellow of the American College of Surgeons.
Fellow of the American College of Surgeons
fluorescence-activated cell sorter. , FACPE, Executive Director, Nassau County Nassau County is the name of two counties in the United States of America:
...Having been through this a couple of times, I know what I suggest can work; I just don't know Don't know (DK, DKed)
"Don't know the trade." A Street expression used whenever one party lacks knowledge of a trade or receives conflicting instructions from the other party. 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 retrospective review,
a posttreatment assessment of services on a case-by-case or aggregate basis after the services have been performed. of a sampling of Dr.
* Present the facts to the Medical Executive Committee
for discussion to include the concerns, the data, and
* 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 ad·ver·sar·i·al
Relating to or characteristic of an adversary; involving antagonistic elements: "the chasm between management and labor in this country, an often needlessly 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 reassess
to reconsider the value or importance of
Verb 1. reassess - revise or renew one's assessment
reevaluate 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 Impairment
1. A reduction in a company's stated capital.
2. The total capital that is less than the par value of the company's capital stock.
1. This is usually reduced because of poorly estimated losses or gains.
2. 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 in·tro·spect
intr.v. in·tro·spect·ed, in·tro·spect·ing, in·tro·spects
To engage in introspection.
[Latin intr 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 board of trustees Politics The posse of thugs who oversee an institution's administration. See Board of directors. , Wellborn well·born
Of good lineage or stock.
Adj. 1. wellborn - of good or upper-class lineage; "a rich and wellborn husband"
upper-class - occupying the highest socioeconomic position in a society 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
See: Chicago Mercantile Exchange
See Chicago Mercantile Exchange (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
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 ABFP
American Board of Family Practice , ABMM ABMM American Board of Medical Microbiology
ABMM American Board of Medical Management
ABMM Anti-Ballistic Missile Missile
ABMM American Board of Medical Malpractice , Vice President of Medical Affairs, St. Joseph Hospital, Lancaster, Pa.
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 conch (kŏngk, kŏnch, kôngk), common name for certain marine gastropod mollusks having a heavy, spiral shell, the whorls of which overlap each other. , the group's CEO (1) (Chief Executive Officer) The highest individual in command of an organization. Typically the president of the company, the CEO reports to the Chairman of the Board. 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 un·a·bat·ed
Sustaining an original intensity or maintaining full force with no decrease: an unabated windstorm; a battle fought with unabated violence. .
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 stunt 1
tr.v. stunt·ed, stunt·ing, stunts
To check the growth or development of.
1. One that stunts.
2. One that is stunted.
3. . What, he wonders, should be his first step in bringing the issue forward for group discussion?