A tale of a "disruptive" physician.
Q: What is a "disruptive" physician?
A: "Step out of line, the man come and take you away. "This line from the iconic sixties Buffalo Springfield protest song For What It's Worth is particularly prescient in relation to the present day medical profession. The meaning of that line is becoming increasingly clear. Using the descriptors chosen by Robert Wachter, M.D., chairman of the American Board of Internal Medicine (ABIM), we of the "pampered" and "coddled" class (1) must adhere, with evangelical fervor, to "evidence-based" protocols and numerical endpoints. If one dares to artfully apply years of education, training, and experience to a clinical problem, then one can be labeled as disruptive. Hospitals have been armed with absolute coercive power since the publication of the Joint Commission's (formerly the Joint Commission on Accreditation of Health Care Organizations, JCAHO) sentinel event alert on disruptive behavior. (2)
Q: Howare "disuptive" physicians identified?
In a chilling Orwellian scenario, hospitals have developed surveillance programs employing sycophantic medical staff and non-physician staff to keep an eye on one another. A system of anonymous reporting of perceived behavioral aberrancy was developed. These anonymous reports are then collected in a Hooverian file on each staff member. At anytime, at the hospital's discretion, this file can be employed to label the hapless physician as disruptive.
Q: What happens to a physician thus selected?
At a time of the hospital's choosing, the disruptive physician process will be set into motion. The branded physician will be summoned by the hospital administration. In a manner eerily similar to Soviet-style punitive psychiatry, under the cloak of secrecy, and with complete disregard for any due process, the doctor will be directed to obtain an evaluation. The evaluation will be facilitated by the state's healthcare professional service program and will be out of state. This is sold as being fairer as it is distant from local biases. The hospital, with a pretense of compassion, will pay for the evaluation, thereby assuring the desired outcome. The state healthcare professional services program will direct the "offender" to carefully selected programs that "specialize" in these issues. Any attempt to defend oneself by obtaining legal counsel will result in being dropped from the program with a report to the state medical board further cementing the opinion that the physician is incorrigible. A warning is issued that those who do not heed this advice have had their license to practice revoked and are no longer practicing.
Q: How do the physician's colleagues react?
Now the branded physician has been culled from the herd and is isolated. Given the extreme secrecy involved, most of the medical staff is unaware of the process. Colleagues with knowledge of the process shun the marked man. Close friends are usually very bewildered and want to be helpful, but they are kept in the dark. Any questions or comment from them will be ignored by hospital administrators or medical staff officials. Now the "disruptive" physician is completely alone and isolated. There is no one to turn to for reasonable advice.
Q: What are the "options"?
At this point the marked physician is left with three choices: First, just retire from the profession. Second, retain counsel to fight the process and risk losing licensure and therefore the ability to practice and support one's family. Third, go through the process.
Q: How did you decide what to do?
After careful consultation with trusted friends, who were just as puzzled as I was, I came to believe that this was all a bad dream and that there was nothing to the accusations. I decided to go through with the evaluation, believing that the evaluators would see that I am a reasonable person and that the accusations were absurd. I thought I would finally have a chance to defend myself.
Now I know that at this point a conviction has been signed and sealed. All that is left to do is to document the veracity of accusations and seal one's guilt.
Q: What happens at the evaluation center?
The evaluation is conducted by Ph.D., masters, and bachelor-level mental health practitioners. A token psychiatrist will also be involved in the evaluation to proffer an opinion as to what psychotropic drug will be helpful. The center will have access to anonymous accusations, as well as the hospital's own accusations. After a couple of days of psychobabble evaluation and body fluid examination, a DSM IV diagnosis will handed down, and the label Disruptive Physician will be cemented. It might be added that "Disruptive Physician" is not in the DSMIV or DSMV. Much like the Soviet concept of sluggish schizophrenia, a label has been manufactured to discredit the branded physician and thereby silence a dissenting voice.
Q: What happens after the evaluation?
Under the threat of loss of livelihood, the condemned is next directed to another specialized center to get his mind right. Also very important, this phase of the nightmare must be paid for by the physician, and insurance is not accepted. At the "treatment" center, another evaluation is conducted by mental health practitioners. At no time are the accusations clarified, nor is the proposed plan with endpoints explained. Participation is completely open-ended: Release will only come once it is ascertained that the subject's brain has been thoroughly scrubbed and his pocketbook considerably lightened. If complaints of financial hardship are mentioned, one is encouraged to empty out one's retirement account or obtain money from family members. As should be apparent, it is impossible to earn any income throughout this time.
The process involves "inpatient therapy," that is, therapy in residence. There are endless group sessions led by Ph.D. psychologists, social workers, and mental health nurses. As in Mao's Cultural Revolution, (3) these sessions are basically open-ended discussions to coerce the subject to admit guilt and allow him the opportunity see and understand the error of his ways. These sessions are also designed to teach subjects how to identify their emotions.
I entered this macabre environment several years ago after being labeled a disruptive physician. During my "therapy in residence," we were to state our name and identify the emotion we were feeling every morning. During the day, there are breakout sessions to meet with the various "therapists" to further solidify the notion that we are mentally ill and that they are there to help us. There was a recurring appointment with a psychiatrist to coerce the use of psychotropic medication and manage that medication. If the "staff" is convinced that the "patient" is not being entirely forthright, then the lie detector is employed. Once again it must be reiterated, the patient is a "disruptive physician" and therefore not trustworthy. Unfortunately, during this process one begins to question one's own sanity.
Once all is said and done, the price tag for all this "help" is on the order of $60,000.
Q: What happens after release?
Once one completes the brain scrubbing, an aftercare program is designed to monitor the physician. This program includes mandatory counseling sessions and "peer group" sessions. The aftercare programs are facilitated by state physician health programs for a fee. The sentence on average is five years. These five years will cost around $3,600/year, if not more.
Now the "disruptive" physician is unleashed onto the world with the equivalent of a monitoring anklet. The process of continuing practice, either in the same practice (if one is lucky) or in a new environment, is now complicated with the label of disruptive physician, which is comparable to being an ex-con. Every application for licensure and privileging will ask questions relating to this topic, and one must then fully disclose the label and the process one went through. One must allow the licensing/privileging authority access to all documents relating to this nightmare and ongoing monitoring.
Q: How does the experience change your practice?
The result of this experience is a condition that rivals post-traumatic stress disorder. One becomes confused about one's role in the care of the patient. A question arises as to who is charge of patient care, although there is no question as to who is legally liable. When involved with patient care, does one apply years of education, training, and experience for the benefit of the patient, or does one strictly adhere to "evidence-based" protocols?
Having faced dilemmas regarding patients' treatment on multiple occasions, I have to admit to confusion. Who is ultimately responsible for the quality of patient care? I was trained to believe that responsibility fell to me and to my physician colleagues. But now I find that orders I was trained to employ are merely suggestions. I find that a lot of my time is spent trying to obtain consensus on how to care for the patient. When someone chooses to ignore an order because he disagrees with it, I fear correcting the person for fear of giving offense. I am left with taking the corrective action myself and then traipsing to an administrator and attempting to make the case for my approach in my most diplomatic manner. It has been my experience that this rarely results in any changes. I believe that my constant fear of offending someone limits my ability to effectively care for the patient.
Q: How is your family affected?
First of all, there are serious financial worries. Then there is family separation. I have been separated from my family for two years, while I work out of state and my wife and I try to sell a house in this environment without losing everything we have worked for. Such stress often leads to divorce and families splitting up. I know many "disruptive" physicians who have suffered this unfortunate result.
Ironically, this process itself is extremely disruptive.
(1) Orient JM. Inaugural. AAPS News 2013; 69(2):1.
(2) Joint Commission. Behaviors that undermine a culture of safety. Sentinel Event Alert. Issue 40; Jul 9, 2008. Available at: http://www.joint commission.org/assets/1/18/SEA_40.PDF.Accessed May 5, 2013.
(3) Cheng N. Life and Death in Shanghai. Grove Press; 2010.
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|Author:||Orient, Jane M.|
|Publication:||Journal of American Physicians and Surgeons|
|Date:||Jun 22, 2013|
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