Treading awkward waters when reporting colleagues
■ How do I know when to report a fellow physician, and how do I do it?
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Professional self-regulation is a foundation of medicine. For the protection of patients and the integrity of the profession, physicians must be aware of their colleagues' performance and conduct and report violations. So why do physicians say that reporting a colleague is so difficult?
Reply: Reporting colleagues to a medical board or hospital administration and referring them to a physician health program are serious, necessary and often painful procedures. But not doing so can harm the colleague, who may continue destructive behavior. If needed treatment for illness or addiction is delayed, the doctor and patients may experience harm.
Doctors might face an ethical dilemma about reporting a physician colleague. Discussing the situation with a close friend or a trusted colleague can be valuable. You also can call the medical director of your state physician health program. Even though the physician health program is not a legal entity, the medical director can help you determine whether the behavior you observed was in violation of regulation or law. Have several observations over time and detailed records when you refer a physician to a state agency, hospital or program. This approach is preferable to confronting the physician yourself. The accused physician often will believe that what you say is invalid, and he or she may retaliate or respond with anger.
Identifying a physician whose behavior is of concern is sometimes obvious, but it may not be clear in other cases. Criminal and unethical behavior may be caused by a serious personality disorder, so it is important to take care and, perhaps, make initial state medical board inquiries anonymously. Sometimes the behavior is caused by a psychiatric illness such as major depression, bipolar disorder, alcohol or drug dependence, or attention-deficit/hyperactivity disorder. Neurological disorders and metabolic illnesses also can cause impairment.
The most important thing to look for is a change in personality. For example, the medical director of a local hospital referred a physician to the state health program because the respected, experienced surgeon had not responded to requests to complete charts and had not attended mandatory staff meetings.
This was uncharacteristic for an exemplary staff member who had been friendly and supportive to colleagues and always had followed hospital procedures. The surgeon was sent to a national center for a multidisciplinary independent medical evaluation, where he was diagnosed with Huntington's disease.
Often the behavior that qualifies for a referral is secondary to a substance abuse disorder. The results of referring such a physician to a state physician health program are excellent, because frequently the physician's career is preserved. Although physicians with a substance abuse disorder may relapse, their recovery rate has been high.
A successful and dedicated hospitalist was referred to a state physician health program for disruptive and angry behavior. Upon initial assessment, the physician protested that he had a large number of patients and that the hospital was being unfair. Furthermore, he felt his competitors in other hospitalist groups were encouraging the referral.
When asked to submit a urine and hair sample for toxicology studies, he followed his attorney's advice and submitted to the tests, which came back positive for substantial levels of tetrahydrocannabinol. On his attorney's advice, he waived the procedure for an evaluation and went directly into treatment.
The program was successful, and he has remained drug-free.
Procedures vary by state
The procedures for reporting and referring are different in each state, but in general, a physician can call the medical board's executive director, the state physician health program, or the hospital medical director or chief of staff.
It may be useful to call anonymously and ask for advice about a particular case. The executive director of a medical board may suggest that you refer the doctor to the state physician health program.
Many doctors prefer to call the state physician health program as a first step, because doing so may avert the need to call the medical board or hospital leaders who may decide or be required to discipline the physician. Most states allow a physician to refer a colleague to a state physician health program in lieu of referral to the board. The state physician health program's executive director may be able to provide valuable guidance in the decision process.
The Joint Commission has medical staff standards that govern management of physicians who have illnesses and impairments. The standards require hospitals to:
- Handle physician health separately from physician discipline.
- Educate physicians and staff members about physician health and impairment.
- Provide procedures for identifying and referring impaired physicians for evaluation and treatment.
Although medical staff standards have been around for quite some time, many hospitals have not set up policies for impaired physicians. Hospitals that follow the standards can provide support for reporting or referring colleagues.
Most hospitals have two lines of command -- the medical administrative line and the medical staff line -- and it is generally the latter that has the task of credentialing and disciplining physicians.
If the hospital does not support your concern, you face the problem of whether to report on your own. In most states, the decision is not yours; reporting a physician who is impaired or has violated state regulations to the medical board is mandatory. Failing to report leaves you vulnerable to discipline. Most states consider reporting to be in the public interest and, in return, provide immunity to the reporting physician.
Peter A. Mansky, MD, medical executive director, Nevada Professionals Assistance Program