Corrective medical education: CME focused on physician behavior
■ Courses offered around the country are aimed at helping doctors who have been disciplined learn from their mistakes and prevent future ones.
A young medical resident prescribes some medication to ease his girlfriend's knee pain after she stumbled and fell over the weekend.
A physician going through a painful divorce lashes out at a nurse, insulting him in front of his co-workers and patients.
A doctor sends a series of e-mails to a patient expressing concern and offers to meet for dinner to discuss a secret the patient mentioned in confidence during an office visit.
Each year, physicians are caught crossing the lines of appropriate practice behavior and are reported to regulatory boards. Their actions may not warrant revoking a medical license, but they signal poor judgment and a lack of understanding about rules governing medical practice.
Hoping to curtail such behavior and prevent it from leading to more serious offenses, state licensing boards, hospitals and medical groups are turning to continuing medical education programs for help. CME classes similar to those that doctors take to maintain a medical license are being used as a disciplinary tool when physicians get into trouble.
In such instances, mandated CME course topics may include physician-patient communication, anger management, maintaining appropriate boundaries between professional practice and personal life, and proper prescribing and recordkeeping. Courses are designed to help physicians avert future transgressions.
"These are not the most egregious types of cases," said Mari Robinson, executive director of the Texas Medical Board.
CME often is coupled with other corrective action, such as a fine or a request that the physician undergo an evaluation of his or her competency to practice medicine. Assigning such courses is a way to reprimand physicians without the onus of more restrictive disciplinary action, said William Swiggart, psychotherapist, assistant in medicine and co-director of the Center for Professional Health at Vanderbilt University in Nashville, Tenn., which offers several CME courses.
"It takes some of the stigma away," he said. "Our approach is that a person lacks certain skills that can be learned."
Medical board officials say courses help physicians understand the repercussions and causes of inappropriate actions. The CME approach fits with the assumption that people can be educated and rehabilitated, said Scott Kirby, MD, medical director of the North Carolina Medical Board. Sometimes doctors have forgotten past lessons or never learned them, he added.
Disciplined doctors pay for the CME, with fees ranging from $500 to $4,000. Courses typically run one to three days, and many count as American Medical Association PRA category 1 CME credit. Though some states allow physicians to use the courses toward annual CME credits needed to maintain a medical license, states such as Texas and California require the courses on top of annual CME credits.
"It is always hoped that the educational opportunity will enhance a physician's professional perspective and make the physician a safer practitioner," said Jennifer Simoes, a spokeswoman for the Medical Board of California.
A higher standard
Physicians who get into disciplinary trouble may become overwhelmed by the profound responsibilities of medical practice, said Bill Norcross, MD, professor of family medicine and director of the Physician Assessment and Clinical Education Program at the University of California, San Diego.
"Society holds doctors to a higher standard," he said.
They also may struggle to keep up with the many rules and regulations governing medical practice, said James Montgomery, MD, medical director of the Sante Center for Healing in Argyle, Texas. "We're expected to know everything, to be able to do everything, and a lot of our training is based on our mistakes."
Dealing with life-and-death matters on a regular basis may make it easy to become detached, experts say. Physicians often forget that what is normal for them may be major, life-changing events for patients or family members.
It is when they lose sight of that power differential that doctors can get into trouble, Dr. Montgomery said.
"The majority of physicians who get into trouble need to change their coping style," said Peter Mansky, MD, president of the Federation of State Physician Health Programs.
Along with the pressure to be perfect are ever-increasing demands on the medical profession. Doctors are being told to do more, leaving less time with each patient. The most effective corrective programs educate physicians without shaming them, allowing them to keep their dignity and sense of self-worth, Dr. Mansky said.
Even so, some physicians inevitably will resist. They feel they have been disciplined unjustly and blame others for their troubles, he said. "There are a number of docs who don't want to be told what to do by anybody. For those who do want help or are willing to accept it, we can do wonders."
At Vanderbilt's Center for Professional Health, most physicians are referred through state licensing boards, hospital governing boards or the courts, said Charlene Dewey, MD, the center's co-director.
Most participants are good doctors who found themselves in a distressing situation that led them to behave out of character, she said. Some physicians don't understand how their health and wellness can affect their practices.
She routinely sees doctors undergo a visible metamorphosis during required CME courses. Many enter the classroom with their heads down. "You can see almost as if they are wearing shame on their shirt. It is disheartening for me to see as a physician," Dr. Dewey said.
But by the end of the course, they are more engaged and positive. They begin to understand what they can do to change, she said.
A common reason doctors are disciplined is recordkeeping errors, including overbilling and under-billing. "That may be the No. 1 reason doctors get into trouble," Dr. Norcross said.
Courses are designed to help physicians identify issues and get advice on billing and coding. They learn to keep thorough notes on patient visits so they have a record if their clinical judgment and treatment methods are questioned.
Dr. Kirby said the North Carolina board is seeing more record violations with increased use of electronic medical records. Recordkeeping and prescribing violations often are linked. About half of the recordkeeping violations the board handles involve improper prescribing of controlled substances. But rarely does a physician maliciously violate prescribing rules.
"The idea of a doctor selling prescriptions out of the trunk of a car on a playground just doesn't happen," Dr. Norcross said. "They get manipulated or bamboozled by drug-seeking patients, or they themselves can't put reasonable limits on prescribing for the patient."
Prescribing courses focus on the challenges of prescribing controlled substances, and participants learn about rules governing prescribing. For example, they learn that they can't prescribe for someone they haven't examined as a patient. Physicians often get in trouble for prescribing for a friend, family member or co-worker.
Doctors are taught to screen patients for drug-seeking behaviors and understand why some have trouble saying no to patients' requests.
Boundary violations are a particularly sensitive area. At the Sante Center in Texas, violators may include a physician who treated an employee and a doctor who developed a personal relationship with a patient.
Vanderbilt's boundaries course covers issues such as sexual harassment and includes lessons on the dangers of interacting with patients and co-workers on social networking websites.
"We have found that physicians have very little training about what the rules are and what the consequences are," Swiggart said.
Physicians also get into trouble for financial boundary violations, such as entering into a business relationship with a patient.
"The question becomes, 'What does that do to the clinical relationship?' " Dr. Norcross said.
Though most physicians are ordered to attend the CME courses, medical board officials and program leaders would like to see greater voluntary attendance. Many physicians would benefit from the lessons, they said.
Vanderbilt's center plans to expand and offer a preventive course for physicians and medical students nationwide, as well as other health care professionals, including nurse practitioners and physician assistants.
Dr. Montgomery, of the Sante Center, said educating doctors about potential problem areas could prevent many physicians from getting into trouble in the first place. "It would be nice to treat people before they fall into the water, rather than waiting for them to drown and having to resuscitate them," he said.