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Wrongful birth claim: Child has a chromosomal disorder...and more
A WOMAN’S HUSBAND AND AN INTERPRETER came to her first prenatal appointment at 10 weeks’ gestation, as she spoke only Mandarin and the father’s English was limited. The ObGyn offered maternal serum sequential screening. At subsequent visits, with the husband and interpreter present, the mother saw a geneticist, genetic counselor, and nurse practitioner. At no time was additional genetic testing offered. At the 23-week visit, the husband was present, but the interpreter had not yet arrived; the ObGyn attempted to communicate through the husband.
The baby was born at term with cri-du-chat syndrome. The child is severely physically and mentally handicapped, and will require constant medical and attendant care for life.
PATIENT’S CLAIM The ObGyn did not offer amniocentesis or chorionic villus sampling (CVS), and failed to inform the parents that the chance of a 37-year-old woman having a child with a chromosomal aberration was 1.5%. The ObGyn did not obtain the woman’s signature waiving the presence of an interpreter at the 23-week visit. If the physician offered amniocentesis then, the parents did not understand. She would have terminated the pregnancy if she had been told the fetus had a severe chromosomal defect.
PHYSICIAN’S DEFENSE The ObGyn claimed to have offered amniocentesis at the 23-week visit, but it was declined. Proper care and treatment was provided.
VERDICT A $7 million Massachusetts settlement was reached.
Hematoma after biopsy; death
A 77-YEAR -OLD WOMAN underwent percutaneous biopsy of three right axillary lymph nodes. She developed a hematoma. She was sent to the hospital from the physician’s office because of the increasing size of the hematoma, low blood pressure, and pain, then admitted to the ICU for monitoring. She declined exploratory surgery to discover and repair the bleeding source. When her blood pressure and hemoglobin level dropped overnight, the physician again tried to persuade the woman to have surgery; she refused. The physician then undertook surgery on another patient.
An ICU resident and nurse subsequently obtained consent from the woman’s family. The surgeon was not told this for 4 hours, at which time the woman was taken immediately to the operating room. The surgeon repaired a severed axillary vein and punctured axillary artery.
The woman suffered two episodes of asystole during surgery. She later died of multiple organ failure.
ESTATE’S CLAIM The surgeon failed to take adequate measures to obtain surgical consent to repair the hematoma, and failed to perform surgery in a timely manner once consent was given.
PHYSICIAN’S DEFENSE The woman was awake, alert, and oriented both times she refused consent; her family could not be contacted without her authorization. Proper actions were taken when consent was obtained.
VERDICT An Illinois defense verdict was returned.
Epidural pump stolen—while in use
A WOMAN WAS GIVEN AN EPIDURAL during labor. While she slept, a newly hired physician assistant (PA) entered her room, disconnected the epidural pump, and stole it. The woman awoke but the PA assured her that everything was fine. Soon, she experienced significant labor pains and called the nurses, who paged an anesthesiologist to administer another epidural. Security personnel questioned the woman.
She gave birth to a healthy child.
PATIENT’S CLAIM The hospital failed to provide adequate security. Security personnel unduly questioned the woman before the second epidural was administered, delaying the procedure and increasing the length of time she was in pain.
DEFENDANTS’ DEFENSE The hospital claimed no responsibility for the theft; the PA’s actions were outside the scope of his employment, and his criminal behavior was unforeseeable.
VERDICT A Connecticut defense verdict was returned for the hospital. (The PA pleaded guilty to stealing the epidural pump, received 3 years’ probation, and lost his license.)
Ectopic pregnancy didn’t miscarry despite methotrexate
THINKING SHE WAS PREGNANT, a woman saw her ObGyn, Dr. A, who found no evidence of pregnancy, and suspected that she had miscarried. The next day, Dr. A’s office called the woman to return because of an elevated hCG level. A sonogram performed at the second visit did not reveal any signs of pregnancy.
Eleven days later, she went to the emergency department (ED) in excruciating pain. A sonogram revealed an ectopic pregnancy. Methotrexate was administered to terminate the pregnancy. The woman was advised to follow up with her ObGyn. Ten days later, blood tests continued to show an elevated hCG level, but Dr. A did not order further testing or follow up.
Two weeks later, the woman went to Dr. B, a different ObGyn, who ordered blood work to monitor her hCG. The next day, she went to the ED in great pain. The ED physician contacted Dr. B, who advised that the woman should be discharged with instructions to follow up with him. Nine days later, the woman saw Dr. B, who diagnosed and surgically removed a ruptured fallopian tube.
PATIENT’S CLAIM Neither physician properly monitored the patient after administration of methotrexate. The ectopic pregnancy continued, and caused rupture of the fallopian tube. Dr. B failed to respond properly to the call from the ED physician.
PHYSICIANS’ DEFENSE Dr. A admitted that the patient had not been properly monitored, but claimed that the lack of monitoring caused no harm. Dr. B denied any negligence.
VERDICT A Georgia defense verdict was returned for both physicians.
Uterine laceration during cesarean
A WOMAN BEGAN TO BLEED excessively in the recovery room after a nonemergent cesarean delivery. Blood pressure and blood oxygen saturation decreased, heart rate increased, and she passed large clots. The recovery room nurse notified the woman’s ObGyn, who ordered medication to constrict the uterus and diminish blood flow, but treatment was unsuccessful.
She was returned to the operating room, where the ObGyn repaired a low-segment uterine laceration. Blood was administered with additional uterotonics. After surgery, the woman was sent to the labor and delivery recovery room. When tests indicated that her hematocrit and hemoglobin level had decreased and she showed signs of a clotting difficulty, the ObGyn ordered additional blood products and fundal massage. Two hours later, the woman suffered cardiac arrest and was revived, but suffered significant brain damage. After six months, mechanical ventilation was withdrawn and she died.
ESTATE’S CLAIM The patient’s vital signs never returned to normal after uterine repair surgery. The ObGyn and anesthesiologist did not stabilize the patient, and failed to perform a hysterectomy to save her life. The nurses did not notify the ObGyn and anesthesiologist of unstable vital signs that signaled blood loss.
DEFENDANTS’ DEFENSE The anesthesiologist found the patient’s vital signs normal after repair of the laceration and left the woman in the care of the nursing staff and ObGyn. The ObGyn was not notified of unstable vital signs. The nurses asserted that they did not tell the ObGyn of the changes because they expected him to look at, review, and interpret the monitor. The physicians claimed that the arrest and death were due to an amniotic fluid embolism or amniotic fluid syndrome that was sudden, unpredictable, and difficult to treat.
VERDICT A $1,350,000 Virginia settlement was reached.
Was she discharged too early?
AN OBGYN PERFORMED total transvaginal hysterectomy on a 54-year-old patient, and discharged her the next day. Several hours later, she began to have severe abdominal pain, and was readmitted. The ObGyn prescribed IV antibiotics and ordered fluid management. When she continued to deteriorate, she was transferred to the ICU.
The next day, the ICU physician ordered diagnostic laparoscopy. A perforation of the sigmoid colon was found and repaired, but the woman continued to deteriorate. Nine days later, she was transferred to another hospital, where she died.
ESTATE’S CLAIM The ObGyn failed to find the perforation during hysterectomy. He did not properly follow-up with the patient after surgery, and improperly discharged her despite abnormal blood work and vital signs; elevated temperature and pulse rate; and an increase in her white blood cell count. Both physicians failed to diagnose and treat the perforation in a timely manner. Delay in diagnosis and treatment led to the woman’s death.
PHYSICIANS’ DEFENSE The physicians denied negligence.
VERDICT A $7 million North Carolina verdict was returned against the ObGyn. A defense verdict was returned for the ICU physician.
These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
We want to hear from you! Tell us what you think.
A WOMAN’S HUSBAND AND AN INTERPRETER came to her first prenatal appointment at 10 weeks’ gestation, as she spoke only Mandarin and the father’s English was limited. The ObGyn offered maternal serum sequential screening. At subsequent visits, with the husband and interpreter present, the mother saw a geneticist, genetic counselor, and nurse practitioner. At no time was additional genetic testing offered. At the 23-week visit, the husband was present, but the interpreter had not yet arrived; the ObGyn attempted to communicate through the husband.
The baby was born at term with cri-du-chat syndrome. The child is severely physically and mentally handicapped, and will require constant medical and attendant care for life.
PATIENT’S CLAIM The ObGyn did not offer amniocentesis or chorionic villus sampling (CVS), and failed to inform the parents that the chance of a 37-year-old woman having a child with a chromosomal aberration was 1.5%. The ObGyn did not obtain the woman’s signature waiving the presence of an interpreter at the 23-week visit. If the physician offered amniocentesis then, the parents did not understand. She would have terminated the pregnancy if she had been told the fetus had a severe chromosomal defect.
PHYSICIAN’S DEFENSE The ObGyn claimed to have offered amniocentesis at the 23-week visit, but it was declined. Proper care and treatment was provided.
VERDICT A $7 million Massachusetts settlement was reached.
Hematoma after biopsy; death
A 77-YEAR -OLD WOMAN underwent percutaneous biopsy of three right axillary lymph nodes. She developed a hematoma. She was sent to the hospital from the physician’s office because of the increasing size of the hematoma, low blood pressure, and pain, then admitted to the ICU for monitoring. She declined exploratory surgery to discover and repair the bleeding source. When her blood pressure and hemoglobin level dropped overnight, the physician again tried to persuade the woman to have surgery; she refused. The physician then undertook surgery on another patient.
An ICU resident and nurse subsequently obtained consent from the woman’s family. The surgeon was not told this for 4 hours, at which time the woman was taken immediately to the operating room. The surgeon repaired a severed axillary vein and punctured axillary artery.
The woman suffered two episodes of asystole during surgery. She later died of multiple organ failure.
ESTATE’S CLAIM The surgeon failed to take adequate measures to obtain surgical consent to repair the hematoma, and failed to perform surgery in a timely manner once consent was given.
PHYSICIAN’S DEFENSE The woman was awake, alert, and oriented both times she refused consent; her family could not be contacted without her authorization. Proper actions were taken when consent was obtained.
VERDICT An Illinois defense verdict was returned.
Epidural pump stolen—while in use
A WOMAN WAS GIVEN AN EPIDURAL during labor. While she slept, a newly hired physician assistant (PA) entered her room, disconnected the epidural pump, and stole it. The woman awoke but the PA assured her that everything was fine. Soon, she experienced significant labor pains and called the nurses, who paged an anesthesiologist to administer another epidural. Security personnel questioned the woman.
She gave birth to a healthy child.
PATIENT’S CLAIM The hospital failed to provide adequate security. Security personnel unduly questioned the woman before the second epidural was administered, delaying the procedure and increasing the length of time she was in pain.
DEFENDANTS’ DEFENSE The hospital claimed no responsibility for the theft; the PA’s actions were outside the scope of his employment, and his criminal behavior was unforeseeable.
VERDICT A Connecticut defense verdict was returned for the hospital. (The PA pleaded guilty to stealing the epidural pump, received 3 years’ probation, and lost his license.)
Ectopic pregnancy didn’t miscarry despite methotrexate
THINKING SHE WAS PREGNANT, a woman saw her ObGyn, Dr. A, who found no evidence of pregnancy, and suspected that she had miscarried. The next day, Dr. A’s office called the woman to return because of an elevated hCG level. A sonogram performed at the second visit did not reveal any signs of pregnancy.
Eleven days later, she went to the emergency department (ED) in excruciating pain. A sonogram revealed an ectopic pregnancy. Methotrexate was administered to terminate the pregnancy. The woman was advised to follow up with her ObGyn. Ten days later, blood tests continued to show an elevated hCG level, but Dr. A did not order further testing or follow up.
Two weeks later, the woman went to Dr. B, a different ObGyn, who ordered blood work to monitor her hCG. The next day, she went to the ED in great pain. The ED physician contacted Dr. B, who advised that the woman should be discharged with instructions to follow up with him. Nine days later, the woman saw Dr. B, who diagnosed and surgically removed a ruptured fallopian tube.
PATIENT’S CLAIM Neither physician properly monitored the patient after administration of methotrexate. The ectopic pregnancy continued, and caused rupture of the fallopian tube. Dr. B failed to respond properly to the call from the ED physician.
PHYSICIANS’ DEFENSE Dr. A admitted that the patient had not been properly monitored, but claimed that the lack of monitoring caused no harm. Dr. B denied any negligence.
VERDICT A Georgia defense verdict was returned for both physicians.
Uterine laceration during cesarean
A WOMAN BEGAN TO BLEED excessively in the recovery room after a nonemergent cesarean delivery. Blood pressure and blood oxygen saturation decreased, heart rate increased, and she passed large clots. The recovery room nurse notified the woman’s ObGyn, who ordered medication to constrict the uterus and diminish blood flow, but treatment was unsuccessful.
She was returned to the operating room, where the ObGyn repaired a low-segment uterine laceration. Blood was administered with additional uterotonics. After surgery, the woman was sent to the labor and delivery recovery room. When tests indicated that her hematocrit and hemoglobin level had decreased and she showed signs of a clotting difficulty, the ObGyn ordered additional blood products and fundal massage. Two hours later, the woman suffered cardiac arrest and was revived, but suffered significant brain damage. After six months, mechanical ventilation was withdrawn and she died.
ESTATE’S CLAIM The patient’s vital signs never returned to normal after uterine repair surgery. The ObGyn and anesthesiologist did not stabilize the patient, and failed to perform a hysterectomy to save her life. The nurses did not notify the ObGyn and anesthesiologist of unstable vital signs that signaled blood loss.
DEFENDANTS’ DEFENSE The anesthesiologist found the patient’s vital signs normal after repair of the laceration and left the woman in the care of the nursing staff and ObGyn. The ObGyn was not notified of unstable vital signs. The nurses asserted that they did not tell the ObGyn of the changes because they expected him to look at, review, and interpret the monitor. The physicians claimed that the arrest and death were due to an amniotic fluid embolism or amniotic fluid syndrome that was sudden, unpredictable, and difficult to treat.
VERDICT A $1,350,000 Virginia settlement was reached.
Was she discharged too early?
AN OBGYN PERFORMED total transvaginal hysterectomy on a 54-year-old patient, and discharged her the next day. Several hours later, she began to have severe abdominal pain, and was readmitted. The ObGyn prescribed IV antibiotics and ordered fluid management. When she continued to deteriorate, she was transferred to the ICU.
The next day, the ICU physician ordered diagnostic laparoscopy. A perforation of the sigmoid colon was found and repaired, but the woman continued to deteriorate. Nine days later, she was transferred to another hospital, where she died.
ESTATE’S CLAIM The ObGyn failed to find the perforation during hysterectomy. He did not properly follow-up with the patient after surgery, and improperly discharged her despite abnormal blood work and vital signs; elevated temperature and pulse rate; and an increase in her white blood cell count. Both physicians failed to diagnose and treat the perforation in a timely manner. Delay in diagnosis and treatment led to the woman’s death.
PHYSICIANS’ DEFENSE The physicians denied negligence.
VERDICT A $7 million North Carolina verdict was returned against the ObGyn. A defense verdict was returned for the ICU physician.
These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
A WOMAN’S HUSBAND AND AN INTERPRETER came to her first prenatal appointment at 10 weeks’ gestation, as she spoke only Mandarin and the father’s English was limited. The ObGyn offered maternal serum sequential screening. At subsequent visits, with the husband and interpreter present, the mother saw a geneticist, genetic counselor, and nurse practitioner. At no time was additional genetic testing offered. At the 23-week visit, the husband was present, but the interpreter had not yet arrived; the ObGyn attempted to communicate through the husband.
The baby was born at term with cri-du-chat syndrome. The child is severely physically and mentally handicapped, and will require constant medical and attendant care for life.
PATIENT’S CLAIM The ObGyn did not offer amniocentesis or chorionic villus sampling (CVS), and failed to inform the parents that the chance of a 37-year-old woman having a child with a chromosomal aberration was 1.5%. The ObGyn did not obtain the woman’s signature waiving the presence of an interpreter at the 23-week visit. If the physician offered amniocentesis then, the parents did not understand. She would have terminated the pregnancy if she had been told the fetus had a severe chromosomal defect.
PHYSICIAN’S DEFENSE The ObGyn claimed to have offered amniocentesis at the 23-week visit, but it was declined. Proper care and treatment was provided.
VERDICT A $7 million Massachusetts settlement was reached.
Hematoma after biopsy; death
A 77-YEAR -OLD WOMAN underwent percutaneous biopsy of three right axillary lymph nodes. She developed a hematoma. She was sent to the hospital from the physician’s office because of the increasing size of the hematoma, low blood pressure, and pain, then admitted to the ICU for monitoring. She declined exploratory surgery to discover and repair the bleeding source. When her blood pressure and hemoglobin level dropped overnight, the physician again tried to persuade the woman to have surgery; she refused. The physician then undertook surgery on another patient.
An ICU resident and nurse subsequently obtained consent from the woman’s family. The surgeon was not told this for 4 hours, at which time the woman was taken immediately to the operating room. The surgeon repaired a severed axillary vein and punctured axillary artery.
The woman suffered two episodes of asystole during surgery. She later died of multiple organ failure.
ESTATE’S CLAIM The surgeon failed to take adequate measures to obtain surgical consent to repair the hematoma, and failed to perform surgery in a timely manner once consent was given.
PHYSICIAN’S DEFENSE The woman was awake, alert, and oriented both times she refused consent; her family could not be contacted without her authorization. Proper actions were taken when consent was obtained.
VERDICT An Illinois defense verdict was returned.
Epidural pump stolen—while in use
A WOMAN WAS GIVEN AN EPIDURAL during labor. While she slept, a newly hired physician assistant (PA) entered her room, disconnected the epidural pump, and stole it. The woman awoke but the PA assured her that everything was fine. Soon, she experienced significant labor pains and called the nurses, who paged an anesthesiologist to administer another epidural. Security personnel questioned the woman.
She gave birth to a healthy child.
PATIENT’S CLAIM The hospital failed to provide adequate security. Security personnel unduly questioned the woman before the second epidural was administered, delaying the procedure and increasing the length of time she was in pain.
DEFENDANTS’ DEFENSE The hospital claimed no responsibility for the theft; the PA’s actions were outside the scope of his employment, and his criminal behavior was unforeseeable.
VERDICT A Connecticut defense verdict was returned for the hospital. (The PA pleaded guilty to stealing the epidural pump, received 3 years’ probation, and lost his license.)
Ectopic pregnancy didn’t miscarry despite methotrexate
THINKING SHE WAS PREGNANT, a woman saw her ObGyn, Dr. A, who found no evidence of pregnancy, and suspected that she had miscarried. The next day, Dr. A’s office called the woman to return because of an elevated hCG level. A sonogram performed at the second visit did not reveal any signs of pregnancy.
Eleven days later, she went to the emergency department (ED) in excruciating pain. A sonogram revealed an ectopic pregnancy. Methotrexate was administered to terminate the pregnancy. The woman was advised to follow up with her ObGyn. Ten days later, blood tests continued to show an elevated hCG level, but Dr. A did not order further testing or follow up.
Two weeks later, the woman went to Dr. B, a different ObGyn, who ordered blood work to monitor her hCG. The next day, she went to the ED in great pain. The ED physician contacted Dr. B, who advised that the woman should be discharged with instructions to follow up with him. Nine days later, the woman saw Dr. B, who diagnosed and surgically removed a ruptured fallopian tube.
PATIENT’S CLAIM Neither physician properly monitored the patient after administration of methotrexate. The ectopic pregnancy continued, and caused rupture of the fallopian tube. Dr. B failed to respond properly to the call from the ED physician.
PHYSICIANS’ DEFENSE Dr. A admitted that the patient had not been properly monitored, but claimed that the lack of monitoring caused no harm. Dr. B denied any negligence.
VERDICT A Georgia defense verdict was returned for both physicians.
Uterine laceration during cesarean
A WOMAN BEGAN TO BLEED excessively in the recovery room after a nonemergent cesarean delivery. Blood pressure and blood oxygen saturation decreased, heart rate increased, and she passed large clots. The recovery room nurse notified the woman’s ObGyn, who ordered medication to constrict the uterus and diminish blood flow, but treatment was unsuccessful.
She was returned to the operating room, where the ObGyn repaired a low-segment uterine laceration. Blood was administered with additional uterotonics. After surgery, the woman was sent to the labor and delivery recovery room. When tests indicated that her hematocrit and hemoglobin level had decreased and she showed signs of a clotting difficulty, the ObGyn ordered additional blood products and fundal massage. Two hours later, the woman suffered cardiac arrest and was revived, but suffered significant brain damage. After six months, mechanical ventilation was withdrawn and she died.
ESTATE’S CLAIM The patient’s vital signs never returned to normal after uterine repair surgery. The ObGyn and anesthesiologist did not stabilize the patient, and failed to perform a hysterectomy to save her life. The nurses did not notify the ObGyn and anesthesiologist of unstable vital signs that signaled blood loss.
DEFENDANTS’ DEFENSE The anesthesiologist found the patient’s vital signs normal after repair of the laceration and left the woman in the care of the nursing staff and ObGyn. The ObGyn was not notified of unstable vital signs. The nurses asserted that they did not tell the ObGyn of the changes because they expected him to look at, review, and interpret the monitor. The physicians claimed that the arrest and death were due to an amniotic fluid embolism or amniotic fluid syndrome that was sudden, unpredictable, and difficult to treat.
VERDICT A $1,350,000 Virginia settlement was reached.
Was she discharged too early?
AN OBGYN PERFORMED total transvaginal hysterectomy on a 54-year-old patient, and discharged her the next day. Several hours later, she began to have severe abdominal pain, and was readmitted. The ObGyn prescribed IV antibiotics and ordered fluid management. When she continued to deteriorate, she was transferred to the ICU.
The next day, the ICU physician ordered diagnostic laparoscopy. A perforation of the sigmoid colon was found and repaired, but the woman continued to deteriorate. Nine days later, she was transferred to another hospital, where she died.
ESTATE’S CLAIM The ObGyn failed to find the perforation during hysterectomy. He did not properly follow-up with the patient after surgery, and improperly discharged her despite abnormal blood work and vital signs; elevated temperature and pulse rate; and an increase in her white blood cell count. Both physicians failed to diagnose and treat the perforation in a timely manner. Delay in diagnosis and treatment led to the woman’s death.
PHYSICIANS’ DEFENSE The physicians denied negligence.
VERDICT A $7 million North Carolina verdict was returned against the ObGyn. A defense verdict was returned for the ICU physician.
These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
We want to hear from you! Tell us what you think.
We want to hear from you! Tell us what you think.
How Hospitalists Can Team with Nursing to Improve Patient Care
Establishing mutual respect and trust between hospitalists and nurses is an important part of ensuring patient safety, whether you’re on your first job or your 20th, says Angela Beck, RN, director of critical-care services at Nebraska Medical Center in Omaha.
“Nurses are important coordinators of care,” she says. “Recognizing and valuing nurses for that is truly the most important thing for the patient, and can also help hospitalists build relationships.”
Key Partners
Forming a collaborative relationship with the nursing service might depend on where you start. At Northwestern Memorial Hospital in Chicago, the nursing service enjoys a “close and collaborative relationship” with hospitalists, according to Kristin Ramsey, RN, MSN, MPPM, NE-BC, associate chief nurse and executive director of operations. New hospitalists are oriented to the care-delivery models on the inpatient care units. In addition, hospitalists are acculturated into the hospital’s coleadership model.
—Kristin Ramsey, RN, MSN, MPPM, NE-BC, associate chief nurse and executive director of operations, Northwestern Memorial Hospital, Chicago
“We have partnered with our hospitalists to create a model in which the physician and nurse leader collaboratively lead the development of multidisciplinary, subspecialty teams to ensure quality outcomes,” Ramsey says. “The model is so successful with the hospitalists that we are now extending it to other areas in the organization.”
Round Sharing
Absent a formalized training protocol for partnering with nursing, hospitalists still can learn a great deal by listening to and communicating with the nursing staff, says Connie Ogden, RN, MSN, NEA-BC, executive director of adult acute services at Nebraska Medical Center. “Nurses are there around the clock caring for patients and may have a different insight” about patients’ evolving conditions, she says.
Care for the patient improves if everyone is on the same page, Ogden adds. That’s why it makes sense, she says, to include nurses during rounds. Beck agrees: “If nurses aren’t there to hear how the plan of care comes about, there is no reason to believe they can effectively describe it once the physician turns around and walks away to see another patient.”
In critical-care units, according to Beck, nurses can function as a bridge between patients and physicians. For example, they can help patients define and express their goals. Some of these goals can be incremental, she notes, such as “I really want to get out of bed this afternoon,” or “I really want my family here to listen to this message.”
Different Role, Same Goal
As director of adult acute services, Ogden often receives complaints from physicians about calls they receive from nurses. Often, these calls emanate from a concern for the patient (e.g. a 2 a.m. call for a Tylenol order to address a headache) or from the requirement that nurses follow policy and clarify orders. If hospitalists understand the back story of the call, their perception of its purpose can change.
Although there have been strides toward better nurse-physician collaboration, “we still have a lot of opportunities for improvement,” Beck asserts.
Establishing mutual respect and trust is not an overnight accomplishment. As Ogden explains, physicians and nurses have different roles, but they share the same goal: quality outcomes in patient care.
Gretchen Henkel is a freelance writer based in southern California.
► For more career-related articles, visit the SHM Career Center.
BEST WAYS TO IMPROVE HOSPITALIST-NURSING COLLABORATION
“A good portion of nurses are relationship builders,” says Beck, director of critical-care services at Nebraska Medical Center. She urges hospitalists on a new job to just “be physically present, in the beginning, on inpatient units” whenever possible. “Acting like you care is really important, and nurses will respond to that,” she says. “You can create an environment in which nurses’ feedback is valued.”
She also recommends, especially for new hospitalists, Dr. Peter J. Pronovost’s three-part talk “The Science of Safety,” delivered to incoming residents at Johns Hopkins University Medical Center in Baltimore, where Dr. Provonost is medical director of the quality and safety research group.—GH
Establishing mutual respect and trust between hospitalists and nurses is an important part of ensuring patient safety, whether you’re on your first job or your 20th, says Angela Beck, RN, director of critical-care services at Nebraska Medical Center in Omaha.
“Nurses are important coordinators of care,” she says. “Recognizing and valuing nurses for that is truly the most important thing for the patient, and can also help hospitalists build relationships.”
Key Partners
Forming a collaborative relationship with the nursing service might depend on where you start. At Northwestern Memorial Hospital in Chicago, the nursing service enjoys a “close and collaborative relationship” with hospitalists, according to Kristin Ramsey, RN, MSN, MPPM, NE-BC, associate chief nurse and executive director of operations. New hospitalists are oriented to the care-delivery models on the inpatient care units. In addition, hospitalists are acculturated into the hospital’s coleadership model.
—Kristin Ramsey, RN, MSN, MPPM, NE-BC, associate chief nurse and executive director of operations, Northwestern Memorial Hospital, Chicago
“We have partnered with our hospitalists to create a model in which the physician and nurse leader collaboratively lead the development of multidisciplinary, subspecialty teams to ensure quality outcomes,” Ramsey says. “The model is so successful with the hospitalists that we are now extending it to other areas in the organization.”
Round Sharing
Absent a formalized training protocol for partnering with nursing, hospitalists still can learn a great deal by listening to and communicating with the nursing staff, says Connie Ogden, RN, MSN, NEA-BC, executive director of adult acute services at Nebraska Medical Center. “Nurses are there around the clock caring for patients and may have a different insight” about patients’ evolving conditions, she says.
Care for the patient improves if everyone is on the same page, Ogden adds. That’s why it makes sense, she says, to include nurses during rounds. Beck agrees: “If nurses aren’t there to hear how the plan of care comes about, there is no reason to believe they can effectively describe it once the physician turns around and walks away to see another patient.”
In critical-care units, according to Beck, nurses can function as a bridge between patients and physicians. For example, they can help patients define and express their goals. Some of these goals can be incremental, she notes, such as “I really want to get out of bed this afternoon,” or “I really want my family here to listen to this message.”
Different Role, Same Goal
As director of adult acute services, Ogden often receives complaints from physicians about calls they receive from nurses. Often, these calls emanate from a concern for the patient (e.g. a 2 a.m. call for a Tylenol order to address a headache) or from the requirement that nurses follow policy and clarify orders. If hospitalists understand the back story of the call, their perception of its purpose can change.
Although there have been strides toward better nurse-physician collaboration, “we still have a lot of opportunities for improvement,” Beck asserts.
Establishing mutual respect and trust is not an overnight accomplishment. As Ogden explains, physicians and nurses have different roles, but they share the same goal: quality outcomes in patient care.
Gretchen Henkel is a freelance writer based in southern California.
► For more career-related articles, visit the SHM Career Center.
BEST WAYS TO IMPROVE HOSPITALIST-NURSING COLLABORATION
“A good portion of nurses are relationship builders,” says Beck, director of critical-care services at Nebraska Medical Center. She urges hospitalists on a new job to just “be physically present, in the beginning, on inpatient units” whenever possible. “Acting like you care is really important, and nurses will respond to that,” she says. “You can create an environment in which nurses’ feedback is valued.”
She also recommends, especially for new hospitalists, Dr. Peter J. Pronovost’s three-part talk “The Science of Safety,” delivered to incoming residents at Johns Hopkins University Medical Center in Baltimore, where Dr. Provonost is medical director of the quality and safety research group.—GH
Establishing mutual respect and trust between hospitalists and nurses is an important part of ensuring patient safety, whether you’re on your first job or your 20th, says Angela Beck, RN, director of critical-care services at Nebraska Medical Center in Omaha.
“Nurses are important coordinators of care,” she says. “Recognizing and valuing nurses for that is truly the most important thing for the patient, and can also help hospitalists build relationships.”
Key Partners
Forming a collaborative relationship with the nursing service might depend on where you start. At Northwestern Memorial Hospital in Chicago, the nursing service enjoys a “close and collaborative relationship” with hospitalists, according to Kristin Ramsey, RN, MSN, MPPM, NE-BC, associate chief nurse and executive director of operations. New hospitalists are oriented to the care-delivery models on the inpatient care units. In addition, hospitalists are acculturated into the hospital’s coleadership model.
—Kristin Ramsey, RN, MSN, MPPM, NE-BC, associate chief nurse and executive director of operations, Northwestern Memorial Hospital, Chicago
“We have partnered with our hospitalists to create a model in which the physician and nurse leader collaboratively lead the development of multidisciplinary, subspecialty teams to ensure quality outcomes,” Ramsey says. “The model is so successful with the hospitalists that we are now extending it to other areas in the organization.”
Round Sharing
Absent a formalized training protocol for partnering with nursing, hospitalists still can learn a great deal by listening to and communicating with the nursing staff, says Connie Ogden, RN, MSN, NEA-BC, executive director of adult acute services at Nebraska Medical Center. “Nurses are there around the clock caring for patients and may have a different insight” about patients’ evolving conditions, she says.
Care for the patient improves if everyone is on the same page, Ogden adds. That’s why it makes sense, she says, to include nurses during rounds. Beck agrees: “If nurses aren’t there to hear how the plan of care comes about, there is no reason to believe they can effectively describe it once the physician turns around and walks away to see another patient.”
In critical-care units, according to Beck, nurses can function as a bridge between patients and physicians. For example, they can help patients define and express their goals. Some of these goals can be incremental, she notes, such as “I really want to get out of bed this afternoon,” or “I really want my family here to listen to this message.”
Different Role, Same Goal
As director of adult acute services, Ogden often receives complaints from physicians about calls they receive from nurses. Often, these calls emanate from a concern for the patient (e.g. a 2 a.m. call for a Tylenol order to address a headache) or from the requirement that nurses follow policy and clarify orders. If hospitalists understand the back story of the call, their perception of its purpose can change.
Although there have been strides toward better nurse-physician collaboration, “we still have a lot of opportunities for improvement,” Beck asserts.
Establishing mutual respect and trust is not an overnight accomplishment. As Ogden explains, physicians and nurses have different roles, but they share the same goal: quality outcomes in patient care.
Gretchen Henkel is a freelance writer based in southern California.
► For more career-related articles, visit the SHM Career Center.
BEST WAYS TO IMPROVE HOSPITALIST-NURSING COLLABORATION
“A good portion of nurses are relationship builders,” says Beck, director of critical-care services at Nebraska Medical Center. She urges hospitalists on a new job to just “be physically present, in the beginning, on inpatient units” whenever possible. “Acting like you care is really important, and nurses will respond to that,” she says. “You can create an environment in which nurses’ feedback is valued.”
She also recommends, especially for new hospitalists, Dr. Peter J. Pronovost’s three-part talk “The Science of Safety,” delivered to incoming residents at Johns Hopkins University Medical Center in Baltimore, where Dr. Provonost is medical director of the quality and safety research group.—GH
Should You Report a Substance-Abusing Colleague to the State Licensing Board?
PRO
Hospitalists’ moral obligation is to protect the patient
In this era of historic budget deficits, wars, and political strife surrounding healthcare reform, one might ask if we can afford to spend valuable time and energy on the issue of reporting physicians who abuse substances.
At first glance, I certainly had skepticism about the subject, but then I dug deeper. To my surprise (and likely yours), studies indicate that physicians develop substance-abuse problems as often or more than the general population does.1 Recent reports detail horrific patient outcomes at the hands of health providers whose actions are compromised by drug use. With data showing the prevalence of substance abuse among physicians hovering around 10% to 12%, we must accept the reality that hospitalists are not exempt.2,3,4,5
As medical doctors, our promise to our patients is to provide care in an ethical manner. Even if we try to live in denial, most of us would agree that with great blessing (or power) comes great responsibility. So when the question of reporting a fellow hospitalist who is abusing substances was asked, my response was unequivocally yes.
In my opinion, this discussion can be limited to two overarching principles: First, we are compelled to put our patients first. As hospitalists, we are blessed to be caring for some of the most frail and vulnerable in our society. Fortunately, an overwhelming number of us do so with pride, skill, and integrity.
The task of providing high-quality care to an empowered patient population is difficult enough with us being physically, emotionally, and mentally exhausted. But to add substance abuse to this is just a complete and utter violation of our patients’ trust. We must agree that putting our patients’ well-being beyond reproach requires us to report any colleague who is compromised.
Second, delayed help for a colleague in trouble with substance-abuse issues could be fatal—and for more than just that single colleague. At some point, we are compelled to do more than just raise an eyebrow and shake our head. Usually at the time of discovery, months if not years of substance abuse already have gone by undetected. Deferring to the next person is just not an option. There is too much at stake. It is our moral duty to help our colleagues who are unable to realize the danger they are posing to themselves, the team, and, most importantly, the patients.
Certainly, physicians do not need another lecture about the perils of substance abuse. Whether discussing prescription drugs, alcohol, marijuana, cocaine, or the like, we all have witnessed the devastating effects of abuse. The fact is, any substance that alters our ability to perform our trusted duty must be avoided.
Colleagues, the algorithm is simple: Be vigilant, observe, confirm, and report. It is our moral and ethical imperative.
Dr. Pyke is chief medical officer of Medicus Consulting, LLC.
CON
Responsible, helpful action doesn’t always mean official involvement
Recognizing impairment in our colleagues is both difficult and ethically challenging. Despite national trends, medicine remains a largely self-regulated profession, and we have an ethical obligation to report impaired, incompetent, or unethical colleagues. Rarely are the indications for reporting or identifying a colleague clear.
As trained clinicians, we know the signs of substance abuse:6
- Frequent tardiness and absences;
- Unexplained disappearances during working hours;
- Inappropriate behavior;
- Affective lability or irritability;
- Interpersonal conflict;
- Avoidance of peers or supervisors;
- Keeping odd hours;
- Disorganized and forgetful;
- Incomplete charts and work performance;
- Heavy drinking at social functions;
- Unexplained changes in weight or energy level;
- Diminished personal hygiene;
- Slurred or rapid speech;
- Frequently dilated pupils or red, watery eyes and a runny nose;
- Defensiveness, anxiety, apathy, and manipulative behaviors; and
- Withdrawal from long-standing relationships.
Yet when it is a colleague, we are often in denial about their substance abuse. Certainly, simple seasonal allergies and allergy medications can cause a number of the above symptoms. We also are aware of and fear the potential impact of licensing board notification on a physician’s career. In fact, in a national survey of physicians, 45% of respondents who had encountered impaired or incompetent physicians had not reported them, even though 96% of those surveyed agreed that physicians should report impaired or incompetent colleagues.7
Similar to reporting child or elder abuse, you don’t want to be wrong.
At the same time, impaired physicians are disruptive. They negatively impact the lives of their patients, colleagues, and hospital staff.
It is possible to do both the responsible thing and not go directly to the licensing board. You are not responsible for diagnosing your colleagues, but rather recognizing possible impairment.
Check out the Federation of State Physician Health Programs’ website (www.fsphp.org) to identify a local physician health program. Call them and place a report of concern identifying your impaired colleague. While it’s possibly new to you, they have years of experience working with this situation. Trust these organizations, many of which are independent from licensing, to intervene responsibly and confidentially. They can evaluate your colleague and provide a treatment plan and monitoring, as needed. Their approach is rehabilitative rather than punitive, and they resist reporting to the medical board unless the physician-patient is noncompliant.
Physicians have better outcomes than the general population, with reported abstinence rates of 70% to 90% for those who complete treatment.8,9 Between 75% and 85% of physicians who complete rehabilitation and comply with close monitoring and follow-up care are able to return to work.9,10
There is hope for your impaired colleague. Contact your local physician health program.
Dr. Guerrasio is a hospitalist and director of resident and medical student remediation at the University of Colorado Denver.
References
- Hughes PH, Brandenburg N, Baldwin DC Jr., et al. Prevalence of substance use among US physicians. JAMA. 1992;267:2333-2339.
- Gold KB, Teitelbaum SA. Physicians impaired by substance abuse disorders. The Journal of Global Drug Policy and Practice website. Available at: http://www.globaldrugpolicy.org/2/2/3.php. Accessed June 27, 2011.
- Wolfgang AP. Substance abuse potential and job stress: a study of pharmacists, physicians, and nurses. J Pharm Mark Manage. 1989;3(4):97-110.
- Cicala RS. Substance abuse among physicians: What you need to know. Hosp Phys. 2003:39-46.
- Berge KH, Seppala MD, Schipper AM. Chemical dependency and the physician. Mayo Clin Proc. 2009;84(7):625-631.
- Bright RP, Krahn L. Impaired physicians: How to recognize, when to report, and where to refer. Curr Psy. 2010;9(6):11-20.
- Campbell EG, Regan S, Gruen RL, et al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med. 2007;147:795-802.
- Femino J, Nirenberg TD. Treatment outcome studies on physician impairment: a review of the literature. R I Med. 1994;77:345-350.
- Alpern F, Correnti CE, Dolan TE, Llufrio MC, Sill A. A survey of recovering Maryland physicians. Md Med J. 1992;41:301-303.
- Gallegos KV, Lubin BH, Bowers C, Blevins JW, Talbott GD, Wilson PO. Relapse and recovery: five to ten year follow-up study of chemically dependent physicians—the Georgia experience. Md Med J. 1992;41:315-319.
PRO
Hospitalists’ moral obligation is to protect the patient
In this era of historic budget deficits, wars, and political strife surrounding healthcare reform, one might ask if we can afford to spend valuable time and energy on the issue of reporting physicians who abuse substances.
At first glance, I certainly had skepticism about the subject, but then I dug deeper. To my surprise (and likely yours), studies indicate that physicians develop substance-abuse problems as often or more than the general population does.1 Recent reports detail horrific patient outcomes at the hands of health providers whose actions are compromised by drug use. With data showing the prevalence of substance abuse among physicians hovering around 10% to 12%, we must accept the reality that hospitalists are not exempt.2,3,4,5
As medical doctors, our promise to our patients is to provide care in an ethical manner. Even if we try to live in denial, most of us would agree that with great blessing (or power) comes great responsibility. So when the question of reporting a fellow hospitalist who is abusing substances was asked, my response was unequivocally yes.
In my opinion, this discussion can be limited to two overarching principles: First, we are compelled to put our patients first. As hospitalists, we are blessed to be caring for some of the most frail and vulnerable in our society. Fortunately, an overwhelming number of us do so with pride, skill, and integrity.
The task of providing high-quality care to an empowered patient population is difficult enough with us being physically, emotionally, and mentally exhausted. But to add substance abuse to this is just a complete and utter violation of our patients’ trust. We must agree that putting our patients’ well-being beyond reproach requires us to report any colleague who is compromised.
Second, delayed help for a colleague in trouble with substance-abuse issues could be fatal—and for more than just that single colleague. At some point, we are compelled to do more than just raise an eyebrow and shake our head. Usually at the time of discovery, months if not years of substance abuse already have gone by undetected. Deferring to the next person is just not an option. There is too much at stake. It is our moral duty to help our colleagues who are unable to realize the danger they are posing to themselves, the team, and, most importantly, the patients.
Certainly, physicians do not need another lecture about the perils of substance abuse. Whether discussing prescription drugs, alcohol, marijuana, cocaine, or the like, we all have witnessed the devastating effects of abuse. The fact is, any substance that alters our ability to perform our trusted duty must be avoided.
Colleagues, the algorithm is simple: Be vigilant, observe, confirm, and report. It is our moral and ethical imperative.
Dr. Pyke is chief medical officer of Medicus Consulting, LLC.
CON
Responsible, helpful action doesn’t always mean official involvement
Recognizing impairment in our colleagues is both difficult and ethically challenging. Despite national trends, medicine remains a largely self-regulated profession, and we have an ethical obligation to report impaired, incompetent, or unethical colleagues. Rarely are the indications for reporting or identifying a colleague clear.
As trained clinicians, we know the signs of substance abuse:6
- Frequent tardiness and absences;
- Unexplained disappearances during working hours;
- Inappropriate behavior;
- Affective lability or irritability;
- Interpersonal conflict;
- Avoidance of peers or supervisors;
- Keeping odd hours;
- Disorganized and forgetful;
- Incomplete charts and work performance;
- Heavy drinking at social functions;
- Unexplained changes in weight or energy level;
- Diminished personal hygiene;
- Slurred or rapid speech;
- Frequently dilated pupils or red, watery eyes and a runny nose;
- Defensiveness, anxiety, apathy, and manipulative behaviors; and
- Withdrawal from long-standing relationships.
Yet when it is a colleague, we are often in denial about their substance abuse. Certainly, simple seasonal allergies and allergy medications can cause a number of the above symptoms. We also are aware of and fear the potential impact of licensing board notification on a physician’s career. In fact, in a national survey of physicians, 45% of respondents who had encountered impaired or incompetent physicians had not reported them, even though 96% of those surveyed agreed that physicians should report impaired or incompetent colleagues.7
Similar to reporting child or elder abuse, you don’t want to be wrong.
At the same time, impaired physicians are disruptive. They negatively impact the lives of their patients, colleagues, and hospital staff.
It is possible to do both the responsible thing and not go directly to the licensing board. You are not responsible for diagnosing your colleagues, but rather recognizing possible impairment.
Check out the Federation of State Physician Health Programs’ website (www.fsphp.org) to identify a local physician health program. Call them and place a report of concern identifying your impaired colleague. While it’s possibly new to you, they have years of experience working with this situation. Trust these organizations, many of which are independent from licensing, to intervene responsibly and confidentially. They can evaluate your colleague and provide a treatment plan and monitoring, as needed. Their approach is rehabilitative rather than punitive, and they resist reporting to the medical board unless the physician-patient is noncompliant.
Physicians have better outcomes than the general population, with reported abstinence rates of 70% to 90% for those who complete treatment.8,9 Between 75% and 85% of physicians who complete rehabilitation and comply with close monitoring and follow-up care are able to return to work.9,10
There is hope for your impaired colleague. Contact your local physician health program.
Dr. Guerrasio is a hospitalist and director of resident and medical student remediation at the University of Colorado Denver.
References
- Hughes PH, Brandenburg N, Baldwin DC Jr., et al. Prevalence of substance use among US physicians. JAMA. 1992;267:2333-2339.
- Gold KB, Teitelbaum SA. Physicians impaired by substance abuse disorders. The Journal of Global Drug Policy and Practice website. Available at: http://www.globaldrugpolicy.org/2/2/3.php. Accessed June 27, 2011.
- Wolfgang AP. Substance abuse potential and job stress: a study of pharmacists, physicians, and nurses. J Pharm Mark Manage. 1989;3(4):97-110.
- Cicala RS. Substance abuse among physicians: What you need to know. Hosp Phys. 2003:39-46.
- Berge KH, Seppala MD, Schipper AM. Chemical dependency and the physician. Mayo Clin Proc. 2009;84(7):625-631.
- Bright RP, Krahn L. Impaired physicians: How to recognize, when to report, and where to refer. Curr Psy. 2010;9(6):11-20.
- Campbell EG, Regan S, Gruen RL, et al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med. 2007;147:795-802.
- Femino J, Nirenberg TD. Treatment outcome studies on physician impairment: a review of the literature. R I Med. 1994;77:345-350.
- Alpern F, Correnti CE, Dolan TE, Llufrio MC, Sill A. A survey of recovering Maryland physicians. Md Med J. 1992;41:301-303.
- Gallegos KV, Lubin BH, Bowers C, Blevins JW, Talbott GD, Wilson PO. Relapse and recovery: five to ten year follow-up study of chemically dependent physicians—the Georgia experience. Md Med J. 1992;41:315-319.
PRO
Hospitalists’ moral obligation is to protect the patient
In this era of historic budget deficits, wars, and political strife surrounding healthcare reform, one might ask if we can afford to spend valuable time and energy on the issue of reporting physicians who abuse substances.
At first glance, I certainly had skepticism about the subject, but then I dug deeper. To my surprise (and likely yours), studies indicate that physicians develop substance-abuse problems as often or more than the general population does.1 Recent reports detail horrific patient outcomes at the hands of health providers whose actions are compromised by drug use. With data showing the prevalence of substance abuse among physicians hovering around 10% to 12%, we must accept the reality that hospitalists are not exempt.2,3,4,5
As medical doctors, our promise to our patients is to provide care in an ethical manner. Even if we try to live in denial, most of us would agree that with great blessing (or power) comes great responsibility. So when the question of reporting a fellow hospitalist who is abusing substances was asked, my response was unequivocally yes.
In my opinion, this discussion can be limited to two overarching principles: First, we are compelled to put our patients first. As hospitalists, we are blessed to be caring for some of the most frail and vulnerable in our society. Fortunately, an overwhelming number of us do so with pride, skill, and integrity.
The task of providing high-quality care to an empowered patient population is difficult enough with us being physically, emotionally, and mentally exhausted. But to add substance abuse to this is just a complete and utter violation of our patients’ trust. We must agree that putting our patients’ well-being beyond reproach requires us to report any colleague who is compromised.
Second, delayed help for a colleague in trouble with substance-abuse issues could be fatal—and for more than just that single colleague. At some point, we are compelled to do more than just raise an eyebrow and shake our head. Usually at the time of discovery, months if not years of substance abuse already have gone by undetected. Deferring to the next person is just not an option. There is too much at stake. It is our moral duty to help our colleagues who are unable to realize the danger they are posing to themselves, the team, and, most importantly, the patients.
Certainly, physicians do not need another lecture about the perils of substance abuse. Whether discussing prescription drugs, alcohol, marijuana, cocaine, or the like, we all have witnessed the devastating effects of abuse. The fact is, any substance that alters our ability to perform our trusted duty must be avoided.
Colleagues, the algorithm is simple: Be vigilant, observe, confirm, and report. It is our moral and ethical imperative.
Dr. Pyke is chief medical officer of Medicus Consulting, LLC.
CON
Responsible, helpful action doesn’t always mean official involvement
Recognizing impairment in our colleagues is both difficult and ethically challenging. Despite national trends, medicine remains a largely self-regulated profession, and we have an ethical obligation to report impaired, incompetent, or unethical colleagues. Rarely are the indications for reporting or identifying a colleague clear.
As trained clinicians, we know the signs of substance abuse:6
- Frequent tardiness and absences;
- Unexplained disappearances during working hours;
- Inappropriate behavior;
- Affective lability or irritability;
- Interpersonal conflict;
- Avoidance of peers or supervisors;
- Keeping odd hours;
- Disorganized and forgetful;
- Incomplete charts and work performance;
- Heavy drinking at social functions;
- Unexplained changes in weight or energy level;
- Diminished personal hygiene;
- Slurred or rapid speech;
- Frequently dilated pupils or red, watery eyes and a runny nose;
- Defensiveness, anxiety, apathy, and manipulative behaviors; and
- Withdrawal from long-standing relationships.
Yet when it is a colleague, we are often in denial about their substance abuse. Certainly, simple seasonal allergies and allergy medications can cause a number of the above symptoms. We also are aware of and fear the potential impact of licensing board notification on a physician’s career. In fact, in a national survey of physicians, 45% of respondents who had encountered impaired or incompetent physicians had not reported them, even though 96% of those surveyed agreed that physicians should report impaired or incompetent colleagues.7
Similar to reporting child or elder abuse, you don’t want to be wrong.
At the same time, impaired physicians are disruptive. They negatively impact the lives of their patients, colleagues, and hospital staff.
It is possible to do both the responsible thing and not go directly to the licensing board. You are not responsible for diagnosing your colleagues, but rather recognizing possible impairment.
Check out the Federation of State Physician Health Programs’ website (www.fsphp.org) to identify a local physician health program. Call them and place a report of concern identifying your impaired colleague. While it’s possibly new to you, they have years of experience working with this situation. Trust these organizations, many of which are independent from licensing, to intervene responsibly and confidentially. They can evaluate your colleague and provide a treatment plan and monitoring, as needed. Their approach is rehabilitative rather than punitive, and they resist reporting to the medical board unless the physician-patient is noncompliant.
Physicians have better outcomes than the general population, with reported abstinence rates of 70% to 90% for those who complete treatment.8,9 Between 75% and 85% of physicians who complete rehabilitation and comply with close monitoring and follow-up care are able to return to work.9,10
There is hope for your impaired colleague. Contact your local physician health program.
Dr. Guerrasio is a hospitalist and director of resident and medical student remediation at the University of Colorado Denver.
References
- Hughes PH, Brandenburg N, Baldwin DC Jr., et al. Prevalence of substance use among US physicians. JAMA. 1992;267:2333-2339.
- Gold KB, Teitelbaum SA. Physicians impaired by substance abuse disorders. The Journal of Global Drug Policy and Practice website. Available at: http://www.globaldrugpolicy.org/2/2/3.php. Accessed June 27, 2011.
- Wolfgang AP. Substance abuse potential and job stress: a study of pharmacists, physicians, and nurses. J Pharm Mark Manage. 1989;3(4):97-110.
- Cicala RS. Substance abuse among physicians: What you need to know. Hosp Phys. 2003:39-46.
- Berge KH, Seppala MD, Schipper AM. Chemical dependency and the physician. Mayo Clin Proc. 2009;84(7):625-631.
- Bright RP, Krahn L. Impaired physicians: How to recognize, when to report, and where to refer. Curr Psy. 2010;9(6):11-20.
- Campbell EG, Regan S, Gruen RL, et al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med. 2007;147:795-802.
- Femino J, Nirenberg TD. Treatment outcome studies on physician impairment: a review of the literature. R I Med. 1994;77:345-350.
- Alpern F, Correnti CE, Dolan TE, Llufrio MC, Sill A. A survey of recovering Maryland physicians. Md Med J. 1992;41:301-303.
- Gallegos KV, Lubin BH, Bowers C, Blevins JW, Talbott GD, Wilson PO. Relapse and recovery: five to ten year follow-up study of chemically dependent physicians—the Georgia experience. Md Med J. 1992;41:315-319.
Escalating Postsurgical Pain Not Addressed
Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
At age 19, an Illinois woman underwent radical open anterior and posterior synovectomy for a rare knee disease at the defendant hospital. Examination immediately after surgery revealed no complications and a normal neurovascular status. That night and into the next morning, however, the patient repeatedly complained of pain below her knee and in her foot, and her neurovascular status was abnormal.
She was given repeated doses of pain medication with increasing dosage. Two resident physicians were contacted by the nursing staff, but neither came to the hospital to examine the patient. The attending physician was never contacted.
Early the next morning, the patient was examined by the attending physician, who made a diagnosis of compartment syndrome and performed a fasciotomy. The patient required several debridements to remove necrotic muscle and tissue below her knee. She lost about 90% of the muscle in the affected leg and has foot drop and severe nerve dysfunction.
The plaintiff claimed that the nurses and resident physicians failed to recognize her condition and communicate it to the attending physician. According to the plaintiff, the delay in diagnosis and treatment of compartment syndrome led to extensive muscle and tissue death.
The defendants argued that the plaintiff did not complain on the night of the surgery as she claimed, and that compartment syndrome was diagnosed in a timely manner. The defendants claimed that fasciotomy performed by the attending physician was too conservative, permitting compartment syndrome to recur or persist.
Continue for the outcome and David Lang's discussion >>
OUTCOME
A $14,891,123.02 verdict was returned.
COMMENT
Many clinical situations can lead to compartment syndrome, including sources inside the limb (fractures) or outside the limb (burns), as well as patient factors in the setting of seemingly trivial trauma (bleeding diathesis/anticoagulation therapy). In any practice setting where limbs are crushed, fractured, surgically manipulated, splinted, burned, or compressed, compartment syndrome may occur. Clinicians working in ambulatory or surgical settings should routinely alert patients to the possibility of this complication, and they must remain vigilant for patient reports of intense or escalating limb pain.
In a typical case of compartment syndrome, blood accumulates in a closed space (compartment) of an extremity, raising pressure sufficient to cause ischemia, followed by nerve damage and muscle necrosis. The classic diagnostic findings include pain, pallor, “pulselessness,” and paralysis (the “four Ps”). Disproportional pain (at times refractory to narcotic analgesia) is the earliest indicator of compartment syndrome. Pain is often described as deep, unremitting, and poorly localized; stretching of the muscle group within the compartment also worsens pain.
Malpractice cases involving missed compartment syndrome often result in a substantial verdict. This is so because patients are often young, and limb damage is severe—possibly including muscle loss, paralysis, or debilitating ischemic contracture. Fasciotomy is a relatively straightforward, curative treatment, but by the time it is performed, substantial damage may have been done.
To make matters worse, many causes of compartment syndrome are iatrogenic (eg, casting, surgery, instrumentation of a limb in an anticoagulated patient), which can compound the jury’s wrath. Lastly, the plaintiff’s lawyer can paint a vivid picture in which the limb is filling, time is ticking, the patient is screaming, damage is mounting—yet nothing is done. The jury is easily able to understand the elevating pressure in the limb, see the connection between the pressure and the damage, and recognize that a surgical release would have cured the problem. So guided, the jury can become incensed that the limb was allowed to “implode,” seriously degrading a patient’s life—as exemplified by the substantial verdict in favor of this unfortunate 19-year-old woman.
In any injury or intervention involving a limb, instruct the patient to return in the event of intense escalating pain. Exercise caution when the demand for analgesics seems high, escalating, or unduly urgent, or when pain is difficult to control. If compartment syndrome is suspected, compartment pressure measurements should be obtained promptly. —DML
Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
At age 19, an Illinois woman underwent radical open anterior and posterior synovectomy for a rare knee disease at the defendant hospital. Examination immediately after surgery revealed no complications and a normal neurovascular status. That night and into the next morning, however, the patient repeatedly complained of pain below her knee and in her foot, and her neurovascular status was abnormal.
She was given repeated doses of pain medication with increasing dosage. Two resident physicians were contacted by the nursing staff, but neither came to the hospital to examine the patient. The attending physician was never contacted.
Early the next morning, the patient was examined by the attending physician, who made a diagnosis of compartment syndrome and performed a fasciotomy. The patient required several debridements to remove necrotic muscle and tissue below her knee. She lost about 90% of the muscle in the affected leg and has foot drop and severe nerve dysfunction.
The plaintiff claimed that the nurses and resident physicians failed to recognize her condition and communicate it to the attending physician. According to the plaintiff, the delay in diagnosis and treatment of compartment syndrome led to extensive muscle and tissue death.
The defendants argued that the plaintiff did not complain on the night of the surgery as she claimed, and that compartment syndrome was diagnosed in a timely manner. The defendants claimed that fasciotomy performed by the attending physician was too conservative, permitting compartment syndrome to recur or persist.
Continue for the outcome and David Lang's discussion >>
OUTCOME
A $14,891,123.02 verdict was returned.
COMMENT
Many clinical situations can lead to compartment syndrome, including sources inside the limb (fractures) or outside the limb (burns), as well as patient factors in the setting of seemingly trivial trauma (bleeding diathesis/anticoagulation therapy). In any practice setting where limbs are crushed, fractured, surgically manipulated, splinted, burned, or compressed, compartment syndrome may occur. Clinicians working in ambulatory or surgical settings should routinely alert patients to the possibility of this complication, and they must remain vigilant for patient reports of intense or escalating limb pain.
In a typical case of compartment syndrome, blood accumulates in a closed space (compartment) of an extremity, raising pressure sufficient to cause ischemia, followed by nerve damage and muscle necrosis. The classic diagnostic findings include pain, pallor, “pulselessness,” and paralysis (the “four Ps”). Disproportional pain (at times refractory to narcotic analgesia) is the earliest indicator of compartment syndrome. Pain is often described as deep, unremitting, and poorly localized; stretching of the muscle group within the compartment also worsens pain.
Malpractice cases involving missed compartment syndrome often result in a substantial verdict. This is so because patients are often young, and limb damage is severe—possibly including muscle loss, paralysis, or debilitating ischemic contracture. Fasciotomy is a relatively straightforward, curative treatment, but by the time it is performed, substantial damage may have been done.
To make matters worse, many causes of compartment syndrome are iatrogenic (eg, casting, surgery, instrumentation of a limb in an anticoagulated patient), which can compound the jury’s wrath. Lastly, the plaintiff’s lawyer can paint a vivid picture in which the limb is filling, time is ticking, the patient is screaming, damage is mounting—yet nothing is done. The jury is easily able to understand the elevating pressure in the limb, see the connection between the pressure and the damage, and recognize that a surgical release would have cured the problem. So guided, the jury can become incensed that the limb was allowed to “implode,” seriously degrading a patient’s life—as exemplified by the substantial verdict in favor of this unfortunate 19-year-old woman.
In any injury or intervention involving a limb, instruct the patient to return in the event of intense escalating pain. Exercise caution when the demand for analgesics seems high, escalating, or unduly urgent, or when pain is difficult to control. If compartment syndrome is suspected, compartment pressure measurements should be obtained promptly. —DML
Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
At age 19, an Illinois woman underwent radical open anterior and posterior synovectomy for a rare knee disease at the defendant hospital. Examination immediately after surgery revealed no complications and a normal neurovascular status. That night and into the next morning, however, the patient repeatedly complained of pain below her knee and in her foot, and her neurovascular status was abnormal.
She was given repeated doses of pain medication with increasing dosage. Two resident physicians were contacted by the nursing staff, but neither came to the hospital to examine the patient. The attending physician was never contacted.
Early the next morning, the patient was examined by the attending physician, who made a diagnosis of compartment syndrome and performed a fasciotomy. The patient required several debridements to remove necrotic muscle and tissue below her knee. She lost about 90% of the muscle in the affected leg and has foot drop and severe nerve dysfunction.
The plaintiff claimed that the nurses and resident physicians failed to recognize her condition and communicate it to the attending physician. According to the plaintiff, the delay in diagnosis and treatment of compartment syndrome led to extensive muscle and tissue death.
The defendants argued that the plaintiff did not complain on the night of the surgery as she claimed, and that compartment syndrome was diagnosed in a timely manner. The defendants claimed that fasciotomy performed by the attending physician was too conservative, permitting compartment syndrome to recur or persist.
Continue for the outcome and David Lang's discussion >>
OUTCOME
A $14,891,123.02 verdict was returned.
COMMENT
Many clinical situations can lead to compartment syndrome, including sources inside the limb (fractures) or outside the limb (burns), as well as patient factors in the setting of seemingly trivial trauma (bleeding diathesis/anticoagulation therapy). In any practice setting where limbs are crushed, fractured, surgically manipulated, splinted, burned, or compressed, compartment syndrome may occur. Clinicians working in ambulatory or surgical settings should routinely alert patients to the possibility of this complication, and they must remain vigilant for patient reports of intense or escalating limb pain.
In a typical case of compartment syndrome, blood accumulates in a closed space (compartment) of an extremity, raising pressure sufficient to cause ischemia, followed by nerve damage and muscle necrosis. The classic diagnostic findings include pain, pallor, “pulselessness,” and paralysis (the “four Ps”). Disproportional pain (at times refractory to narcotic analgesia) is the earliest indicator of compartment syndrome. Pain is often described as deep, unremitting, and poorly localized; stretching of the muscle group within the compartment also worsens pain.
Malpractice cases involving missed compartment syndrome often result in a substantial verdict. This is so because patients are often young, and limb damage is severe—possibly including muscle loss, paralysis, or debilitating ischemic contracture. Fasciotomy is a relatively straightforward, curative treatment, but by the time it is performed, substantial damage may have been done.
To make matters worse, many causes of compartment syndrome are iatrogenic (eg, casting, surgery, instrumentation of a limb in an anticoagulated patient), which can compound the jury’s wrath. Lastly, the plaintiff’s lawyer can paint a vivid picture in which the limb is filling, time is ticking, the patient is screaming, damage is mounting—yet nothing is done. The jury is easily able to understand the elevating pressure in the limb, see the connection between the pressure and the damage, and recognize that a surgical release would have cured the problem. So guided, the jury can become incensed that the limb was allowed to “implode,” seriously degrading a patient’s life—as exemplified by the substantial verdict in favor of this unfortunate 19-year-old woman.
In any injury or intervention involving a limb, instruct the patient to return in the event of intense escalating pain. Exercise caution when the demand for analgesics seems high, escalating, or unduly urgent, or when pain is difficult to control. If compartment syndrome is suspected, compartment pressure measurements should be obtained promptly. —DML
Cancer Patient Urged to Sue By Later Provider
Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
A 52-year-old woman had a long history of abdominal pain and adhesions. In September 2005, after five years of adhesion-type abdominal pain, she underwent removal of her ovaries and fallopian tubes. A prior laparoscopic adhesiolysis had failed to resolve the pain. After the surgery, a tissue sample was sent to Dr. B., who diagnosed a “benign serous papillary tumor with psammoma bodies.”
In early 2007, the abdominal pain returned. The woman’s primary care physician immediately sent her for a series of MRIs over the next eight months. These revealed very minor changes in the lower pelvis. Ultimately, another diagnostic laparoscopy was performed, which revealed primary peritoneal cancer.
Staging surgery was performed by Dr. G., who testified at trial that she found cancer “everywhere” in the peritoneal cavity. After personally comparing pathology slides from the 2008 surgery with the tissue from the 2005 surgery, Dr. G. concluded that the tissue was virtually identical and the patient had cancer in 2005.
Dr. G. gave the woman a copy of Dr. B.’s 2005 pathology report with the advice to see a lawyer. Dr. G., however, did not provide a copy of the pathology report she had received from a gynecologic pathology expert, who had reviewed both tissue samples and concluded that Dr. B.’s diagnosis was reasonable.
The patient was ultimately diagnosed with low-grade primary peritoneal carcinoma, which was thought to have originated in her ovaries and fallopian tubes. She claimed that Dr. B.’s failure to diagnose cancer or borderline cancer in 2005 reduced her chance of survival by almost 70%. The defendant claimed that an earlier diagnosis would not have changed the plaintiff’s prognosis.
Outcome on next page >>
OUTCOME
A defense verdict was returned.
COMMENT
One of the most common reasons a patient decides to file a medical malpractice lawsuit is because a later treating professional recommends it. In this case, the staging surgeon reviewed the prior slides and concluded that the cancer should have been discovered at the time of the original surgery. It does not appear that she was a pathologist.
What is puzzling is why this provider would recommend that the patient see a lawyer, while withholding an expert pathology opinion stating that the original pathologist’s findings were reasonable. She did neither the patient nor her lawyer a favor. I am not surprised by the defense verdict in this case. —JP
Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
A 52-year-old woman had a long history of abdominal pain and adhesions. In September 2005, after five years of adhesion-type abdominal pain, she underwent removal of her ovaries and fallopian tubes. A prior laparoscopic adhesiolysis had failed to resolve the pain. After the surgery, a tissue sample was sent to Dr. B., who diagnosed a “benign serous papillary tumor with psammoma bodies.”
In early 2007, the abdominal pain returned. The woman’s primary care physician immediately sent her for a series of MRIs over the next eight months. These revealed very minor changes in the lower pelvis. Ultimately, another diagnostic laparoscopy was performed, which revealed primary peritoneal cancer.
Staging surgery was performed by Dr. G., who testified at trial that she found cancer “everywhere” in the peritoneal cavity. After personally comparing pathology slides from the 2008 surgery with the tissue from the 2005 surgery, Dr. G. concluded that the tissue was virtually identical and the patient had cancer in 2005.
Dr. G. gave the woman a copy of Dr. B.’s 2005 pathology report with the advice to see a lawyer. Dr. G., however, did not provide a copy of the pathology report she had received from a gynecologic pathology expert, who had reviewed both tissue samples and concluded that Dr. B.’s diagnosis was reasonable.
The patient was ultimately diagnosed with low-grade primary peritoneal carcinoma, which was thought to have originated in her ovaries and fallopian tubes. She claimed that Dr. B.’s failure to diagnose cancer or borderline cancer in 2005 reduced her chance of survival by almost 70%. The defendant claimed that an earlier diagnosis would not have changed the plaintiff’s prognosis.
Outcome on next page >>
OUTCOME
A defense verdict was returned.
COMMENT
One of the most common reasons a patient decides to file a medical malpractice lawsuit is because a later treating professional recommends it. In this case, the staging surgeon reviewed the prior slides and concluded that the cancer should have been discovered at the time of the original surgery. It does not appear that she was a pathologist.
What is puzzling is why this provider would recommend that the patient see a lawyer, while withholding an expert pathology opinion stating that the original pathologist’s findings were reasonable. She did neither the patient nor her lawyer a favor. I am not surprised by the defense verdict in this case. —JP
Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
A 52-year-old woman had a long history of abdominal pain and adhesions. In September 2005, after five years of adhesion-type abdominal pain, she underwent removal of her ovaries and fallopian tubes. A prior laparoscopic adhesiolysis had failed to resolve the pain. After the surgery, a tissue sample was sent to Dr. B., who diagnosed a “benign serous papillary tumor with psammoma bodies.”
In early 2007, the abdominal pain returned. The woman’s primary care physician immediately sent her for a series of MRIs over the next eight months. These revealed very minor changes in the lower pelvis. Ultimately, another diagnostic laparoscopy was performed, which revealed primary peritoneal cancer.
Staging surgery was performed by Dr. G., who testified at trial that she found cancer “everywhere” in the peritoneal cavity. After personally comparing pathology slides from the 2008 surgery with the tissue from the 2005 surgery, Dr. G. concluded that the tissue was virtually identical and the patient had cancer in 2005.
Dr. G. gave the woman a copy of Dr. B.’s 2005 pathology report with the advice to see a lawyer. Dr. G., however, did not provide a copy of the pathology report she had received from a gynecologic pathology expert, who had reviewed both tissue samples and concluded that Dr. B.’s diagnosis was reasonable.
The patient was ultimately diagnosed with low-grade primary peritoneal carcinoma, which was thought to have originated in her ovaries and fallopian tubes. She claimed that Dr. B.’s failure to diagnose cancer or borderline cancer in 2005 reduced her chance of survival by almost 70%. The defendant claimed that an earlier diagnosis would not have changed the plaintiff’s prognosis.
Outcome on next page >>
OUTCOME
A defense verdict was returned.
COMMENT
One of the most common reasons a patient decides to file a medical malpractice lawsuit is because a later treating professional recommends it. In this case, the staging surgeon reviewed the prior slides and concluded that the cancer should have been discovered at the time of the original surgery. It does not appear that she was a pathologist.
What is puzzling is why this provider would recommend that the patient see a lawyer, while withholding an expert pathology opinion stating that the original pathologist’s findings were reasonable. She did neither the patient nor her lawyer a favor. I am not surprised by the defense verdict in this case. —JP
Physician impairment: When should you report?
Discuss this article at www.facebook.com/CurrentPsychiatry
Dear Dr. Mossman:
Lately, a physician colleague has been arriving late for work. He seemed drunk a couple of times, and he’s been making some careless but minor mistakes. When would I have a duty to report him for suspected impairment? He is a longtime friend, which makes me uncomfortable with the prospect of having to report him.—Submitted by “Dr. Z”
Holding ourselves to ethical guidelines and standards of conduct sometimes is hard, but when we become responsible for our colleagues’ behavior, things can get awkward. Yet the responsibilities of practicing medicine include professional self-regulation.1 Failure to monitor ourselves and each other would put the reputation and integrity of the medical profession at risk—not to mention the safety of our patients. Despite this, many physicians are understandably reluctant to report colleagues who appear impaired.
To decide whether you should report a colleague, you must:
- know what behaviors constitute impairment
- understand the duty to report impaired colleagues
- realize reporting colleagues often creates emotional conflict
- understand recovery options and resources available for impaired practitioners.
After we examine these matters, we’ll see what Dr. Z should do.
Impairment defined
Physician impairment is a public health issue that affects not just physicians but their families, colleagues, and patients. In this context, “impairment” means a physical, mental, or substance-related disorder that interferes with a physician’s ability to undertake professional activities competently and safely.2
Although many mental conditions can cause impairment, we focus here on substance abuse, a condition that often leads to functional impairment. Physicians develop addictions at rates at least as high as those in the general population.3 Physicians-in- training—including psychiatric residents—are at particularly high risk for developing stress-related problems, depression, and substance misuse.4,5
Occupational demands, self-criticism, and denial of one’s own distress are common failings among physicians,5 as is self-treatment, which may help explain the high rates of substance misuse among physicians.6 Behaviors that suggest a colleague may be abusing substances and experiencing occupational impairment appear in Table 1.7
Table 1
Signs of physician impairment
| Deteriorating personal hygiene |
| Increased absence from professional functions or duties |
| Emotional lability |
| Appearing sleep-deprived |
| Increased professional errors (eg, prescriptions, dictations, clinical judgment) |
| Not responding to pages or telephone calls |
| Decreased concern for patient well-being |
| Citing unexplained ‘personal problems’ to mask deficits in concentration or patient care |
| Increased patient complaints about quality of care and bedside manner |
| Many ‘accidental’ injuries (possibly contrived to obtain narcotic prescriptions) |
| Source: Reference 7 |
Reporting duties
Doctors and physician health programs have a duty to report impaired colleagues who continue to practice despite reasonable offers of assistance. This obligation appears in professional guidelines (Table 2)2,8 and in laws and regulations governing the practice of medicine. Laws and regulations are similar in spirit across jurisdictions, although the exact wording varies from state to state (Table 3).9-11 Physicians are responsible for being familiar with reporting requirements in states they practice and complying accordingly.
Physicians must follow state guidelines and protocols for reporting a colleague’s impairment. In many situations, an intermediate step—such as notifying a chief of service or a physician health program—might occur before a report of impairment goes to a licensing board. Options for reporting impaired physicians appear in Table 4.2,12
Table 2
Medical associations’ official positions on reporting impairment
| American Medical Association (Policy H-275.952)2 | ‘Physicians have an ethical obligation to report impaired, incompetent, and unethical colleagues.’ |
| Federation of State Medical Boards8 | Physician health programs have ‘a primary commitment to [help] state medical boards … protect the public … [These] programs [should] demonstrate an ongoing track record of ensuring safety to the public and reveal deficiencies if they occur.’ |
Table 3
State medical board rules on reporting physician impairment: 3 examples
| State | Rules |
|---|---|
| California9 | California’s Medical Practice Act contains no mandatory reporting requirement. ‘However, … the Board clearly is concerned about physicians who potentially present a danger to their patients. Reporting an impaired colleague to the Medical Board will allow the Board to ensure adequate protections are in place so a colleague who requires assistance will not harm the public. The Board keeps the sources of complaint information confidential.’ |
| Montana10 | ‘[E]ach licensed physician … shall … report to the board any information … that appears to show that a physician is’ impaired. However, ‘[i]nformation that relates to possible physical or mental impairment connected to [substance misuse or illness] may be reported to’ Montana’s physician rehabilitation program ‘in lieu of reporting directly to the board.’ |
| Ohio11 | ‘Any Board licensee having knowledge’ that a physician is impaired because of substance misuse ‘is required … to report that information to the Board. … [H]owever, … the [impaired] physician’s colleagues may be excused from reporting the physician’s impairment … if the [impaired] physician has completed treatment with a Board approved treatment provider and maintained uninterrupted sobriety, and violated no other provisions of the Ohio Medical Practice Act.’ |
Table 4
Options for reporting impaired colleagues
| Impairment in hospital-based physicians may be reported to the hospital’s in-house impairment program, the hospital’s chief of staff, or another appropriate supervisor (eg, a chief resident) |
| Impairment in physicians with office-based practices may be reported to hospitals where they have privileges or to the state’s physician health program |
| Colleagues who continue to practice despite offers of assistance and referrals for treatment or for whom the above options are not available should be reported to the state licensing board |
| Source: References 2,12 |
Overcoming emotional factors
Doctors facing the need to report an impaired colleague often experience emotional conflicts because the impaired is a mentor, supervisor, trainee, friend, or practice partner. Denial, stigmatization, concerns about practice coverage, and fear of retaliation also can contribute to non-reporting. Although we know a colleague’s substance misuse represents a threat to his patients’ welfare and safety,13 reporting a colleague forces us to overcome our allegiance to a fellow practitioner.
Medical professionals should remember, however, that it is always better to identify and treat illnesses early in their course. When early referrals are not made, doctors afflicted by illness often remain without treatment until more severe impairment causes workplace errors. Withholding information about an impaired colleague from supervisors or state medical boards does a disservice to patients and to the colleague. The colleague’s drug or alcohol problems may worsen, and recovery or acquisition of future licenses might become more difficult or impossible. Initial application for medical licensure in 47 states and the District of Columbia inquire about physicians’ recent history of mental health and substance abuse problems, as well as their functional impairment.14 Even renewal of state medical licensure examines applicants’ mental health, physical health, and substance abuse histories.15
Recovery resources
Many institutions and medical board committees have instituted written policies for dealing with workplace addiction.13 An awareness of and sensitivity to physician vulnerability and early detection and prevention of impairment are important.2
At least 39 states have “sick doctor statutes” that permit licensure suspension for physicians who cannot practice medicine safely because of illness or substance use disorders.16 Several states have forms of “immunity”—license protection and preservation—for physicians who seek treatment voluntarily, and some states have legislative provisions that require impaired physicians to get treatment and be monitored so they can keep their licenses.17 In almost every state, medical societies have established physicians’ health committees and treatment programs (Table 5).18
Table 5
Examples of state physician health programs
| State | Organization | Contact |
|---|---|---|
| Colorado | Colorado Physician Health Program | (303) 860-0122 www.cphp.org |
| Florida | Professional Resources Network | (800) 888-8776 www.flprn.org |
| Illinois | Illinois Professional Health Program | (800) 323-8622 www.advocatehealth.com/IPHP |
| Massachusetts | Physician Health Services, Inc. | (781) 434-7404 www.massmed.org |
| Minnesota | Health Professionals Services Program | (651) 643-2120 www.hpsp.state.mn.us |
| Nevada | Nevada Professionals Assistance Program | (702) 521-1398 www.medboard.nv.gov |
| New York | Committee for Physician Health, Medical Society of the State of New York | (518) 436-4723 www.cphny.org |
| Ohio | Ohio Physicians Health Program | (614) 841-9690 www.ophp.org |
| Oregon | Oregon Health Professionals Program | (503) 620-9117 www.oregon.gov/OHA/addiction/health-professionals.shtml |
| Tennessee | Physicians Health Program, Tennessee Medical Foundation | (615) 467-6411 www.e-tmf.org |
| Texas | Committee on Physician Health and Rehabilitation, Texas Medical Association | (512) 370-1342 www.texmed.org |
| Source: Reference 18 | ||
Physicians often recover
Physician treatment is unique for several reasons. First, it is rarely voluntary, and because treatment is coerced in some way, physicians are sicker when they enter treatment. They have more social dysfunction, more medical consequences, and simply are more complicated to treat. Still, most treatment programs for impaired professionals report better rates of long-term recovery than those of the general public, perhaps because physicians are monitored intensively and have the strong motivation of not wanting to lose their medical licenses. For example, in a study of 100 alcoholic U.S. doctors followed for 21 years, 73% had recovered. This study and others show a strong relationship between recovery and attending meetings of self-help groups.19
What should Dr. Z do?
Dr. Z is a member of a professional community that has an ethical obligation to police itself and to report observations that suggest impairment. His colleague’s suspected substance use disorder could interfere with his ability to function and pose a risk to patient welfare and safety.
Although reporting a colleague is unpleasant, impaired physicians often recover, and the data support optimism about returning to clinical practice for physicians who get appropriate treatment. In this case, Dr. Z’s reporting of his concerns about impairment would help uphold the integrity of the medical profession and would offer his colleague the potential benefits of treatment and recovery programs.
Related Resources
- Bright RP, Krahn L. Impaired physicians: How to recognize, when to report, and where to refer. Current Psychiatry. 2010;9(6):11-20.
- DuPont RL, McLellan AT, White WL, et al. Setting the standard for recovery: Physicians’ Health Programs. J Subst Abuse Treat. 2009;36(2):159-171.
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Ernhart CB, Scarr S, Geneson DF. On being a whistleblower: the Needleman case Ethics Behav. 1993;3(1):73-93.
2. American Medical Association. Policies related to physician health. Available at: http://www.ama-assn.org/resources/doc/physician-health/policies-physicain-health.pdf. Accessed June 19, 2011.
3. Berge KH, Seppala MD, Schipper AM. Chemical dependency and the physician. Mayo Clin Proc. 2009;84(7):625-631.
4. Broquet KE, Rockey PH. Teaching residents and program directors about physician impairment. Acad Psychiatry. 2004;28(3):221-225.
5. Meier DE, Back AL, Morrison RS. The inner life of physicians and care of the seriously ill. JAMA. 2001;286(23):3007-3014.
6. Firth-Cozens J. Improving the health of psychiatrists. Adv Psychiatr Treat. 2007;13(3):161-168.
7. McGovern MP, Angres DH, Leon S. Characteristics of physicians presenting for assessment at a behavioral health center. J Addict Dis. 2000;19(2):59-73.
8. Federation of State Medical Boards of the United States. Policy on physician impairment. Available at: http://www.csam-asam.org/pdf/misc/FSMB2011.pdf. Accessed June 8, 2011.
9. Medical Board of California. Complaint process - frequently asked questions. Available at: http://www.medbd.ca.gov/consumer/complaint_info_questions_process.html. Accessed June 8, 2011.
10. Montana Code Ann § 37-3-401 (2005)
11. State Medical Board of Ohio. Policies and positions: licensure of chemically impaired resident physicians. Available at: http://www.med.ohio.gov/positionpapers/resident.htm. Accessed June 19, 2011.
12. American Medical Association. Code of medical ethics, opinion 9.031. Reporting impaired, incompetent, or unethical colleagues. Available at: http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion9031.page. Accessed June 19, 2011.
13. Hulse G, Sim MG, Khong E. Management of the impaired doctor. Aust Fam Physician. 2004;33(9):703-707.
14. Sansone RA, Wiederman MW, Sansone LA. Physician mental health and substance abuse. What are state medical licensure applications asking? Arch Fam Med. 1999;8(5):448-451.
15. Hansen TE, Goetz RR, Bloom JD, et al. Changes in questions about psychiatric illness asked on medical licensure applications between 1993 and 1996. Psychiatr Serv. 1998;49(2):202-206.
16. Boisaubin EV, Levine RE. Identifying and assisting the impaired physician. Am J Med Sci. 2001;322(1):31-36.
17. Verghese A. Physicians and addiction. N Engl J Med. 2002;346(20):1510-1511.
18. Federation of State Physicians Health Programs. Available at: http://www.fsphp.org. Accessed June 8, 2011.
19. Lloyd G. One hundred alcoholic doctors: a 21-year follow-up. Alcohol Alcohol. 2002;37(4):370-374
Douglas Mossman, MD
Dr. Mossman is administrative director, Glenn M. Weaver Institute of Law and Psychiatry, University of Cincinnati College of Law, and Adjunct Professor of Clinical Psychiatry and Training Director for the University of Cincinnati Forensic Psychiatry Fellowship, Cincinnati, OH.
Helen M. Farrell, MD
Dr. Farrell is an instructor at Harvard Medical School and a staff psychiatrist at Beth Israel Deaconess Medical Center, Boston, MA.
Douglas Mossman, MD
Dr. Mossman is administrative director, Glenn M. Weaver Institute of Law and Psychiatry, University of Cincinnati College of Law, and Adjunct Professor of Clinical Psychiatry and Training Director for the University of Cincinnati Forensic Psychiatry Fellowship, Cincinnati, OH.
Helen M. Farrell, MD
Dr. Farrell is an instructor at Harvard Medical School and a staff psychiatrist at Beth Israel Deaconess Medical Center, Boston, MA.
Douglas Mossman, MD
Dr. Mossman is administrative director, Glenn M. Weaver Institute of Law and Psychiatry, University of Cincinnati College of Law, and Adjunct Professor of Clinical Psychiatry and Training Director for the University of Cincinnati Forensic Psychiatry Fellowship, Cincinnati, OH.
Helen M. Farrell, MD
Dr. Farrell is an instructor at Harvard Medical School and a staff psychiatrist at Beth Israel Deaconess Medical Center, Boston, MA.
Discuss this article at www.facebook.com/CurrentPsychiatry
Dear Dr. Mossman:
Lately, a physician colleague has been arriving late for work. He seemed drunk a couple of times, and he’s been making some careless but minor mistakes. When would I have a duty to report him for suspected impairment? He is a longtime friend, which makes me uncomfortable with the prospect of having to report him.—Submitted by “Dr. Z”
Holding ourselves to ethical guidelines and standards of conduct sometimes is hard, but when we become responsible for our colleagues’ behavior, things can get awkward. Yet the responsibilities of practicing medicine include professional self-regulation.1 Failure to monitor ourselves and each other would put the reputation and integrity of the medical profession at risk—not to mention the safety of our patients. Despite this, many physicians are understandably reluctant to report colleagues who appear impaired.
To decide whether you should report a colleague, you must:
- know what behaviors constitute impairment
- understand the duty to report impaired colleagues
- realize reporting colleagues often creates emotional conflict
- understand recovery options and resources available for impaired practitioners.
After we examine these matters, we’ll see what Dr. Z should do.
Impairment defined
Physician impairment is a public health issue that affects not just physicians but their families, colleagues, and patients. In this context, “impairment” means a physical, mental, or substance-related disorder that interferes with a physician’s ability to undertake professional activities competently and safely.2
Although many mental conditions can cause impairment, we focus here on substance abuse, a condition that often leads to functional impairment. Physicians develop addictions at rates at least as high as those in the general population.3 Physicians-in- training—including psychiatric residents—are at particularly high risk for developing stress-related problems, depression, and substance misuse.4,5
Occupational demands, self-criticism, and denial of one’s own distress are common failings among physicians,5 as is self-treatment, which may help explain the high rates of substance misuse among physicians.6 Behaviors that suggest a colleague may be abusing substances and experiencing occupational impairment appear in Table 1.7
Table 1
Signs of physician impairment
| Deteriorating personal hygiene |
| Increased absence from professional functions or duties |
| Emotional lability |
| Appearing sleep-deprived |
| Increased professional errors (eg, prescriptions, dictations, clinical judgment) |
| Not responding to pages or telephone calls |
| Decreased concern for patient well-being |
| Citing unexplained ‘personal problems’ to mask deficits in concentration or patient care |
| Increased patient complaints about quality of care and bedside manner |
| Many ‘accidental’ injuries (possibly contrived to obtain narcotic prescriptions) |
| Source: Reference 7 |
Reporting duties
Doctors and physician health programs have a duty to report impaired colleagues who continue to practice despite reasonable offers of assistance. This obligation appears in professional guidelines (Table 2)2,8 and in laws and regulations governing the practice of medicine. Laws and regulations are similar in spirit across jurisdictions, although the exact wording varies from state to state (Table 3).9-11 Physicians are responsible for being familiar with reporting requirements in states they practice and complying accordingly.
Physicians must follow state guidelines and protocols for reporting a colleague’s impairment. In many situations, an intermediate step—such as notifying a chief of service or a physician health program—might occur before a report of impairment goes to a licensing board. Options for reporting impaired physicians appear in Table 4.2,12
Table 2
Medical associations’ official positions on reporting impairment
| American Medical Association (Policy H-275.952)2 | ‘Physicians have an ethical obligation to report impaired, incompetent, and unethical colleagues.’ |
| Federation of State Medical Boards8 | Physician health programs have ‘a primary commitment to [help] state medical boards … protect the public … [These] programs [should] demonstrate an ongoing track record of ensuring safety to the public and reveal deficiencies if they occur.’ |
Table 3
State medical board rules on reporting physician impairment: 3 examples
| State | Rules |
|---|---|
| California9 | California’s Medical Practice Act contains no mandatory reporting requirement. ‘However, … the Board clearly is concerned about physicians who potentially present a danger to their patients. Reporting an impaired colleague to the Medical Board will allow the Board to ensure adequate protections are in place so a colleague who requires assistance will not harm the public. The Board keeps the sources of complaint information confidential.’ |
| Montana10 | ‘[E]ach licensed physician … shall … report to the board any information … that appears to show that a physician is’ impaired. However, ‘[i]nformation that relates to possible physical or mental impairment connected to [substance misuse or illness] may be reported to’ Montana’s physician rehabilitation program ‘in lieu of reporting directly to the board.’ |
| Ohio11 | ‘Any Board licensee having knowledge’ that a physician is impaired because of substance misuse ‘is required … to report that information to the Board. … [H]owever, … the [impaired] physician’s colleagues may be excused from reporting the physician’s impairment … if the [impaired] physician has completed treatment with a Board approved treatment provider and maintained uninterrupted sobriety, and violated no other provisions of the Ohio Medical Practice Act.’ |
Table 4
Options for reporting impaired colleagues
| Impairment in hospital-based physicians may be reported to the hospital’s in-house impairment program, the hospital’s chief of staff, or another appropriate supervisor (eg, a chief resident) |
| Impairment in physicians with office-based practices may be reported to hospitals where they have privileges or to the state’s physician health program |
| Colleagues who continue to practice despite offers of assistance and referrals for treatment or for whom the above options are not available should be reported to the state licensing board |
| Source: References 2,12 |
Overcoming emotional factors
Doctors facing the need to report an impaired colleague often experience emotional conflicts because the impaired is a mentor, supervisor, trainee, friend, or practice partner. Denial, stigmatization, concerns about practice coverage, and fear of retaliation also can contribute to non-reporting. Although we know a colleague’s substance misuse represents a threat to his patients’ welfare and safety,13 reporting a colleague forces us to overcome our allegiance to a fellow practitioner.
Medical professionals should remember, however, that it is always better to identify and treat illnesses early in their course. When early referrals are not made, doctors afflicted by illness often remain without treatment until more severe impairment causes workplace errors. Withholding information about an impaired colleague from supervisors or state medical boards does a disservice to patients and to the colleague. The colleague’s drug or alcohol problems may worsen, and recovery or acquisition of future licenses might become more difficult or impossible. Initial application for medical licensure in 47 states and the District of Columbia inquire about physicians’ recent history of mental health and substance abuse problems, as well as their functional impairment.14 Even renewal of state medical licensure examines applicants’ mental health, physical health, and substance abuse histories.15
Recovery resources
Many institutions and medical board committees have instituted written policies for dealing with workplace addiction.13 An awareness of and sensitivity to physician vulnerability and early detection and prevention of impairment are important.2
At least 39 states have “sick doctor statutes” that permit licensure suspension for physicians who cannot practice medicine safely because of illness or substance use disorders.16 Several states have forms of “immunity”—license protection and preservation—for physicians who seek treatment voluntarily, and some states have legislative provisions that require impaired physicians to get treatment and be monitored so they can keep their licenses.17 In almost every state, medical societies have established physicians’ health committees and treatment programs (Table 5).18
Table 5
Examples of state physician health programs
| State | Organization | Contact |
|---|---|---|
| Colorado | Colorado Physician Health Program | (303) 860-0122 www.cphp.org |
| Florida | Professional Resources Network | (800) 888-8776 www.flprn.org |
| Illinois | Illinois Professional Health Program | (800) 323-8622 www.advocatehealth.com/IPHP |
| Massachusetts | Physician Health Services, Inc. | (781) 434-7404 www.massmed.org |
| Minnesota | Health Professionals Services Program | (651) 643-2120 www.hpsp.state.mn.us |
| Nevada | Nevada Professionals Assistance Program | (702) 521-1398 www.medboard.nv.gov |
| New York | Committee for Physician Health, Medical Society of the State of New York | (518) 436-4723 www.cphny.org |
| Ohio | Ohio Physicians Health Program | (614) 841-9690 www.ophp.org |
| Oregon | Oregon Health Professionals Program | (503) 620-9117 www.oregon.gov/OHA/addiction/health-professionals.shtml |
| Tennessee | Physicians Health Program, Tennessee Medical Foundation | (615) 467-6411 www.e-tmf.org |
| Texas | Committee on Physician Health and Rehabilitation, Texas Medical Association | (512) 370-1342 www.texmed.org |
| Source: Reference 18 | ||
Physicians often recover
Physician treatment is unique for several reasons. First, it is rarely voluntary, and because treatment is coerced in some way, physicians are sicker when they enter treatment. They have more social dysfunction, more medical consequences, and simply are more complicated to treat. Still, most treatment programs for impaired professionals report better rates of long-term recovery than those of the general public, perhaps because physicians are monitored intensively and have the strong motivation of not wanting to lose their medical licenses. For example, in a study of 100 alcoholic U.S. doctors followed for 21 years, 73% had recovered. This study and others show a strong relationship between recovery and attending meetings of self-help groups.19
What should Dr. Z do?
Dr. Z is a member of a professional community that has an ethical obligation to police itself and to report observations that suggest impairment. His colleague’s suspected substance use disorder could interfere with his ability to function and pose a risk to patient welfare and safety.
Although reporting a colleague is unpleasant, impaired physicians often recover, and the data support optimism about returning to clinical practice for physicians who get appropriate treatment. In this case, Dr. Z’s reporting of his concerns about impairment would help uphold the integrity of the medical profession and would offer his colleague the potential benefits of treatment and recovery programs.
Related Resources
- Bright RP, Krahn L. Impaired physicians: How to recognize, when to report, and where to refer. Current Psychiatry. 2010;9(6):11-20.
- DuPont RL, McLellan AT, White WL, et al. Setting the standard for recovery: Physicians’ Health Programs. J Subst Abuse Treat. 2009;36(2):159-171.
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Discuss this article at www.facebook.com/CurrentPsychiatry
Dear Dr. Mossman:
Lately, a physician colleague has been arriving late for work. He seemed drunk a couple of times, and he’s been making some careless but minor mistakes. When would I have a duty to report him for suspected impairment? He is a longtime friend, which makes me uncomfortable with the prospect of having to report him.—Submitted by “Dr. Z”
Holding ourselves to ethical guidelines and standards of conduct sometimes is hard, but when we become responsible for our colleagues’ behavior, things can get awkward. Yet the responsibilities of practicing medicine include professional self-regulation.1 Failure to monitor ourselves and each other would put the reputation and integrity of the medical profession at risk—not to mention the safety of our patients. Despite this, many physicians are understandably reluctant to report colleagues who appear impaired.
To decide whether you should report a colleague, you must:
- know what behaviors constitute impairment
- understand the duty to report impaired colleagues
- realize reporting colleagues often creates emotional conflict
- understand recovery options and resources available for impaired practitioners.
After we examine these matters, we’ll see what Dr. Z should do.
Impairment defined
Physician impairment is a public health issue that affects not just physicians but their families, colleagues, and patients. In this context, “impairment” means a physical, mental, or substance-related disorder that interferes with a physician’s ability to undertake professional activities competently and safely.2
Although many mental conditions can cause impairment, we focus here on substance abuse, a condition that often leads to functional impairment. Physicians develop addictions at rates at least as high as those in the general population.3 Physicians-in- training—including psychiatric residents—are at particularly high risk for developing stress-related problems, depression, and substance misuse.4,5
Occupational demands, self-criticism, and denial of one’s own distress are common failings among physicians,5 as is self-treatment, which may help explain the high rates of substance misuse among physicians.6 Behaviors that suggest a colleague may be abusing substances and experiencing occupational impairment appear in Table 1.7
Table 1
Signs of physician impairment
| Deteriorating personal hygiene |
| Increased absence from professional functions or duties |
| Emotional lability |
| Appearing sleep-deprived |
| Increased professional errors (eg, prescriptions, dictations, clinical judgment) |
| Not responding to pages or telephone calls |
| Decreased concern for patient well-being |
| Citing unexplained ‘personal problems’ to mask deficits in concentration or patient care |
| Increased patient complaints about quality of care and bedside manner |
| Many ‘accidental’ injuries (possibly contrived to obtain narcotic prescriptions) |
| Source: Reference 7 |
Reporting duties
Doctors and physician health programs have a duty to report impaired colleagues who continue to practice despite reasonable offers of assistance. This obligation appears in professional guidelines (Table 2)2,8 and in laws and regulations governing the practice of medicine. Laws and regulations are similar in spirit across jurisdictions, although the exact wording varies from state to state (Table 3).9-11 Physicians are responsible for being familiar with reporting requirements in states they practice and complying accordingly.
Physicians must follow state guidelines and protocols for reporting a colleague’s impairment. In many situations, an intermediate step—such as notifying a chief of service or a physician health program—might occur before a report of impairment goes to a licensing board. Options for reporting impaired physicians appear in Table 4.2,12
Table 2
Medical associations’ official positions on reporting impairment
| American Medical Association (Policy H-275.952)2 | ‘Physicians have an ethical obligation to report impaired, incompetent, and unethical colleagues.’ |
| Federation of State Medical Boards8 | Physician health programs have ‘a primary commitment to [help] state medical boards … protect the public … [These] programs [should] demonstrate an ongoing track record of ensuring safety to the public and reveal deficiencies if they occur.’ |
Table 3
State medical board rules on reporting physician impairment: 3 examples
| State | Rules |
|---|---|
| California9 | California’s Medical Practice Act contains no mandatory reporting requirement. ‘However, … the Board clearly is concerned about physicians who potentially present a danger to their patients. Reporting an impaired colleague to the Medical Board will allow the Board to ensure adequate protections are in place so a colleague who requires assistance will not harm the public. The Board keeps the sources of complaint information confidential.’ |
| Montana10 | ‘[E]ach licensed physician … shall … report to the board any information … that appears to show that a physician is’ impaired. However, ‘[i]nformation that relates to possible physical or mental impairment connected to [substance misuse or illness] may be reported to’ Montana’s physician rehabilitation program ‘in lieu of reporting directly to the board.’ |
| Ohio11 | ‘Any Board licensee having knowledge’ that a physician is impaired because of substance misuse ‘is required … to report that information to the Board. … [H]owever, … the [impaired] physician’s colleagues may be excused from reporting the physician’s impairment … if the [impaired] physician has completed treatment with a Board approved treatment provider and maintained uninterrupted sobriety, and violated no other provisions of the Ohio Medical Practice Act.’ |
Table 4
Options for reporting impaired colleagues
| Impairment in hospital-based physicians may be reported to the hospital’s in-house impairment program, the hospital’s chief of staff, or another appropriate supervisor (eg, a chief resident) |
| Impairment in physicians with office-based practices may be reported to hospitals where they have privileges or to the state’s physician health program |
| Colleagues who continue to practice despite offers of assistance and referrals for treatment or for whom the above options are not available should be reported to the state licensing board |
| Source: References 2,12 |
Overcoming emotional factors
Doctors facing the need to report an impaired colleague often experience emotional conflicts because the impaired is a mentor, supervisor, trainee, friend, or practice partner. Denial, stigmatization, concerns about practice coverage, and fear of retaliation also can contribute to non-reporting. Although we know a colleague’s substance misuse represents a threat to his patients’ welfare and safety,13 reporting a colleague forces us to overcome our allegiance to a fellow practitioner.
Medical professionals should remember, however, that it is always better to identify and treat illnesses early in their course. When early referrals are not made, doctors afflicted by illness often remain without treatment until more severe impairment causes workplace errors. Withholding information about an impaired colleague from supervisors or state medical boards does a disservice to patients and to the colleague. The colleague’s drug or alcohol problems may worsen, and recovery or acquisition of future licenses might become more difficult or impossible. Initial application for medical licensure in 47 states and the District of Columbia inquire about physicians’ recent history of mental health and substance abuse problems, as well as their functional impairment.14 Even renewal of state medical licensure examines applicants’ mental health, physical health, and substance abuse histories.15
Recovery resources
Many institutions and medical board committees have instituted written policies for dealing with workplace addiction.13 An awareness of and sensitivity to physician vulnerability and early detection and prevention of impairment are important.2
At least 39 states have “sick doctor statutes” that permit licensure suspension for physicians who cannot practice medicine safely because of illness or substance use disorders.16 Several states have forms of “immunity”—license protection and preservation—for physicians who seek treatment voluntarily, and some states have legislative provisions that require impaired physicians to get treatment and be monitored so they can keep their licenses.17 In almost every state, medical societies have established physicians’ health committees and treatment programs (Table 5).18
Table 5
Examples of state physician health programs
| State | Organization | Contact |
|---|---|---|
| Colorado | Colorado Physician Health Program | (303) 860-0122 www.cphp.org |
| Florida | Professional Resources Network | (800) 888-8776 www.flprn.org |
| Illinois | Illinois Professional Health Program | (800) 323-8622 www.advocatehealth.com/IPHP |
| Massachusetts | Physician Health Services, Inc. | (781) 434-7404 www.massmed.org |
| Minnesota | Health Professionals Services Program | (651) 643-2120 www.hpsp.state.mn.us |
| Nevada | Nevada Professionals Assistance Program | (702) 521-1398 www.medboard.nv.gov |
| New York | Committee for Physician Health, Medical Society of the State of New York | (518) 436-4723 www.cphny.org |
| Ohio | Ohio Physicians Health Program | (614) 841-9690 www.ophp.org |
| Oregon | Oregon Health Professionals Program | (503) 620-9117 www.oregon.gov/OHA/addiction/health-professionals.shtml |
| Tennessee | Physicians Health Program, Tennessee Medical Foundation | (615) 467-6411 www.e-tmf.org |
| Texas | Committee on Physician Health and Rehabilitation, Texas Medical Association | (512) 370-1342 www.texmed.org |
| Source: Reference 18 | ||
Physicians often recover
Physician treatment is unique for several reasons. First, it is rarely voluntary, and because treatment is coerced in some way, physicians are sicker when they enter treatment. They have more social dysfunction, more medical consequences, and simply are more complicated to treat. Still, most treatment programs for impaired professionals report better rates of long-term recovery than those of the general public, perhaps because physicians are monitored intensively and have the strong motivation of not wanting to lose their medical licenses. For example, in a study of 100 alcoholic U.S. doctors followed for 21 years, 73% had recovered. This study and others show a strong relationship between recovery and attending meetings of self-help groups.19
What should Dr. Z do?
Dr. Z is a member of a professional community that has an ethical obligation to police itself and to report observations that suggest impairment. His colleague’s suspected substance use disorder could interfere with his ability to function and pose a risk to patient welfare and safety.
Although reporting a colleague is unpleasant, impaired physicians often recover, and the data support optimism about returning to clinical practice for physicians who get appropriate treatment. In this case, Dr. Z’s reporting of his concerns about impairment would help uphold the integrity of the medical profession and would offer his colleague the potential benefits of treatment and recovery programs.
Related Resources
- Bright RP, Krahn L. Impaired physicians: How to recognize, when to report, and where to refer. Current Psychiatry. 2010;9(6):11-20.
- DuPont RL, McLellan AT, White WL, et al. Setting the standard for recovery: Physicians’ Health Programs. J Subst Abuse Treat. 2009;36(2):159-171.
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Ernhart CB, Scarr S, Geneson DF. On being a whistleblower: the Needleman case Ethics Behav. 1993;3(1):73-93.
2. American Medical Association. Policies related to physician health. Available at: http://www.ama-assn.org/resources/doc/physician-health/policies-physicain-health.pdf. Accessed June 19, 2011.
3. Berge KH, Seppala MD, Schipper AM. Chemical dependency and the physician. Mayo Clin Proc. 2009;84(7):625-631.
4. Broquet KE, Rockey PH. Teaching residents and program directors about physician impairment. Acad Psychiatry. 2004;28(3):221-225.
5. Meier DE, Back AL, Morrison RS. The inner life of physicians and care of the seriously ill. JAMA. 2001;286(23):3007-3014.
6. Firth-Cozens J. Improving the health of psychiatrists. Adv Psychiatr Treat. 2007;13(3):161-168.
7. McGovern MP, Angres DH, Leon S. Characteristics of physicians presenting for assessment at a behavioral health center. J Addict Dis. 2000;19(2):59-73.
8. Federation of State Medical Boards of the United States. Policy on physician impairment. Available at: http://www.csam-asam.org/pdf/misc/FSMB2011.pdf. Accessed June 8, 2011.
9. Medical Board of California. Complaint process - frequently asked questions. Available at: http://www.medbd.ca.gov/consumer/complaint_info_questions_process.html. Accessed June 8, 2011.
10. Montana Code Ann § 37-3-401 (2005)
11. State Medical Board of Ohio. Policies and positions: licensure of chemically impaired resident physicians. Available at: http://www.med.ohio.gov/positionpapers/resident.htm. Accessed June 19, 2011.
12. American Medical Association. Code of medical ethics, opinion 9.031. Reporting impaired, incompetent, or unethical colleagues. Available at: http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion9031.page. Accessed June 19, 2011.
13. Hulse G, Sim MG, Khong E. Management of the impaired doctor. Aust Fam Physician. 2004;33(9):703-707.
14. Sansone RA, Wiederman MW, Sansone LA. Physician mental health and substance abuse. What are state medical licensure applications asking? Arch Fam Med. 1999;8(5):448-451.
15. Hansen TE, Goetz RR, Bloom JD, et al. Changes in questions about psychiatric illness asked on medical licensure applications between 1993 and 1996. Psychiatr Serv. 1998;49(2):202-206.
16. Boisaubin EV, Levine RE. Identifying and assisting the impaired physician. Am J Med Sci. 2001;322(1):31-36.
17. Verghese A. Physicians and addiction. N Engl J Med. 2002;346(20):1510-1511.
18. Federation of State Physicians Health Programs. Available at: http://www.fsphp.org. Accessed June 8, 2011.
19. Lloyd G. One hundred alcoholic doctors: a 21-year follow-up. Alcohol Alcohol. 2002;37(4):370-374
1. Ernhart CB, Scarr S, Geneson DF. On being a whistleblower: the Needleman case Ethics Behav. 1993;3(1):73-93.
2. American Medical Association. Policies related to physician health. Available at: http://www.ama-assn.org/resources/doc/physician-health/policies-physicain-health.pdf. Accessed June 19, 2011.
3. Berge KH, Seppala MD, Schipper AM. Chemical dependency and the physician. Mayo Clin Proc. 2009;84(7):625-631.
4. Broquet KE, Rockey PH. Teaching residents and program directors about physician impairment. Acad Psychiatry. 2004;28(3):221-225.
5. Meier DE, Back AL, Morrison RS. The inner life of physicians and care of the seriously ill. JAMA. 2001;286(23):3007-3014.
6. Firth-Cozens J. Improving the health of psychiatrists. Adv Psychiatr Treat. 2007;13(3):161-168.
7. McGovern MP, Angres DH, Leon S. Characteristics of physicians presenting for assessment at a behavioral health center. J Addict Dis. 2000;19(2):59-73.
8. Federation of State Medical Boards of the United States. Policy on physician impairment. Available at: http://www.csam-asam.org/pdf/misc/FSMB2011.pdf. Accessed June 8, 2011.
9. Medical Board of California. Complaint process - frequently asked questions. Available at: http://www.medbd.ca.gov/consumer/complaint_info_questions_process.html. Accessed June 8, 2011.
10. Montana Code Ann § 37-3-401 (2005)
11. State Medical Board of Ohio. Policies and positions: licensure of chemically impaired resident physicians. Available at: http://www.med.ohio.gov/positionpapers/resident.htm. Accessed June 19, 2011.
12. American Medical Association. Code of medical ethics, opinion 9.031. Reporting impaired, incompetent, or unethical colleagues. Available at: http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion9031.page. Accessed June 19, 2011.
13. Hulse G, Sim MG, Khong E. Management of the impaired doctor. Aust Fam Physician. 2004;33(9):703-707.
14. Sansone RA, Wiederman MW, Sansone LA. Physician mental health and substance abuse. What are state medical licensure applications asking? Arch Fam Med. 1999;8(5):448-451.
15. Hansen TE, Goetz RR, Bloom JD, et al. Changes in questions about psychiatric illness asked on medical licensure applications between 1993 and 1996. Psychiatr Serv. 1998;49(2):202-206.
16. Boisaubin EV, Levine RE. Identifying and assisting the impaired physician. Am J Med Sci. 2001;322(1):31-36.
17. Verghese A. Physicians and addiction. N Engl J Med. 2002;346(20):1510-1511.
18. Federation of State Physicians Health Programs. Available at: http://www.fsphp.org. Accessed June 8, 2011.
19. Lloyd G. One hundred alcoholic doctors: a 21-year follow-up. Alcohol Alcohol. 2002;37(4):370-374
Power Through Afternoon Energy Slumps
Late-afternoon slowdowns are natural, explains Susan Swadener, PhD, RD, dietetic internship director and lecturer in the Food Science and Nutrition Department at California State University San Luis Obispo. "Your enzyme levels go down, which is part of your diurnal pattern to slow down the body's processes to get ready for the evening and sleep," she says.
Common-Sense Nutrition
To fight afternoon fatigue, adopt good nutritional habits throughout your day. It's essential to have a healthy breakfast in the morning, advises Dr. Swadener, who's also a registered dietitian in private practice. Make sure you eat lunch, too, with a balance of protein, carbohydrates, and fats.
Afternoon snacks are a good idea, especially if they incorporate some protein. Foods high in protein can increase norepinephrine and epinephrine production, which helps you stay alert. Some examples of quick and nutritious snacks: string cheese and an apple; sliced cheese or peanut butter on whole-wheat crackers; yogurt; a handful of almonds or walnuts; or trail mix.
And don't forget one of the most common directives to your patients: "Push the fluids." Have a glass of water or nonfat milk with your lunch, and make sure you keep your water bottle handy at your desk.
As for coffee, "you don't want to be drinking it constantly to keep your energy level up, because you'll just crash afterwards," Dr. Swadener says. If you don't abuse caffeine, one cup of coffee in the morning and one in the afternoon is found to be most effective in increasing your alertness.
Change It Up
Desk tasks can make you drowsy. Daniel Markovitz is president of TimeBack Management, which specializes in applying Lean manufacturing principles to increase personal productivity for healthcare workers. He's found—and research such as a 2003 study in Ergonomics and a 2007 National Institute for Occupational Safety and Health study in the American Journal of Industrial Medicine supports these conclusions—that taking mini-breaks and then returning to the task at hand can refresh you and make you more productive.
You also get energy by using it, so a brisk walk around the hospital or walking up and down a couple of flights of stairs can increase circulation and blood flow to the brain. "You don't even have to get up from your desk," Markovitz says. "Just by changing the nature of the work you're doing, it's refreshing to your brain." That might mean switching from dictation to administrative work, or from scheduling to research.
And remember the value of play, Markovitz advises. "We tend to discourage going on Facebook or playing a video game at work. But if you take a 15-minute break to do something that's pleasurable, that causes your brain to fire in different ways, that can be another helpful adaptation."
Gretchen Henkel is a freelance writer based in California.
Interactions are Engaging
You've just finished a brain-numbing administrative report, and you've got 10 minutes before your next task. Don't just fill that time with checking your email.
Corporate consultant Daniel Markovitz advises another tack: Walk down the hall to touch base with colleagues. "You don't have to get into an involved conversation about their QI project. Just ask them how it's going for them," he advises.
Breaking up a busy day with exercise or a social call can get you over the doldrums hump, he says, because "you're getting up and interacting with someone. At the same time, you're doing something that's really important for the hospital: You're strengthening those bonds and interrelationships with people.—GH
Late-afternoon slowdowns are natural, explains Susan Swadener, PhD, RD, dietetic internship director and lecturer in the Food Science and Nutrition Department at California State University San Luis Obispo. "Your enzyme levels go down, which is part of your diurnal pattern to slow down the body's processes to get ready for the evening and sleep," she says.
Common-Sense Nutrition
To fight afternoon fatigue, adopt good nutritional habits throughout your day. It's essential to have a healthy breakfast in the morning, advises Dr. Swadener, who's also a registered dietitian in private practice. Make sure you eat lunch, too, with a balance of protein, carbohydrates, and fats.
Afternoon snacks are a good idea, especially if they incorporate some protein. Foods high in protein can increase norepinephrine and epinephrine production, which helps you stay alert. Some examples of quick and nutritious snacks: string cheese and an apple; sliced cheese or peanut butter on whole-wheat crackers; yogurt; a handful of almonds or walnuts; or trail mix.
And don't forget one of the most common directives to your patients: "Push the fluids." Have a glass of water or nonfat milk with your lunch, and make sure you keep your water bottle handy at your desk.
As for coffee, "you don't want to be drinking it constantly to keep your energy level up, because you'll just crash afterwards," Dr. Swadener says. If you don't abuse caffeine, one cup of coffee in the morning and one in the afternoon is found to be most effective in increasing your alertness.
Change It Up
Desk tasks can make you drowsy. Daniel Markovitz is president of TimeBack Management, which specializes in applying Lean manufacturing principles to increase personal productivity for healthcare workers. He's found—and research such as a 2003 study in Ergonomics and a 2007 National Institute for Occupational Safety and Health study in the American Journal of Industrial Medicine supports these conclusions—that taking mini-breaks and then returning to the task at hand can refresh you and make you more productive.
You also get energy by using it, so a brisk walk around the hospital or walking up and down a couple of flights of stairs can increase circulation and blood flow to the brain. "You don't even have to get up from your desk," Markovitz says. "Just by changing the nature of the work you're doing, it's refreshing to your brain." That might mean switching from dictation to administrative work, or from scheduling to research.
And remember the value of play, Markovitz advises. "We tend to discourage going on Facebook or playing a video game at work. But if you take a 15-minute break to do something that's pleasurable, that causes your brain to fire in different ways, that can be another helpful adaptation."
Gretchen Henkel is a freelance writer based in California.
Interactions are Engaging
You've just finished a brain-numbing administrative report, and you've got 10 minutes before your next task. Don't just fill that time with checking your email.
Corporate consultant Daniel Markovitz advises another tack: Walk down the hall to touch base with colleagues. "You don't have to get into an involved conversation about their QI project. Just ask them how it's going for them," he advises.
Breaking up a busy day with exercise or a social call can get you over the doldrums hump, he says, because "you're getting up and interacting with someone. At the same time, you're doing something that's really important for the hospital: You're strengthening those bonds and interrelationships with people.—GH
Late-afternoon slowdowns are natural, explains Susan Swadener, PhD, RD, dietetic internship director and lecturer in the Food Science and Nutrition Department at California State University San Luis Obispo. "Your enzyme levels go down, which is part of your diurnal pattern to slow down the body's processes to get ready for the evening and sleep," she says.
Common-Sense Nutrition
To fight afternoon fatigue, adopt good nutritional habits throughout your day. It's essential to have a healthy breakfast in the morning, advises Dr. Swadener, who's also a registered dietitian in private practice. Make sure you eat lunch, too, with a balance of protein, carbohydrates, and fats.
Afternoon snacks are a good idea, especially if they incorporate some protein. Foods high in protein can increase norepinephrine and epinephrine production, which helps you stay alert. Some examples of quick and nutritious snacks: string cheese and an apple; sliced cheese or peanut butter on whole-wheat crackers; yogurt; a handful of almonds or walnuts; or trail mix.
And don't forget one of the most common directives to your patients: "Push the fluids." Have a glass of water or nonfat milk with your lunch, and make sure you keep your water bottle handy at your desk.
As for coffee, "you don't want to be drinking it constantly to keep your energy level up, because you'll just crash afterwards," Dr. Swadener says. If you don't abuse caffeine, one cup of coffee in the morning and one in the afternoon is found to be most effective in increasing your alertness.
Change It Up
Desk tasks can make you drowsy. Daniel Markovitz is president of TimeBack Management, which specializes in applying Lean manufacturing principles to increase personal productivity for healthcare workers. He's found—and research such as a 2003 study in Ergonomics and a 2007 National Institute for Occupational Safety and Health study in the American Journal of Industrial Medicine supports these conclusions—that taking mini-breaks and then returning to the task at hand can refresh you and make you more productive.
You also get energy by using it, so a brisk walk around the hospital or walking up and down a couple of flights of stairs can increase circulation and blood flow to the brain. "You don't even have to get up from your desk," Markovitz says. "Just by changing the nature of the work you're doing, it's refreshing to your brain." That might mean switching from dictation to administrative work, or from scheduling to research.
And remember the value of play, Markovitz advises. "We tend to discourage going on Facebook or playing a video game at work. But if you take a 15-minute break to do something that's pleasurable, that causes your brain to fire in different ways, that can be another helpful adaptation."
Gretchen Henkel is a freelance writer based in California.
Interactions are Engaging
You've just finished a brain-numbing administrative report, and you've got 10 minutes before your next task. Don't just fill that time with checking your email.
Corporate consultant Daniel Markovitz advises another tack: Walk down the hall to touch base with colleagues. "You don't have to get into an involved conversation about their QI project. Just ask them how it's going for them," he advises.
Breaking up a busy day with exercise or a social call can get you over the doldrums hump, he says, because "you're getting up and interacting with someone. At the same time, you're doing something that's really important for the hospital: You're strengthening those bonds and interrelationships with people.—GH
ONLINE EXCLUSIVE: Listen to program directors discuss managing a group when a hospitalist is out on maternity leave
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Was Nurse-Midwife to Blame for Shoulder Dystocia?
Case reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
During a vaginal delivery performed by a nurse-midwife, the infant of a North Carolina woman sustained a moderate brachial plexus injury with shoulder dystocia.
The plaintiff claimed that the nurse-midwife failed to call in her backup physician to help with the delivery. The plaintiff also claimed that the nurse-midwife pulled too hard on the infant’s head during the delivery, leading to the injury. The defendant denied negligence.
Outcome
According to a published account, a $950,000 verdict was returned.
Comment
Cases involving shoulder dystocia in a vaginal delivery are notoriously difficult to defend. Plaintiffs are successful in claiming that infant size, with known potential for shoulder dystocia, should have been anticipated, especially when sonograms are so widely available. Once again, an advanced practice nurse, in this case a nurse-midwife, is faulted for failing to consult a physician. It is no wonder there is such an increase in the number of cesarean deliveries that are being performed. The cost of taking a chance is just too great.
It is difficult to know from the facts presented here whether the nurse-midwife erred. But it is well known among plaintiff lawyers that every parent expects a perfect baby, and when that is not the outcome, someone must be blamed. —JP
Case reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
During a vaginal delivery performed by a nurse-midwife, the infant of a North Carolina woman sustained a moderate brachial plexus injury with shoulder dystocia.
The plaintiff claimed that the nurse-midwife failed to call in her backup physician to help with the delivery. The plaintiff also claimed that the nurse-midwife pulled too hard on the infant’s head during the delivery, leading to the injury. The defendant denied negligence.
Outcome
According to a published account, a $950,000 verdict was returned.
Comment
Cases involving shoulder dystocia in a vaginal delivery are notoriously difficult to defend. Plaintiffs are successful in claiming that infant size, with known potential for shoulder dystocia, should have been anticipated, especially when sonograms are so widely available. Once again, an advanced practice nurse, in this case a nurse-midwife, is faulted for failing to consult a physician. It is no wonder there is such an increase in the number of cesarean deliveries that are being performed. The cost of taking a chance is just too great.
It is difficult to know from the facts presented here whether the nurse-midwife erred. But it is well known among plaintiff lawyers that every parent expects a perfect baby, and when that is not the outcome, someone must be blamed. —JP
Case reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
During a vaginal delivery performed by a nurse-midwife, the infant of a North Carolina woman sustained a moderate brachial plexus injury with shoulder dystocia.
The plaintiff claimed that the nurse-midwife failed to call in her backup physician to help with the delivery. The plaintiff also claimed that the nurse-midwife pulled too hard on the infant’s head during the delivery, leading to the injury. The defendant denied negligence.
Outcome
According to a published account, a $950,000 verdict was returned.
Comment
Cases involving shoulder dystocia in a vaginal delivery are notoriously difficult to defend. Plaintiffs are successful in claiming that infant size, with known potential for shoulder dystocia, should have been anticipated, especially when sonograms are so widely available. Once again, an advanced practice nurse, in this case a nurse-midwife, is faulted for failing to consult a physician. It is no wonder there is such an increase in the number of cesarean deliveries that are being performed. The cost of taking a chance is just too great.
It is difficult to know from the facts presented here whether the nurse-midwife erred. But it is well known among plaintiff lawyers that every parent expects a perfect baby, and when that is not the outcome, someone must be blamed. —JP
Clinician “Guarantees” Patient Does Not Have Appendicitis
Case reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
A 54-year-old Utah man awoke in late February 2002 with a “gurgling” sensation and pain in his mid-abdomen. He felt sick all that day and into the next. He vomited three times the next day and noticed the pain move to the lower-right quadrant of the abdomen.
His sister took him to an urgent care clinic, where he was examined by a PA. The patient was diagnosed with flu, and antiviral medication, ibuprofen, and bed rest were prescribed. When asked about appendicitis, the PA responded, “I guarantee you do not have appendicitis.”
The patient initially felt better, but then his condition worsened. Calls to the clinic for more medication were not returned. The man was taken to another clinic 10 days later and then referred to a hospital, where he was diagnosed with a ruptured appendix.
An emergency appendectomy was performed. The patient was hospitalized for 12 days and required six months to fully recover. The plaintiff alleged negligence in the PA’s failure to diagnose appendicitis.
Outcome
According to a published report, a confidential settlement was reached in mediation.
Comment
The patient in this case presented with generalized mid-abdominal pain and vomiting, with pain moving to his right lower quadrant. Migrating pain is one of the more specific findings of appendicitis, so it is not entirely clear from the facts presented why appendicitis was not considered more fully. It seems that a more complete workup, including diagnostic imaging and laboratory analysis, was indicated.
Appendicitis is common; so are complaints of abdominal pain. Appendicitis must be considered in all cases of abdominal pain, as must meningitis in all cases of headache. Yet any abdominal pain could be appendicitis, and any headache could be meningitis. The trick is panning out the few with a serious illness from the many with mild disease—all potentially presenting with the same symptom complex early on.
We cannot observe all patients indefinitely. Often, a patient must be discharged with vague symptoms and nonspecific findings that could be the start of something more grave. In such cases, clinicians should document the negative findings that make further emergency evaluation unwarranted and enlist the patient to monitor for signs and symptoms warranting an immediate return. Document those instructions fully. This approach can be defended in court, because the clinician considered a grave diagnosis yet had no reason to act on it in the absence of more specific symptomatology, and informed the patient of changes requiring immediate return.
Patients often raise the specter of ominous diagnoses. Such concerns should be met with an acknowledgement that such concerns are a “good thought,” followed by what is hopefully a laundry list of signs and symptoms that the patient does not have. Discharging patients with specific instructions builds rapport with the patient and family. I’ve found that patients so informed will often return if symptoms change to fit a previously discussed pattern and will even credit the clinician for making the diagnosis.
Of course, squarely at odds with this approach are dogmatic pronouncements “guaranteeing” patients of a diagnosis or outcome. Such certitude should be reserved for actors practicing medicine on television or the truly clairvoyant. (Most of us are neither).
One thing is certain: If such pronouncements are wrong, a plaintiff’s attorney will hang them around the neck of a defending clinician as an albatross—and a jury will be invited to conclude that the clinician was arrogant and imprudent.
In sum, rarely speak in terms of absolutes. Always respect the chance of a changing clinical course. And document your concern and instructions clearly. —DML
Case reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
A 54-year-old Utah man awoke in late February 2002 with a “gurgling” sensation and pain in his mid-abdomen. He felt sick all that day and into the next. He vomited three times the next day and noticed the pain move to the lower-right quadrant of the abdomen.
His sister took him to an urgent care clinic, where he was examined by a PA. The patient was diagnosed with flu, and antiviral medication, ibuprofen, and bed rest were prescribed. When asked about appendicitis, the PA responded, “I guarantee you do not have appendicitis.”
The patient initially felt better, but then his condition worsened. Calls to the clinic for more medication were not returned. The man was taken to another clinic 10 days later and then referred to a hospital, where he was diagnosed with a ruptured appendix.
An emergency appendectomy was performed. The patient was hospitalized for 12 days and required six months to fully recover. The plaintiff alleged negligence in the PA’s failure to diagnose appendicitis.
Outcome
According to a published report, a confidential settlement was reached in mediation.
Comment
The patient in this case presented with generalized mid-abdominal pain and vomiting, with pain moving to his right lower quadrant. Migrating pain is one of the more specific findings of appendicitis, so it is not entirely clear from the facts presented why appendicitis was not considered more fully. It seems that a more complete workup, including diagnostic imaging and laboratory analysis, was indicated.
Appendicitis is common; so are complaints of abdominal pain. Appendicitis must be considered in all cases of abdominal pain, as must meningitis in all cases of headache. Yet any abdominal pain could be appendicitis, and any headache could be meningitis. The trick is panning out the few with a serious illness from the many with mild disease—all potentially presenting with the same symptom complex early on.
We cannot observe all patients indefinitely. Often, a patient must be discharged with vague symptoms and nonspecific findings that could be the start of something more grave. In such cases, clinicians should document the negative findings that make further emergency evaluation unwarranted and enlist the patient to monitor for signs and symptoms warranting an immediate return. Document those instructions fully. This approach can be defended in court, because the clinician considered a grave diagnosis yet had no reason to act on it in the absence of more specific symptomatology, and informed the patient of changes requiring immediate return.
Patients often raise the specter of ominous diagnoses. Such concerns should be met with an acknowledgement that such concerns are a “good thought,” followed by what is hopefully a laundry list of signs and symptoms that the patient does not have. Discharging patients with specific instructions builds rapport with the patient and family. I’ve found that patients so informed will often return if symptoms change to fit a previously discussed pattern and will even credit the clinician for making the diagnosis.
Of course, squarely at odds with this approach are dogmatic pronouncements “guaranteeing” patients of a diagnosis or outcome. Such certitude should be reserved for actors practicing medicine on television or the truly clairvoyant. (Most of us are neither).
One thing is certain: If such pronouncements are wrong, a plaintiff’s attorney will hang them around the neck of a defending clinician as an albatross—and a jury will be invited to conclude that the clinician was arrogant and imprudent.
In sum, rarely speak in terms of absolutes. Always respect the chance of a changing clinical course. And document your concern and instructions clearly. —DML
Case reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
A 54-year-old Utah man awoke in late February 2002 with a “gurgling” sensation and pain in his mid-abdomen. He felt sick all that day and into the next. He vomited three times the next day and noticed the pain move to the lower-right quadrant of the abdomen.
His sister took him to an urgent care clinic, where he was examined by a PA. The patient was diagnosed with flu, and antiviral medication, ibuprofen, and bed rest were prescribed. When asked about appendicitis, the PA responded, “I guarantee you do not have appendicitis.”
The patient initially felt better, but then his condition worsened. Calls to the clinic for more medication were not returned. The man was taken to another clinic 10 days later and then referred to a hospital, where he was diagnosed with a ruptured appendix.
An emergency appendectomy was performed. The patient was hospitalized for 12 days and required six months to fully recover. The plaintiff alleged negligence in the PA’s failure to diagnose appendicitis.
Outcome
According to a published report, a confidential settlement was reached in mediation.
Comment
The patient in this case presented with generalized mid-abdominal pain and vomiting, with pain moving to his right lower quadrant. Migrating pain is one of the more specific findings of appendicitis, so it is not entirely clear from the facts presented why appendicitis was not considered more fully. It seems that a more complete workup, including diagnostic imaging and laboratory analysis, was indicated.
Appendicitis is common; so are complaints of abdominal pain. Appendicitis must be considered in all cases of abdominal pain, as must meningitis in all cases of headache. Yet any abdominal pain could be appendicitis, and any headache could be meningitis. The trick is panning out the few with a serious illness from the many with mild disease—all potentially presenting with the same symptom complex early on.
We cannot observe all patients indefinitely. Often, a patient must be discharged with vague symptoms and nonspecific findings that could be the start of something more grave. In such cases, clinicians should document the negative findings that make further emergency evaluation unwarranted and enlist the patient to monitor for signs and symptoms warranting an immediate return. Document those instructions fully. This approach can be defended in court, because the clinician considered a grave diagnosis yet had no reason to act on it in the absence of more specific symptomatology, and informed the patient of changes requiring immediate return.
Patients often raise the specter of ominous diagnoses. Such concerns should be met with an acknowledgement that such concerns are a “good thought,” followed by what is hopefully a laundry list of signs and symptoms that the patient does not have. Discharging patients with specific instructions builds rapport with the patient and family. I’ve found that patients so informed will often return if symptoms change to fit a previously discussed pattern and will even credit the clinician for making the diagnosis.
Of course, squarely at odds with this approach are dogmatic pronouncements “guaranteeing” patients of a diagnosis or outcome. Such certitude should be reserved for actors practicing medicine on television or the truly clairvoyant. (Most of us are neither).
One thing is certain: If such pronouncements are wrong, a plaintiff’s attorney will hang them around the neck of a defending clinician as an albatross—and a jury will be invited to conclude that the clinician was arrogant and imprudent.
In sum, rarely speak in terms of absolutes. Always respect the chance of a changing clinical course. And document your concern and instructions clearly. —DML