By Steve Berkowitz
Hardly a conversation goes by between myself and a fellow Chief Medical Officer where one of us does not bring up an issue regarding a difficult physician on the medical staff and how best to deal with it.
Whether the presenting issue is disruptiveness, inappropriateness, incompetency, impairment or anything else, the medical staff leader ultimately faces the dilemma on how best to resolve the situation. These cases are frequently uncomfortable on multiple levels for the medical staff leadership– in the areas of personal involvement, professional disagreements, and lack of individual experience on the part of the medical leader in dealing with the process.
Over the years, I have developed a few simple rules and questions that have been helpful to me to reach a reasonable remedy in the great majority of the situations that have arisen in my roles of Chief Medical Officer and Consultant.
First, I like to apply four straightforward rules:
Rule 1: Patient safety comes first.
Rule 2: Follow your established Bylaws, policies and procedures.
Rule 3: Involve legal opinion early on.
Rule 4: Implement the least disruptive disposition that will satisfy Rule 1.
As we go through the process, regardless of the nature of the complaint, I like to address the following hierarchical questions in order of severity:
1. Is there an egregious issue going on that constitutes an immediate threat to patient safety and therefore may require a summary suspension or other immediate action? This is the most extreme case and fortunately the most rare. If there is a clear danger to the patient, immediate measures are necessary. We must be sure to protect all patients, present and future, from harm. When I am comfortable that the case does not rise to this level of severity, I go to the next question:
2. Is there an aspect of this case that is reportable to the NPDB, state Medical Boards, or other agency? It is important for the medical leader to be familiar with what must be reported on a national level and with the particular state medical board. A legal opinion is essential if there is any doubt to whether the offense qualifies for immediate notification of any of the agencies. If there are no reportable issues, it generally gives us more flexibility down the road in the resolution process. Not the least of which, it opens up the option of voluntary resignation by the physician as a possible outcome.
3. Is our process completely in compliance with the Bylaws/ Rules and Regulations?Following the established policies and procedures are necessary throughout every step of the process and every participant in the action must be familiar with them. Many of the problems that are encountered through this process are directly due to not following established procedures, rules and policies. We must be sure that the physician is completely aware of the procedures and the resulting consequences of not adhering to the action plan. Of course, the appropriate confidentialities must be maintained throughout the process. The goal is to have a comprehensive action plan that all parties understand, with pre-established goals and timelines.
4. Is the situation remediable? What has been done with the physician to date. Has everything been appropriately documented? Are we following the appropriate graded steps in dealing with the situation? Have we seen improvement toward the desired outcome and is the physician motivated to take the necessary steps down the road so that the particular incident will not occur again.
Ultimately, we come to the disposition and the application of my Rule 4: what is the least disruptive option that ensures the appropriate patient safety. As we consider potential interventions along the continuum of doing nothing at the one extreme and immediate summary suspension at the other extreme, I like to implement the least severe option on that continuum that accomplishes our overall goal of patient safety. Obviously, the appropriate intervention is very individual and based upon the specifics of the case. I strive to do everything that I can for the physician. I very much respect that a physician’s livelihood may be at stake, but even more, I respect that the patient should never be put in potential harm’s way. What is the least disruptive remedy that gets the job done?
Managing medical staff interventions is a very complicated topic, and this post was simply meant to outline the graded steps that should be taken in order to achieve the best outcome for all parties involved. There is much more to say on this matter, but I have found the application of these rules and questions has kept me out of trouble administratively and has led to the best outcome for the physician and the patient.
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