When doctors put patients at risk

Increasingly, there are moves to get physicians whose clinical skills are below par into remediation programs—before they harm patients.

By Ken Terry
Senior Editor

Dr. M, a general surgeon in the Midwest, had his license suspended in 1999 following a review begun when a family physician complained that he was incompetent. The main charge against him, he says, was that he should have transferred critically ill patients to better-equipped urban facilities instead of operating on them himself at his resource-poor rural hospital.

Today, Dr. M, who asked not to be identified, practices in a neighboring state under the supervision of another surgeon who agreed to be his mentor. He'll be on probation for three more years, but has hospital privileges and is on several managed care plans.

Dr. M returned to practice under the guidance of a Denver-based program called the Center for Personalized Education for Physicians (CPEP). One of a dozen similar programs run by universities and private organizations, CPEP evaluates physicians suspected of having clinical skills deficits, and designs personalized interventions to correct those weaknesses.

About half the physicians in the program are in primary care. Most came to a licensing board's attention because of patient complaints or malpractice suits. They were referred to CPEP for overall evaluation because the state board suspected they'd provided substandard care.

CPEP's evaluators find that about 20 percent of the doctors referred by licensing boards, hospitals, and other entities have no skills deficit. Another 15 percent have such serious deficiencies that it's doubtful they should ever practice again. (In other programs, about one third of clients fall into that category.)

How physicians get into programs

Sometimes, state boards merely want to have a doctor's skills assessed before making a licensing decision. In other cases, like Dr. M's, a board has already sanctioned the doctor and has made him enroll in a remedial program as a condition of getting off probation. Boards in Minnesota and North Carolina refer some doctors they deem salvageable without first taking disciplinary measures. If they complete the program successfully, the boards won't impose any sanctions on them.

Hospitals refer physicians to remedial programs, but usually only as a last resort, says Beth Korinek, executive director of CPEP. "We're brought in when privileges have already been suspended, or when they might be and the administration needs data to make a decision."

Physicians may also enter skills programs on their own if they're trying to recover their licenses or have been out of practice for a while. Whatever the reason a doctor enrolls, he'll be guaranteed confidentiality unless he poses an imminent risk to patient safety.

Skills assessments are usually handled by a team of peers in the physician's specialty. CPEP uses written and computerized knowledge tests, clinical interviews based on submitted charts and other materials, an analysis of patient care notes, and simulated patient encounters. The reviewers recommend corrective measures based on their assessment. Dr. M's year-long remediation program, for instance, consisted of a course in documentation and going over cases with his mentor for eight hours a month.

Assessment fees in various programs range from $5,000 to $10,000, and remediation costs more. In one program in upstate New York, a surgeon might have to pay another surgeon as much as $5,000 a day to tutor him on the job.

Clinical skills deficits vary a lot. Psychologist Michael Herkov, who runs a competency assessment program at the University of Florida College of Medicine in Gainesville, says that 30 to 40 percent of the physicians who enroll in the program have pretty good skills. He cites a primary care doctor who hadn't kept up with changes in preferred medications, and a surgeon who missed a complication after an operation because of stress in his personal life. Those doctors just needed some targeted CME, he says.

Sometimes the gaps in knowledge are broader. "When the deficit rises to the level where it draws people's attention, we find it to be across the board," says educational psychologist William Grant, director of the Physician Prescribed Education Program in Syracuse, NY. "These doctors usually haven't kept up with current practices or medications."

"Lack of medical knowledge is the easiest thing to remedy," says FP Martha Illige, medical director of CPEP. "How doctors organize knowledge or solve problems—their clinical judgment—is by far the biggest problem."

Some doctors don't know how to document properly, she adds. "All you have to do is talk to them, and they can tell you a great deal about the patient and the disease, but it's never documented in a way that's useful."

Not enough physicians are being helped

It's estimated that 2 to 5 percent of physicians nationwide—or as many as 40,000—need "focused, prescribed education," according to Dennis K. Wentz, MD, director of the AMA's division of continuing physician professional development. Yet the existing assessment and remedial programs handle only a few hundred a year.

Why are so few physicians receiving help? It's difficult to identify these doctors, says Michael Herkov. "It's much easier to identify a doctor who comes into the OR intoxicated than it is to spot someone whose skills and judgment aren't what they should be."

Another hurdle is that these programs don't suit physician culture. "It isn't normal for physicians to admit they have weak areas, because they're supposed to have all the answers," observes Dale Austin, chief operating officer of the Federation of State Medical Boards.

And, partly because of legal concerns, he adds, doctors rarely inform on colleagues. "It has to be a very serious and obvious problem before someone's going to say, 'This guy shouldn't be treating patients.' "

Physicians are also lenient toward colleagues because of their fear and loathing of malpractice suits. "Many have the attitude that 'we're being picked on more than we deserve to be. And therefore we should bend over backwards to protect our peers,' " says Michael I. Rehmar, a New York internist and addiction medicine specialist, who formerly reviewed cases for a malpractice insurer.

But if a physician makes a mistake that harms a patient, and his error is revealed, his peers will often abandon him. "It's not okay to make mistakes—it's such a damning culture," notes FP Marc Ringel, a former medical education director for CPEP.

More programs offer more choices

While most states have programs for physicians with drug and/or alcohol problems—largely run by state medical societies or medical boards—the Oregon Medical Association is the only society that administers a program for doctors with clinical skills deficits.

This is partly because such programs are expensive and difficult to set up, says psychiatrist John A. Fromson, vice president for professional development at the Massachusetts Medical Society. Others point out that addicted physicians are viewed as more salvageable than those with poor clinical skills.

Finding preceptors who'll supervise physicians for a year or more isn't easy, either. "Other physicians don't have the time or the monetary incentive, and don't want to take on the liability risk to monitor people who have these major deficits," says Fromson.

Some programs offer a kind of mini-residency, rather than rely on a preceptor. The University of Wisconsin program, for instance, prescribes basic science refresher courses followed by a week working in a clinic that's relevant to the client's specialty. And another program brings doctors to the University of California, San Diego medical school for a week of supervised hospital work. But few other medical schools will commit to such a program.

The picture may be changing, though. Because of the current national concern over medical errors, licensing boards are starting to take the same approach toward physicians with clinical skills deficits that they take toward physicians with drug or alcohol problems—getting them into programs before they hurt patients. More and more boards are referring physicians to remedial programs. The Federation of State Medical Boards and the National Board of Medical Examiners have started their own skills assessment program. And a new federally funded initiative encourages licensing boards to work with hospitals to get physicians with deficient clinical skills into remedial programs before they do serious harm (see the box below).

Will all of this encourage poorly performing doctors to seek help? Maybe, says Dale Austin. "The assessment system hasn't been widely available, and perhaps that's helped create this barrier to self-help. But it hasn't been the norm for doctors to learn from what they do well and what they don't do so well."

Breaking through the hospital wall of silence

Most physicians with clinical skills deficits don't come to the attention of medical licensing boards until they've hurt patients. The Citizen Advocacy Center in Washington, DC, is on a mission to make sure that such doctors get help before they make dangerous mistakes.

The CAC, which includes public members of licensing boards, has received federal funding to launch a national program designed to help physicians and nurses with clinical deficiencies. The Practitioner Remediation and Enhancement Partnership Pilot Project will pair licensing boards with hospitals to get faltering clinicians into remedial programs. Enrollment in the programs would be confidential unless the physician or nurse poses a clear danger to patients.

So far, six boards of medicine—in California, Minnesota, Missouri, North Carolina, Oregon, and Rhode Island—have agreed to participate. The boards are negotiating with leading hospitals in their states.

It won't be easy to get hospitals to trust the medical boards. Peer reviewers and medical directors fear the power of the boards to destroy careers. They also know that if they report a physician to the state board, the board has to inform the National Practitioner Data Bank about it.

Many hospitals try to resolve quality of care concerns within the peer review process, says Mark A. Kadzielski, a Los Angeles health care attorney. Some also have informal mentoring programs for doctors with specific problems. They'd rather not restrict or terminate privileges, because such an action involves a long and costly hearing process, he points out. But they wouldn't send poorly performing doctors to remedial programs unless they were sure those physicians wouldn't be reported to the licensing board.

Nevertheless, some medical board directors believe PREP will get physicians' support if they know that its aim is to help them. "The disciplinary approach is not always the answer, because it drives people underground," says Andrew Watry, executive director of the North Carolina Medical Board. "We tempered the punitive angle for drug and alcohol impairment years ago. But we're still stuck on the punitive approach for clinical skills deficits, and that's the core of the problem."

Ken Terry. When doctors put patients at risk.

Medical Economics

2002;22:25.