Professional Jeopardy— Not a Game

Medical professionalism is key to patient care
By Philip B. Dray, MD

Professional difficulties can occur in any career. But a hospital organization may call a physician “on the carpet” to explain an alleged unprofessional incident. Dealing appropriately with all issues gives the physician the best chance to return to optimum participation in the workplace by restoring the confidence of co-workers. Problems along the career path can derail promising young physicians as well as seasoned doctors. When a pattern of difficulties arises and interferes with patient safety, quality of care or the mission and operations of an organization, actions must be taken to protect patients, fellow employees, and the practitioner. The challenges for the individual and the institution are wide-ranging and each case is unique. Yet, all problems have one thing in common—the disruption of care. The hospital is obligated to implement steps that are spelled out in bylaws or policies. Because of the stakes involved, physicians should seek advice from professional counsel.

Risks to patient care and disruption of the institution’s operations are paramount concerns that an organization must address. Professionalism deficiencies of all varieties can be a threat to the safety of everyone involved. Lack of competence in surgical work or medical decision-making is a well-recognized reason for concern but other key professionalism issues play major roles too. Impairment by drugs or alcohol; medical conditions that prevent safe delivery of care; anger management issues; failure to fulfill agreed upon responsibilities such as call or rounds; hostile work environment; inappropriate patient contact; and stealing or diversion of medications are all reasons for some manner of professional intervention.

The physician is called out for action because somewhere along the line, a fellow worker or patient identified a behavior that, in his or her opinion, resulted in or had the potential to result in, disruption of care. The physician’s co-workers are obliged to bring such behavior to the attention of the administration and, in fact, they may be subject to discipline themselves if they knowingly conceal dangerous unprofessional conduct.

Depending upon the individual hospital bylaws and policies, the first step may be a collegial consultation with the department chairperson. This person will typically take an advocacy approach to understand all the facts and circumstances surrounding the alleged professionalism deficiency. Depending upon the severity of the event(s), one or more pathways may be taken. In the general order of increasing perception of risk, the following may occur: (1) No further action; (2) A second meeting or follow-up; (3) Specific voluntary recommendations or recommendations for voluntary referral to a professional assistance program or physician; (4) Focused professional performance review (FPPE); (5) Peer review; (6) Specific disciplinary action (reprimand, suspension); (7) Restriction of privileges or summary suspension. A wide range of disciplinary actions must be disclosed on medical staff applications, including the involuntary restriction of privileges, suspensions of more than 30 days, and terminations—all of which may result in a report to the National Practitioner Data Bank.

Cooperation and voluntary participation in the process will permit both the organization and the physician to resume optimal performance as quickly as possible. But it is not uncommon for fear, denial, anger or suspicion to prevent the efficient recognition and factual identification of the alleged professional misconduct. Specific steps are spelled out in the bylaws or policies that address the rights of the physician when any adverse action is recommended. Physicians should familiarize themselves with the rights afforded them and with the help of their counsel make appropriate requests and inquiries. Under most bylaws, outside lawyers cannot participate directly during disciplinary meetings. They may be allowed to be present during a hearing or appeal but cannot speak for physicians or tell them how to answer questions during the session. Recommendations can be made by each committee as a requirement for continued membership on the medical staff.

Explaining the issues in a dispassionate and straightforward manner is always the best strategy. Hostility, name calling, denial of documented facts are counterproductive. The goal is to get to the bottom of the problem and design a remedy or determine that the circumstance does not merit further attention. Professionalism is not just how fast a surgeon can work or the doctor’s command of the literature. Medical professionalism is represented by all aspects of knowledge, behavior, skill, and ethics. The expectation of co-workers and the hospital is that physicians will be competent in the performance of their duties and will behave honorably and ethically while delivering safe care and maintaining a safe work environment.

A practicing ophthalmologist, Dr. Dray is the past chairman of the Credentials Committee at Stroger Hospital of Cook County and a CMS trustee.