PHOENIX-When faced with sticky ethical issues-such as a colleague who periodically shows up to work smelling of alcohol, or getting complaints from staff about inappropriate behavior from another doctor-what should be done?
Explore This IssueAugust 2009
At a Triological Society session at the recent Combined Otolarygnology Spring Meeting (COSM), panelists discussed how they would handle a series of uncomfortable scenarios. The panel did not include bioethicists or advocates for a reason, Harold Pillsbury, MD, Professor of Otolaryngology-Head and Neck Surgery at the University of North Carolina School of Medicine and the session’s moderator, told ENT Today. The session was designed to see how otolaryngologists would respond to difficult situations in real-life practice.
Panelists included Gerald Healy, MD, Professor of Otology and Laryngology at Harvard Medical School; Derald Brackmann, MD, Professor of Otolaryngology and Neurosurgery at the University of Southern California; Paul Levine, MD, Professor of Otolaryngology-Head and Neck Surgery at the University of Virginia; and Robert Maisel, MD, Professor of Otolaryngology-Head and Neck Surgery at the University of Minnesota.
First, Protect the Patients
The first scenario was of a 40-year-old surgeon with no history of problems related to his surgeries to date, but was reported to his department chief to have alcohol on his breath at work. The physician is often late for conferences and rounds.
According to Dr. Healy, who previously chaired the Judiciary Committee of the American College of Surgeons, it is not common to see physicians with a drinking problem. But the first and foremost thing is that patients be protected, he said.
It is critical for the chief of staff to collect as much information as possible, and review it so that the physician in question undergoes due process. The doctor needs to be told to deal with it, and he or she should no longer see patients or operate until after he or she has received help. Most states have addiction programs designed for physicians, he said.
However, he noted that many hospitals do not have formal rules or regulations for dealing with this. If this is the case, it’s important that physicians go to the hospital leadership and start the process for creating a system to deal with such issues.
Dr. Levine added that the goal is to help a doctor with an addiction problem get back on track with their career. Make it clear helping them get help isn’t a punishment, he said.
It can be a delicate situation to deal with, pointed out Dr. Maisel, and sometimes there is the risk that a report or accusation turns out to be false. We have a group in Minnesota called Physicians Helping Physicians, because nobody trusts their own hospital. We have a remote site that will, by telephone, report back-and, if asked, will make a written report, he said.
The second scenario was of a faculty member who has had complaints from house officers and nurses about sexual innuendos and unwanted contact, but no complaints about his professionalism with patients.
Dr. Brackmann said that he suspected this issue may be more common than the drinking problem. We recently had this occur at our hospital.…The final outcome was that he was asked to leave the staff and he did so and went to another hospital.
This is an issue that can be insidious, said Dr. Maisel. If you have a man who is sexually inappropriate with women, he is usually doing it one on one, and you’re not likely to see it when it happens, he said. This means trying to figure out how severe the problem is and how much to trust the people involved. Talking with the person and discussing boundaries can sometimes solve the problem.
Faculty at university settings often undergo gender sensitivity training, and these situations often are passed on to professionals trained to deal with these issues, Dr. Levine said. But it is important to make sure it is dealt with, either through policies or procedures at your own center, or through the use of experts in the field.
Dr. Healy described a situation in which a surgeon kept telling inappropriate jokes in the OR. After receiving complaints and establishing that the doctor did indeed do this, Dr. Healy told him that aside from the fact that it is inappropriate to make these individuals feel uncomfortable, is this what you want to teach the residents, fellows and medical students-that this is the appropriate conduct for a physician? He told the doctor that if he did it again, he would need to go elsewhere to work.
Know Your Residents
The third scenario was of a third-year resident who continually underperforms in medical judgment and surgical skills, and his contribution to discussions does not equal that of his peers.
Dr. Maisel said that it is important to know the residents, so you can determine whether there are other factors, such as family problems, that are affecting their work. Some issues can be resolved over time. On the other hand, with someone who consistently performs below average, this needs to be kept up front and documented. The resident may need to be encouraged to aim for a level of practice that is appropriate for him or her-not everyone can deal with complex cases.
It is important to evaluate and assess the [resident]’s sense of moral ethics and responsibility to take care of patients.…Make sure they are introspective enough to know their abilities and don’t go beyond that, Dr. Brackmann said.
Competency is a big issue these days, said Dr. Healy. In fact, the Accreditation Council for Graduate Medical Education (ACGME) and American Board of Medical Specialties (ABMS) may be adding an additional competency for surgical disciplines-technical skill. We have to start looking more at competency-based education, he said.
Disagreeing with the Referring Physician
A fourth scenario presented asked what the specialist does when he or she is sent a patient by referral who has been treated incorrectly by the referring physician. Here, panelists discussed the awkwardness of approaching the doctor in question to discuss the issue.
Many can be educated by simply talking to them about the diagnosis, and how the patient should best be treated, said Dr. Maisel. This should be done by talking to them, not by sending a letter (which might not go into enough detail). But, once in a while, you’re faced with a physician who doesn’t see that he or she did something wrong. Generally, you need to communicate with the doctor, and document that you’ve done so, partly for potential legal reasons, but also to help ensure that patients get the best care. Other panelists agreed that the discussion should have a polite tone and maintain a high level of professionalism.
Dr. Healy said that he calls referring physicians regardless of whether the other doctor has done things correctly or not-to discuss the case and his own findings, and provide education where it is needed.
Related to this was the fifth scenario: A physician has recently moved to your state after having been dismissed from an academic department in another state. You start receiving numerous referrals from other physicians of patients who were inappropriately managed by this person.
Panelists concurred that this case is different from the previous scenario, because the physician in the previous scenario could likely be educated. However, in this case, a one-on-one dialogue might not work. We would report them for an investigation by the Board of Medical Quality Assurance, said Dr. Brackmann.
The Question of Professionalism
The sixth scenario discussed was of a director of a medical group who receives reports from the operating room of disruptive behavior by a colleague, including disparaging statements towards the staff and throwing of instruments.
Unprofessional conduct and inappropriate behavior constitute a real issue in the eyes of the American College of Surgeons, said Dr. Healy. A survey of 1500 physician executives found that inappropriate behavior, insults, verbal insults, throwing instruments, physical contact, and more were not uncommon.
Every hospital should have a code of conduct. If your hospital doesn’t have one, you should go before the executive committee and urge them to set up a code of conduct to which every physician and nurse should have to adhere, Dr. Healy said. There may be many reasons leading to physicians misbehaving-such as anger management problems, family issues, or addiction-but they need to either accept help and adhere to the rules of conduct, or leave.
The final scenario was of a medical group that hired a female surgeon who, within the three years after her hire, became pregnant three times and took substantial time off. Colleagues in the group complained about having to carry her workload while she was away.
Institutionally, most places now have a policy that will help you manage this, Dr. Maisel said. But small practice groups have a harder time with this, and many don’t have policies in place. Policies need to address how much time people can take off, at what point one goes without pay, and more.
You need to make sure that’s in there ahead of time before you hire people, he said.
It’s not just maternity or paternity leave that policies need to address, but also illnesses where a person needs several weeks or a few months off. Overall, for a variety of issues, having established policies makes life a lot easier.
©2009 The Triological Society