Research has shown that "the vast majority of mistakes and injuries can be attributed to faulty systems that cause injuries or lead even competent, careful people to make errors," the authors write. And hospitals have begun to embrace principles of "human factors engineering" to correct these system-induced errors. But individual problem doctors still pose a considerable threat to patient safety.
"Performance problems are more widespread than people recognize; it's not just the small number of doctors disciplined annually by state medical boards, which is something like a half a percent of the nation's practicing physicians," said Dr. Lucian Leape, co-author of the article and recognized as the founder of the "medical error movement" with his authorship of the landmark 1994 JAMA paper, "Error in Medicine'. "Up to one-third of doctors may have a condition that impairs their performance at some time during their career, and most of them get little help for it." Leape is an adjunct professor of health policy at Harvard School of Public Health.
The article "Problem Doctors: Is There a System Solution?" appears in the January 17, 2006 issue of The Annals of Internal Medicine. The article is co-authored by Dr. John A. Fromson, an assistant clinical professor of psychiatry at Harvard Medical School and chairman of the department of psychiatry at MetroWest Medical Center. Dr. Fromson was responsible for setting up the Massachusetts Medical Society's program for dealing with impaired physicians.
The authors describe a menu of underlying causes for physician performance deficiency including mental and behavioral problems such as depression, anxiety, substance abuse and personality disorders, physical illness, including age-related and disease-related cognitive impairment, and failure to maintain or acquire knowledge and skills. Contributing to these problems for physicians in particular are environmentally-induced problems such as fatigue, stress, isolation, and easy access to drugs. While the rate of physical illness and alcohol dependence for physicians may be similar to the general population, there may be higher rates of mental illness. For example, the rate of suicide is 40 percent higher in male physicians and more than two-fold higher in female physicians than in the general population.
"The problem now is that typically little or nothing is done about recognized performance problems until someone is hurt or there is a malpractice suit. The doctor may then be warned by the chairman of the department, but it's often informal and without specific remediation assistance," said Leape. "If problems continue, then the physician is disciplined or reported to the state board. The exception is alcohol abuse. Most states have good programs for helping alcoholic doctors. But for all of the other problems, we need a system to enable us to intervene much earlier, before a patient is injured. Doctors have not done it because they have not wanted to be critical of colleagues, and there was no mechanism short of curtailing practice or taking a doctor's license away. But everyone knows at least one doctor with a problem: it's the elephant in the room. What we need to do is set up a regular system to identify these problems early and offer physicians help."
According to the authors' estimate, when all conditions are considered, "at least one third of all physicians will experience, at some time in their career, a period during which they have a condition that impairs their ability to practice medicine safely."
The authors propose that "the current ad hoc, informal, reactive approach to physician performance problems be replaced with a routine, formal, proactive system of monitoring that uses validated measures to focus strictly on clinical and behavioral performance."
To create a model system an institution would:
- Adopt explicit performance standards of behavior and competence, standards set at the national level.
- All physicians would be required to acknowledge that they have read and understand the standards and will follow them and understand that persistent failure will lead to loss of privileges and dismissal.
- Adherence to the standards would be monitored annually by formal evaluation, and results of the evaluations should be provided confidentially to each individual. And if there are deficiencies, the department chairman would be responsible for prompt response, including further evaluation, counseling or referral for treatment.
- In cases that threaten patient welfare, department chiefs and hospitals would take immediate action to limit practice during assessment and rehabilitation.
- Finally, assessment and treatment programs must be available for management of all underlying cause of substandard performance: substance abuse, psychiatric problems, behavioral problems and lack of competency.
The authors note that while the monitoring programs must take place at the local level, hospitals do not have the resources to develop the measures and the methods needed for implementing these systems. The authors therefore call for a national effort by the Federation of State Medical Boards, the American Board of Medical Specialties and the Joint Commission on Accreditation of Healthcare Organizations to ensure safe, competent medical care for patients by developing standards, measures, and methods for a physician performance monitoring system.