Ann Int Med 2006;114(11):862 (letter)
Ann Int Med 2006;114(11):862 (letter). Available at
COMMENTS AND RESPONSES
Problem Doctors: Is There a System-Level Solution?
TO THE EDITOR: Leape and Fromson (1) should be commended for
addressing physician performance failures. However, they overlook
perhaps the most critical aspects of physician quality control while
arguing for more onerous burdens on practicing physicians.
As suggested recently (2), performance problems are often evident
long before a physician enters practice. In fact, many doctors
would agree there is a lack of quality control, starting in medical
school. More directly, it seems nearly impossible to fail medical
school or be fired from residency. Regarding the latter, I have found
that program directors and department heads are loathe to effectively
discipline even the most incompetent individual. Concerns of legal
action are often cited, which seem disingenuous—particularly considering
the fiduciary responsibility noted by Leape and Fromson.
Programs have a responsibility to train such individuals and, if that
fails, prevent them from being unleashed on patients. There are also
clear conflicts of interest: Keeping individuals on the rolls is advantageous
to host departments that are dealing with deranged rotation
and call schedules and receiving Medicare funding for the trainee’s
position. Anyone who has been exposed to community hospital residency
programs can testify that filling slots often takes precedence
over weeding out low-quality candidates.
Practicing physicians are engulfed in paperwork and requirements
that are only likely to increase, with questionable results (3).
More testing (in addition to residency in-service tests, multiple board
examinations, recertification processes, and continuing medical education
requirements) will add to the growing sense of intrusion but is
unlikely to offer significant utility. It is also unlikely that hospital
credentialing, already an onerous process, will improve in its ability
to address problem physicians (4). Finally, it is unclear how one
could standardize evaluations. For example, physicians practicing in
rural areas cannot be held to the same knowledge standards as counterparts
in an urban academic setting, and surgeons handling highrisk
patients should not be expected to have similar outcomes to
community practitioners.
The confrontational tone and anecdotal nature of sections of
the article are disturbing because both the authors and editors must
realize this will be widely quoted in the lay press. The comment “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” seems to be unsupported by
data, discounts that most physicians will not practice during their
compromised condition, and is overdramatized by italics. Although
it may be true that the professional arena is the last affected by
performance issues, one wonders about the significance of “In our
experience” and the subsequent citation of a 25-year-old article (5).
Duncan M. Kuhn, MD
Whitehead Institute
Cambridge, MA 02412
Potential Financial Conflicts of Interest: None disclosed.
References
1. Leape LL, Fromson JA. Problem doctors: is there a system-level solution? Ann Intern
Med. 2006;144:107-15. [PMID: 16418410]
2. Papadakis MA, Teherani A, Banach MA, Knettler TR, Rattner SL, Stern DT, et al.
Disciplinary action by medical boards and prior behavior in medical school. N Engl J
Med. 2005;353:2673-82. [PMID: 16371633]
3. Krasner J. Plan would tie copayments to doctors’ rankings. The Boston Globe. 27
January 2006:A1.
4. Gifford DR, Crausman RS, McIntyre BW. Problem doctors: is there a system-level
solution? [Letter] Ann Intern Med. 2006;144:862-3.
5. Talbott GD, Benson EB. Impaired physicians: the dilemma of identification. Postgrad
Med. 1980;68:56-64. [PMID: 7433316]
TO THE EDITOR: As Leape and Fromson (1) explained in their
recent article, substance abuse and dependence are significant problems
among physicians and have negative consequences for the physicians
themselves, their families, and their patients. We have evaluated,
treated, and reported on impaired physicians for more than 3
decades. Alcohol abuse and dependence are no more common
among physicians than among similarly matched controls; however,
prescription misuse, opiate abuse and dependence, and suicide seem
to be more common among physicians. Physicians, however, may
not be a single homogeneous group. Our recent work has shown that
anesthesiologists, surgeons, and emergency department physicians
are overrepresented among physician opioid addicts (2, 3). We have
reported on drug testing as a treatment for impaired physicians and
believe that it should be integrated into a system to improve patient
care (4). Drug testing is also a method of case finding to be used
before an overdose or patient injury. However, as Leape and Fromson
describe, few physicians are subjected to drug testing as a condition
of employment (1). Physicians who are subject to preemployment
or random drug testing include those employed by Veterans
Affairs and the military and those who are being monitored by staterun
impaired professional programs or by some new model programs
at teaching hospitals (5). Our experience and research on physician
impairment suggest that drug testing (preemployment, for cause, and
random) should be considered for all physicians. Testing complements
initiatives for prevention, education, early intervention, and
treatment. Although all physicians are at risk and should be monitored,
we strongly recommend that priority be given to specialists
with greatest access to and greatest risk for occupational exposure
(anesthesiologists, surgeons, and emergency medicine specialists).
Mark S. Gold, MD
Kimberly Frost-Pineda, MPH
University of Florida McKnight Brain Institute
Gainesville, FL 32611
Potential Financial Conflicts of Interest: None disclosed.
References
1. Leape LL, Fromson JA. Problem doctors: is there a system-level solution? Ann Intern
Med. 2006;144:107-15. [PMID: 16418410]
2. Gold MS, Byars JA, Frost-Pineda K. Occupational exposure and addictions for
physicians: case studies and theoretical implications. Psychiatr Clin North Am. 2004;
27:745-53. [PMID: 15550291]
3. Gold MS, Melker RJ, Dennis DM, Morey TE, Bajpai LK, Pomm R, et al. Fentanyl
abuse and dependence: further evidence for second hand exposure hypothesis. J Addict
Dis. 2006;25:15-21. [PMID: 16597569]
Annals of Internal Medicine Letters
© 2006 American College of Physicians 861
4. Jacobs WS, Repetto M, Vinson S, Pomm R, Gold MS. Random urine testing as an
intervention for drug addiction. Psychiatric Annals. 2004;34:781-5.
5. Department of Veterans Affairs. Drug-Free Workplace Program: VA Directive
5383. Washington, DC: Department of Veterans Affairs; 2004.
TO THE EDITOR: The explosive growth of preemployment and random,
not-for-cause drug testing in industry and health care raises
ethical, legal, and policy questions (1). Such growth has been fueled
by popular misconceptions surrounding substance use and abuse,
junk science, and business interests (Institute for a Drug-Free Workplace,
pharmaceutical firms, and drug-testing companies) and by the
public relations campaigns of a multibillion-dollar industry whose
entrepreneurial interest lies in magnifying the severity of drug-related
problems in the workplace and extolling the benefits of drug testing
as a solution (2).
Preemployment and random drug testing to find one otherwise
hidden drug abuser is estimated to cost between $700 000 and $1.5
million for the U.S. government’s program (3). No solid data show
that such testing deters drug use (3). The National Academy of
Sciences has concluded that frequently cited estimates of lost productivity
from drug use are based on flawed data (4). Drug tests are
subject to sabotage and to false-positive and false-negative results, all
of which can damage workplace morale, reduce productivity, and
hinder recruitment of skilled workers. No court has held an employer
legally liable for not having a drug-testing program; however,
employers have incurred substantial legal costs from defending their
programs against workers’ wrongful dismissal claims (1). It is impossible
to completely ensure that information obtained through drug
testing programs will not be shared with other entities. The Canadian
Human Rights Commission recently disallowed preemployment
and random drug testing of public employees on the grounds
that such policies are human rights violations under the Canadian
Human Rights Act (1).
In 1999, 23 of 44 randomly selected large teaching hospitals
had formal physician drug testing policies. Many policies referred to
preemployment and random, not-for-cause drug testing (5), but
most were vague on procedural details; only half mentioned confidentiality.
Substantial numbers of practicing physicians, residency
program directors, and medical students oppose such testing (1).
To improve patient safety and enhance quality of care, the medical
profession should improve substance abuse education and training.
Error reporting and analysis should be encouraged. Physicians
should undergo impairment testing (vision, reflexes, and coordination)
to uncover substance abuse, physical disabilities, mental illness,
and sleep deprivation. Those found to be impaired or incompetent
should be referred for treatment and, if necessary, disciplined appropriately.
More attention should be paid to job and life satisfaction,
depression, and marital discord. Institutions should support thorough
reference checking, enhanced procedural training and oversight,
mandatory recertification, periodic hospital recredentialing,
and frequent skills appraisal. Computerized ordering systems should
be used to reduce prescribing errors, and sign-out protocols should
be improved. Furthermore, hospitals should utilize ancillary staff to
assist residents in noneducational tasks and discontinue the practice
of replacing registered nurses with licensed practical nurses and nursing
assistants who are less expensive but have less training (1).
Martin T. Donohoe, MD
Portland State University
Potential Financial Conflicts of Interest: None disclosed.
References
1. Donohoe M. Urine trouble: practical, legal, and ethical issues surrounding mandated
drug testing of physicians. J Clin Ethics. 2005;16:85-96. [PMID: 15915849]
2. Lundberg GD. Mandatory unindicated urine drug screening: still chemical Mc-
Carthyism. JAMA. 1986;256:3003-5. [PMID: 3773220]
3. Matlby LL. Drug testing: a bad investment. 1999. Accessed at news
/1999/n090199a.html on 18 May 2000.
4. Normand J. Under the Influence? Drugs and the American Workforce. Washington,
DC: National Academy Pr; 1994.
5. Montoya ID, Carlson JW, Richard AJ. An analysis of drug abuse policies in teaching
hospitals. J Behav Health Serv Res. 1999;26:28-38. [PMID: 10069139]
TO THE EDITOR: Although we agree with Leape and Fromson’s (1)
call for action about the need to address physician performance failures,
we do not believe that relying on the hospital credentialing
process will adequately address this vexing problem for several reasons.
First, many physicians do not have admitting privileges to any
hospital. Second, among those who do have these privileges, most
admit very few patients (2). Third, with the advent of hospitalists
and the shift of more health services to the ambulatory setting, hospital
credentialing committees now only oversee a fraction of the
practicing physicians’ delivery of service. Fourth, as the authors summarize,
the state medical boards run many of the remedial programs
in cooperation with other groups, such as the state medical society.
In Rhode Island, our Board of Medical Licensure and Discipline
works closely with the state medical society’s Physician’s Health
Committee to provide treatment and rehabilitation for impaired
physicians and assessment services for physicians with behavioral
health problems (including sexual boundary violation, gambling, sexual
and Internet addictions, and disruptive behaviors). In addition,
our Board is involved with the Practitioner Remediation and Enhancement
Pilot Project with the Citizen Advocacy Center through a
U.S. Health Resources and Services Administration grant (3). Therefore,
rather than relying on numerous hospital credentialing committees,
we suggest that the state medical boards be empowered and
supported to improve its oversight in these vital areas.
However, such expansion (and in many cases, reorientation) of
activities will require changes on many levels. More than boards of
licensure and discipline, our medical boards must evolve into boards
of licensure, discipline, and remediation. This will require legislative
change, and hospitals, insurers, and the physician community must
improve reporting of potential physician performance failures and of
physicians at risk for such failures because of suspected drug abuse or
other factors. For example, most referrals to the Rhode Island Board
of Medical Licensure and Discipline come from patients; much fewer
come from other physicians or licensed health care facilities, such as
hospitals. Our experience also supports Leape and Fromson’s argument
to identify these physicians before performance failures. Most
physician performance failures had a history leading up to the event
or several suspicious colleagues who did not want to get involved. To
be effective, however, improved reporting programs must offer
meaningful protections to both the reporting entity and to the suspect
physician. A culture of safety cannot be cultivated without a
Letters
862 6 June 2006 Annals of Internal Medicine Volume 144 • Number 11
reorientation from the traditional disciplinary approach. By necessity,
this will require further legislative change and some degree of
malpractice reform.
We are also intrigued that Leape and Fromson did not discuss
the individual physician’s role in working to change the system that
contributes to medical errors, the physician administrators’ responsibility
for identifying and addressing system problems (in addition
to physician performance failures or physicians at risk for committing
such failures), and the potential role that health insurers and
managed care plans might play in reviewing and reporting physician
performance in outpatient settings.
David R. Gifford, MD, MPH
Robert S. Crausman, MD, MMS
Bruce W. McIntyre, JD
Rhode Island Department of Health
Providence, RI 02908
Potential Financial Conflicts of Interest: None disclosed.
References
1. Leape LL, Fromson JA. Problem doctors: is there a system-level solution? Ann Intern
Med. 2006;144:107-15. [PMID: 16418410]
2. Miller ME, Welch WP, Englert E. Physicians practicing in hospitals: implications
for a medical staff policy. Inquiry. 1995;32:204-10. [PMID: 7601518]
3. Citizen Advocacy Center. PreP 4 Patient Safety: The Practitioner Remediation and
Enhancement Partnership Pilot Project. Accessed at on 10
April 2006.
IN RESPONSE: We agree with Dr. Kuhn that much more attention
needs to be paid to assessing medical students and residents for their
suitability and fitness to practice medicine, and that failure to do so
is a breach of the fiduciary responsibility of schools and hospitals.
These are issues that the Association of American Medical Colleges
and specialty boards should address.
However, Dr. Kuhn’s dismissal of the need for additional testing
is diametrically opposed to every specialty board’s strong (and,
we think, laudable) initiative to develop much more rigorous and
effective assessment of physician performance. Although we are sensitive
to the fact that rural practice clearly has unique accountability
issues, the ability of physicians to learn and maintain personal standards
is not one of them. There is neither an ethical nor practical
justification for accepting lower standards for physicians in rural
areas.
We disagree that our data do not justify our estimate that at
least one third of physicians will need help at some time in their
career. The finding that performance problems are not confined to a
small fringe of practitioners is a central point of our paper. Sadly,
most compromised doctors do continue to practice, often with dire
consequences for their patients. This is the problem that we seek to
remedy.
The diametrically opposed views of Dr. Gold and Ms. Frost-
Pineda (who advocate for preemployment and random drug testing
of physicians) and those of Dr. Donohoe (who raises associated “ethical,
legal, and policy questions”) illustrate the controversial nature of
this issue. Clearly, the practice warrants further study and testing.
Drs. Gifford and Crausman and Mr. McIntyre make the important
point that not all physicians participate in hospital credentialing
processes. However, credentialing is a good place to start
improvements because a mechanism and a requirement already exist.
If we can develop effective early identification and assessment practices
for physician performance in hospitals, they should be adaptable
to office, clinic, and ambulatory surgical settings.
Although we applaud these 3 correspondents’ call for expanding
the role of licensing boards to support remediation programs and
agree that these entities should set standards, we do not share their
enthusiasm for having state boards actually perform the credentialing
process. We also do not believe that insurers and managed care plans
should play a role in reviewing physician performance. We believe
most physicians would agree that these duties are the profession’s
responsibility.
Lucian L. Leape, MD
Harvard School of Public Health
Boston, MA 02215
John A. Fromson, MD
MetroWest Medical Center
Natick, MA 01760
Potential Financial Conflicts of Interest: None disclosed.
Letters
6 June 2006 Annals of Internal Medicine Volume 144 • Number 11 863
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