Improving Patient Care17 January 2006

Problem Doctors: Is There a System-Level Solution?

    Author, Article, and Disclosure Information


    Physician performance failures are not rare and pose substantial threats to patient welfare and safety. Few hospitals respond to such failures promptly or effectively. Failure to ensure the quality and safety of the performance of colleagues is a breach of medicine's fiduciary responsibility to the public. A major reason for this deficiency is the hospitals' lack of formal systems to monitor physician performance and to identify and correct shortcomings. To develop and implement these systems, hospitals need better performance measures and substantial expansion of external programs for assessment and remediation. This is a task well beyond the capacities of individual hospitals; a national effort is required. The authors call on the Federation of State Medical Boards, the American Board of Medical Specialties, and the Joint Commission on Accreditation of Healthcare Organizations (organizations that already bear a fiduciary responsibility for ensuring safe, competent care) to collaborate on developing better methods for measuring performance and to expand programs for helping practitioners who are deficient.

    The recent upsurge of interest in improving patient safety has been driven by lessons from the fields of cognitive psychology and human factors engineering. Research in these areas has shown that the vast majority of mistakes and injuries are attributable to faulty systems that cause injuries or lead even competent, careful people to make errors. The safety agenda is to redesign these faulty systems, and great effort is now being devoted to identifying and implementing safer policies and practices.

    Some injuries, however, result from individual performance failures. Such failures may be caused by short-term stressors (such as emotional upset or overwork) or may have serious underlying causes that are less transitory in nature (such as drug or alcohol addiction, mental or physical illness, or declining knowledge and skills). Physicians whose performance persistently falters pose a substantial threat to patient safety that is often unrecognized or unsatisfactorily addressed in hospitals and other health care organizations.


    To facilitate discussion of performance deficiencies that threaten patient safety, we must first define some key terms that are used to categorize professional behaviors. Professional competence has been defined as “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served” (1). The Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties have divided competence into defined sets of “competencies” in specific domains, including those that apply to all physicians and those that are unique to each specialty. A deficiency in any of these domains can be referred to as a “dyscompetency,” which is a useful concept because no one is totally incompetent.

    Mental and behavioral problems include depression, anxiety, substance abuse, personality disorders (for example, antisocial behavior), and disruptive behavior with colleagues, patients, and subordinates. At the extreme are physicians who have severe psychopathologic manifestations, such as psychosis or suicidal behavior, but such cases are rare.

    The term disruptive physician has been applied to physicians who exhibit abusive behavior that “interferes with patient care or could reasonably be expected to interfere with the process of delivering quality care” (2). Examples of disruptive behavior are provided in Table 1(3).

    Table 1. Examples of Disruptive Behavior

    Disruptive, intimidating, or abusive behavior may increase the likelihood of errors by leading nurses, residents, or colleagues to avoid the disruptive physician, to hesitate to ask for help or clarification of orders, and to hesitate to make suggestions about patient care (4, 5). Such behavior may also deflect the physician's attention from the patient, thereby impairing clinical judgment and performance. When patients witness disruptive behavior, it undermines their confidence in the physician and the institution, as well as their willingness to partner in their own care (6). Consequently, disruptive behavior by physicians not only threatens patient safety but has a corrosive effect on morale, making life miserable for the nurses and residents who work closely with these physicians.

    The term impaired has been defined by the American Medical Association as disability resulting from psychiatric illness, alcoholism, or drug dependence. However, the term has sometimes been inappropriately applied to physicians who have returned to good health, are substance-free and in a monitoring program, or have successfully completed a knowledge or skill remediation course.

    We will use the term performance problems to refer to all types of deficiencies, regardless of cause.

    Underlying Causes

    Physician performance problems can be usefully thought of as symptoms of underlying disorders, not as diseases. Underlying causes include mental and behavioral problems, including substance abuse or dependence (drugs or alcohol); physical illness, including age-related and disease-related cognitive impairment; and failure to maintain or acquire knowledge and skills. Contributing stressors include overwork, family strife, a dysfunctional working environment, supervisor pressure, and anxiety. Categories frequently overlap. For example, declining surgical competence can be attributed to knowledge or skill deficits and to alcohol dependence, and both of these problems may reflect underlying mental illness, such as severe depression.

    Contributing to these problems are fatigue, stress, isolation, and easy access to drugs. The “normal” stress of medical practice has been compounded in recent years by large educational debt loads for graduating physicians, increasing malpractice premiums, decreasing reimbursement, and the pressure to see more patients in a shorter amount of time. Stress can lead to isolation and cause physicians to acquire maladaptive coping strategies, including alcohol or drug abuse.

    In our experience, the professional realm is usually the last area in one's life that is affected by substance abuse and mental and behavioral issues (7). By the time these disorders manifest in the workplace, the physician's relationships with significant others, nuclear family, extended family, friends, and community have usually been “impaired” for a long time.

    Extent of the Problem

    The media frequently cite the number of physicians disciplined by state medical boards as a measure of performance issues. In 2002, approximately 0.5% of practicing physicians in the United States were disciplined; 1739 physicians had their licenses revoked, and state boards imposed restrictions on an additional 1218 (8). It is difficult to know how to interpret these figures because physicians are disciplined for various reasons, some of which may be unrelated to performance (such as fraudulent activities involving third-party payers).

    Concerning mental illness, a recent study found a 16% lifetime incidence of major depressive disorders in the general population (9). The rate in physicians may be even higher (10); for example, the rate of suicide is 40% higher in male physicians and more than 2-fold higher in female physicians than in the general population (11).

    Estimates of alcohol dependence vary from 8% to 15% (12-16), the latter being similar to the 13.5% rate for the adult population (16-18). The American Medical Association's estimate for drug dependence is 1% to 2% (18). The Medical Board of California estimated that 18% of physicians in its state abuse alcohol or other drugs at some point during their career (19).

    Sound data are lacking for the incidence of disruptive behavior. Surveys of nurses suggest that most have witnessed episodes caused by 4% to 5% of the physicians at their institutions, but these data are flawed by low response rates (5, 20). Surveys of physician executives indicate that the percentage of disruptive physicians ranges from 1% to 5% (21). Hickson and colleagues (6) found that 6% of physicians received 25 or more complaints from patients over a 6-year period. Our best estimate is that 3% to 5% of physicians present a problem of disruptive behavior.

    We found no studies of the incidence of physical illness among practicing physicians, but a reasonable estimate is that at least 10% of physicians must restrict their practice for several months or more during their career because of a disabling physical illness (such as diabetes, heart disease, or surgical procedures). Like everyone else, physicians are subject to cognitive decline with aging (22-24), but the extent has not been quantified.

    Similarly, there are no overall estimates of the extent of knowledge and skill dyscompetencies. Results from 1 measure, recertification examinations, show that first-time failure rates in 4 specialties ranged from 1.0% to 14.0% (Table 2). Failure rates tend to be higher on subsequent examinations. We estimate that as many as 10% of physicians will demonstrate significant deficiencies in knowledge or skills at some point in their career.

    Table 2. Failure Rates for Specialty Board Recertification Examinations

    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; for a hospital with a staff of 100 physicians, this translates to an average of 1 to 2 physicians per year. Referral rates to state physician health programs suggest that most practitioners get little help. On the basis of our experience, even serious problems are often handled poorly at the hospital or practice level. However, ensuring high standards of professional conduct is arguably the greatest responsibility of a professional and one that the public, lacking an alternative mechanism for oversight, has a right to expect. We believe that our profession's failure to ensure the quality and safety of our colleagues' performance is a breach of its fiduciary obligation to the public.

    An Ineffective System

    Neither physicians nor hospitals have adequately addressed performance problems (3). Few organizations systematically monitor physician performance or have formal programs to identify problem doctors (3). Annual physical examinations are not required of physicians, and only the Department of Veterans Affairs (25) performs random drug testing. State licensing boards have relied on continuing education attendance as evidence of maintenance of competence.

    Once problems are identified, management is also frequently haphazard. In egregious cases, investigations have repeatedly revealed that institutions ignored numerous warning signs months or years before a serious incident occurred (26, 27). Many physicians are reluctant to confront behavioral or competence problems. Independence is so highly valued that physicians are loath to evaluate or confront a colleague whom they perceive as having a problem (28, 29). Doctors abhor making judgments about colleagues who may also be personal friends or practice partners. Department chairs often lack the training and skills needed for managing doctors who perform poorly. The hospital may need the physician's revenue stream (30).

    As a result, managing these situations can be difficult and aggravating for all parties concerned. Offers of assistance may be spurned. If disciplinary action is needed because a physician's performance is unsafe, it can be met with countercharges or a lawsuit, even when evidence is clear and due process is followed. At best, management is often a messy business; at worst, it can be hazardous to everyone involved.

    Hospitals receive little help from regulators. Although they are required to have credentialing and disciplinary processes, the details of implementing such processes are left to the hospitals. There are few national or state standards of conduct or competence, or measures for monitoring performance.

    State medical boards discipline physicians after the fact when unsatisfactory performance is reported by hospitals or patients or when malpractice settlements are reviewed. However, the state boards typically do not define prevention of injury as part of their responsibility.

    Health care's casual approach to monitoring physician performance contrasts markedly to that of other professions whose conduct affects the public welfare. Commercial pilots, for example, must pass both physical and performance examinations every year.

    The challenge is clear: We need to identify problem doctors early and address the problems in a timely fashion. To do this, we require better measures for identifying physicians who need help and better programs for providing help to those who need it. Although performance problems are widespread, we suggest that the place to start is in hospitals, where a credentialing process is already in place.

    Identifying Physicians Whose Performance May Endanger Patients

    We 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. The goal would be to identify problem doctors early, before they jeopardize patient safety.

    This system would have 3 essential characteristics. First, it should be objective. A common criticism of current methods is that they are based on subjective judgments of personality, motivation, or character instead of performance. The solution is to base evaluations on data, such as evidence of compliance with performance standards.

    Second, the system should be fair. To avoid being viewed as stigmatizing or punitive, all physicians should be evaluated on an annual basis according to the same measures. The evaluation process must be open and unbiased, and it must comply with labor regulations.

    Third, the system should be responsive. When physicians with problems are identified, they must be treated promptly. For some physicians, feedback and internal counseling may be all that is necessary. Others may need further assessment and referral to a program to help them to correct their deficiencies and enable them to continue to practice medicine, if possible.

    A Model System

    How would such a system operate? We envision 4 stages to the process: adopting standards, requiring compliance, monitoring performance, and responding to deficiencies.

    First, an institution should adopt explicit performance standards of behavior and competence. These standards need to be developed at the national level; specialty boards are currently at work on such standards for competence. The Federation of State Medical Boards could develop behavioral standards by using currently available material. The Joint Commission on Accreditation of Healthcare Organizations should coordinate with these groups. During the interim, hospitals can develop their own performance standards (as many already have). These should address all aspects of professional behavior. For example, 1 standard might be, “All patients and personnel will be treated with respect.”

    Second, all physicians should be required to acknowledge that they 1) have read and understand the standards, 2) have a responsibility to follow the standards, 3) know that adherence will be monitored, and 4) understand that persistent failure will lead to loss of privileges and dismissal. This acknowledgment should be given in writing as a condition of being granted clinical privileges.

    Third, adherence to standards would be monitored annually by formal evaluations of all members of the staff using accepted and validated measures of competence and behavior. These should include confidential evaluations by colleagues and coworkers and analysis of complaints by patients or others (6, 31).

    Fourth, results of the evaluations should be provided confidentially to each individual (with the identities of their colleagues concealed for protection). If significant deficiencies are identified, the department chairman should be responsible for ensuring a prompt, appropriate response. This response could involve evaluative testing, counseling, or referral for further assessment and treatment. In cases that threaten patient welfare, department chiefs and hospital leaders must take immediate action to limit practice during assessment and rehabilitation.

    An essential element of this system is that everyone clearly understands his or her roles and responsibilities when a practitioner with performance issues has been identified; from the outset, all parties will know who is responsible for collecting data, who should receive reports, and what actions are required by whom at each level. Such a system would provide accountability at all levels: physician to department chair, chair to hospital medical staff, medical staff to hospital board, and hospital to state boards and the Joint Commission on Accreditation of Healthcare Organizations.

    Finally, assessment and treatment programs must be available for management of all underlying causes of substandard performance: substance abuse, psychiatric problems, behavioral problems, and dyscompetencies. Programs should be personalized to enable the individual to use his or her strengths and knowledge in productive ways, ultimately resuming practice if possible. If a physician refuses to accept education, treatment, monitoring, or necessary restrictions of practice, or if these interventions fail, the physician must be promptly referred to the state medical board for disposition.

    We conclude that an effective system for managing physicians with performance issues is built on the ideas that 1) subpar performance can be objectively defined; 2) routine monitoring of all members of the medical staff is necessary to detect problems fairly and early; and 3) the responses to deficiencies should be prompt, constructive, and sustained. The long-term objective is to enable physicians to continue to practice effectively and safely—not to “weed them out.” If the system works properly, that is, if physicians who perform poorly are identified before serious consequences arise, then one might expect referrals to the state medical board for disciplinary action to decrease.

    Moving Ahead

    Implementing such a system requires a national effort on several fronts. Three issues must be addressed: developing better measures for assessing performance, expanding the number of assessment programs for physicians with competence or behavioral problems, and developing and supervising remediation programs.

    Measuring Performance

    Some authorities have contended that performance assessment is not feasible (31). We disagree. However, the obstacles for setting assessment standards for behavioral problems differ from those for dyscompetencies.

    For behavioral problems, several measures could be combined to provide earlier identification of physicians who need help. For example, Hickson and colleagues (6) found that analysis of patient complaints can identify doctors with interpersonal problems and predict the likelihood of malpractice litigation. Physicians with 4 or more complaints over a 6-year period were found to be 16 times more likely to have 2 or more risk management files opened than were physicians with no complaints.

    The Physicians Achievement Review program, which is run by the College of Physicians and Surgeons of Alberta, assesses every physician in Alberta every 5 years (32). Patients, physician colleagues, and nonphysician coworkers complete confidential questionnaires regarding the individual's clinical knowledge and skills, communication skills, psychosocial management, office management, and collegiality. Physicians are provided with detailed aggregate responses for their own practice and a report comparing their personal results with the summary profile of all physicians with similar types of practices. Surveys may also be suitable for identifying physicians with alcohol or drug dependence, physical impairment, and mental illness (33). These measures need to be validated in the clinical setting.

    Serious consideration should be given to implementing annual physical examinations and random drug testing for all physicians. More controversial, but clearly in need of investigation, is the feasibility of routine cognitive evaluations for older physicians.

    Competence is a more difficult area to measure. Myriad instruments have been advanced over the years to measure competence, but most have proven too cumbersome or expensive to be implemented for all physicians on a regular basis. However, the Accreditation Council for Graduate Medical Education and the members of the American Board of Medical Specialties have advanced a massive national effort to define general and specialty-specific competencies. They have started to develop measures of these competencies to assess trainees for certification (34), and these same measures will be used to assess practicing physicians as part of maintenance of certification. These tools could also be used by hospitals. Several specialty organizations, particularly the American Board of Internal Medicine, have already made substantial progress in developing measures (35; Cassel C. Personal communication, 18 December 2005). These assessments might be financed through a combination of user fees and support from the national boards and specialty societies.

    Expanding Assessment Programs

    A second serious challenge is the need to greatly expand the number and capacity of assessment programs for physicians with competence or behavioral problems. All states except Nebraska have physician health programs for doctors with alcoholism or drug abuse, and 41 states offer assistance for physicians coping with mental health issues; however, few state programs address knowledge and skill deficits, clinical dyscompetencies, or disruptive behavior (Table 3).

    Table 3. State Assistance Programs for Physicians

    Nationwide, only 10 programs are available for assessing physicians' skills or for education plans to correct deficiencies (Table 4). Five programs assess disruptive behavior. Others deal with relationship issues, communication skills, medical skills and knowledge, clinical reasoning, and patient care documentation.

    Table 4. National Assessment and Remediation Programs

    The Federation of State Medical Boards administers a standardized examination of clinical knowledge, the Special Purpose Examination, to physicians referred by state medical boards or by themselves. If results are questionable, the physician may undergo an additional assessment by The Institute for Physician Evaluation, which is a joint initiative of the Federation and the National Board of Medical Examiners. The Institute's assessments include computer-based case simulations, structured interviews, multiple-choice examinations, cognitive function screening, and interactive judgment analysis. The evaluations were previously administered in Philadelphia, Pennsylvania, and Dallas, Texas, but are now offered exclusively in cooperation with physician enhancement services at 5 locations: the Physician Assessment and Clinical Education Program (PACE) at the University of California, San Diego; the Clinical Competency and Assessment Training Program (CCAT) at Rush University Medical Center in Chicago, Illinois; the Upstate New York Clinical Competency Center at Albany Medical College in Albany, New York; the Florida Competency Advancement Program (CAP) at the University of Florida in Gainesville, Florida; and the Physician Assessment Program at the University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (36). These collaborators use the Institute's tools to assess competence, then strive to remedy the identified deficiencies (37).

    Developing Remediation Programs

    The final challenge is to use the assessment results to construct successful remediation programs for those with skill deficits. The obstacles to progress in this area are substantial. The first obstacle is a lack of expertise to oversee such programs. Few national programs exist, and hospital-level programs are often poorly organized. A major national effort is needed to develop additional programs. A second barrier is inadequate financing. If physicians who will already be losing practice income are responsible for the full cost, they may be unwilling to participate. Other potential sources of support include specialty societies, licensing boards, federal or state governments, and liability insurers.

    Yet another barrier is the reluctance of hospitals and physician colleagues to voluntarily guide, mentor, and supervise remediation activities. Department chairs rarely have formal supervisory training and often lack the experience needed to effectively manage physicians with performance problems. In addition to time, cost, and liability concerns, many institutions are uncomfortable asking patients to give informed consent for physicians with acknowledged deficits to care for them. Effective models need to be developed and tested.

    Medical schools and their affiliated teaching hospitals should assume a leadership role in developing supervised clinical programs for physicians who have been found to have remediable knowledge and skill deficits. If developed and coordinated like traditional postgraduate training programs, these “mini-residencies” could effectively overcome the time, liability, and informed consent issues.

    A Call to Action

    The responsibility for monitoring and ensuring acceptable physician performance must occur at the local level. However, hospitals lack the resources to develop the systems and measures that are needed. We believe the time has come for a major national effort to develop these systems and measures. The organizations that are best positioned to take on this task are those that already bear a fiduciary responsibility for ensuring safe, competent care: the state medical boards (represented by the Federation of State Medical Boards), the medical specialty boards (represented by the American Board of Medical Specialties), and the Joint Commission on Accreditation of Healthcare Organizations.

    We call on these national organizations to collaborate in an effort to accomplish 3 goals: Develop standards and measures for annual data-based assessment of physician performance and require that they be implemented by all hospitals, launch a major effort to develop better measures of competence and behavior, and develop more state and regional centers for assessment and remediation of physicians with performance deficiencies. The initial specifications should be based on currently available data and should then be improved as better data become available. Demonstration of an individual's compliance with these national standardized measures should be sufficient to satisfy state relicensing and certification requirements.

    Performance failures of one type or another are not uncommon among physicians, posing substantial threats to patient welfare and safety. Few hospitals manage these situations promptly or well. It is time for a national effort to develop better methods for assessing performance and better programs for helping those who are deficient.


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    Sign In to Submit A Comment
    Lucian L. Leape20 March 2006
    Response to Letters to the editor

    To the editor:

    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 AAMC and specialty boards should address.

    However, his dismissal of the need for additional testing is diametrically opposed to the strong, and we think laudable, initiative by all of the specialty boards 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 estimate that at least one third of physician will need help at some time in their career is not justified by the data we present. Indeed, 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, which is what we seek to remedy.

    The diametrically opposed views of Doctor Gold and Ms. Frost-Pineda who advocate for pre-employment and random drug testing of physicians and those of Doctor Donohoe who raises associated "ethical, legal, and policy questions" illustrate the controversial nature of this issue, which clearly warrants further study and testing.

    Doctors Gifford, Crausman, and McIntyre make the important point that not all physicians participate in hospital credentialing processes. However, it 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.

    While we applaud their call for expanding licensing boards support to remediation programs, and agree they should set standards, we do not share their enthusiasm for having state boards actually perform the credentialing process, or for having insurers and managed care plans play a role in reviewing physician performance. We, and we believe the overwhelming majority of physicians, view these as the profession's responsibility.

    Lucian L. Leape John A. Fromson

    Conflict of Interest:

    None declared

    Joseph O. Boggi15 June 2006
    More details

    Dear Annals,

    Every once in awhile doing the right thing brings a positive response. To that end, I am writing to give precise details about the difficulties with the IPE. Thanks to those who encouraged me to do this.

    1. The multiple choice question tests. I was given three of these. I was told that all of them would cover Internal Medicine by the Director of the IPE. Indeed that is not the case at all. The tests titled Mechanisms of disease and Pharmacotherapeutics are best described as Step 3 tests. You may remember that includes OB, Surgery, Psych, IM, Peds, and Prevent Med. While IM covers many of these you don't ever go into a test without clear knowledge of the test material. Every test given by the NBME, NBOME, or ABIM and such gives extremely clear information about the nature of the testing. To do any less is abhorent to the concept of standardized testing.

    2. Two of the tests noted above were given at a rate of 60 MCQ's per hour. I inquired about this rate on multiple occasions. I was never given an answer, and hence practiced at the standard rate of 48-50 questions. This is the rate for every other test given by these organizations.

    3. The Computer Case Simulations. The standard is to take these tests on a computer that is at least 733 MHZ. I practiced on an 850MHZ unit. Frankly, practice is not the correct word. I tried to simulated about a hundred patients, I tried to harm the computer patients to see what it took to do it in cyberspace, I looked up almost all of the thousands of orders, and generally "took the program apart and put it back together again."

    These tests are designed to last about 8 mintues. ( Source, the President of the NBOME ) There was no possible way to get these tests finished properly on the computer provided. I was told just as I hit start that the computer would my much slower. After the testing, the director of the IPE noted that they would look into getting another computer. Yes, there are about 40 standard computers in the testing center. One is reserved for the IPE.

    The computer used makes you go at least two times as fast and probably three times as fast as the standard computer. The director noted to me that I must have computer difficulties. I was pretty astonished to hear that assertion.

    If you have ever taken the CCS you know that the longer it takes you to treat the sicker folks get. Also, if you are rushing, while you don't make mistakes per se, you are not as smooth. You try to make the computer go faster and so on.

    The bottom line is that at the very least you have to get an opportunity to practice at the tested computer speed. The most intereting thing was that the IPE later backed down from the assertion that I had difficulty with the computer. That was my major complaint, until number four that is.

    4. In my experience almost every official examination I have had, and every examiner has laughed at the precepts of medicine. The one examiner who played it straight was relieved of his duty in the army. His boss, the Chief of Psychiatry at Walter Reed Army Medical Center was also relieved. I never met that man. May God Bless him and his family. The Major General who did that later spoke to the ACP about ethics.

    Examiners pretty much walk in literally laighing at me. When you speak to folks who are at the top of the profession, you get a knowing nod. This type of thing is common place. Yes, this particular examiner had a persistent smirk on his face and laughed at least five times. This examiner would raise his voice, all the while maintaining that smirk on his face. He was enjoying tweaking his examinee.

    The only answer to this activity, save a little concern for honor, family name and fear of God, is an audio tape. Better yet a video tape.

    There is no room here to go into the minute details. Suffice it to say, that every official meeting of this sort needs to be taped. This is a disgrace to the practice of Medicine. A complete disgrace. Whenever a transcript was generated it has been altered, every single one. In regard to the CCS, I can and expect to speak for 30 minutes to an hour on each topic of the CCS in front of a serious examiner.

    I let down my guard, this was the NBME. As the examiner walked in, I told him that I had been looking forward to this for a long time.

    Now, you may be surprised to hear that I was told that I did pretty well on the testing. I reject that notion. I've never given my patients pretty good care. Pretty well did not get us into Medicine. I can honestly say that I was more ready for the testing than when I took and passed my ABIM Boards on the first try years ago. Anyone in my position cannot drive through a "stop sign" let alone do pretty well on a test. I have places to go and people who are helping me. I cannot get there with a test result that is pretty good, whatever that means. I studied almost everything available.

    Back in the day, you took a class, studied your butt off and got an A. There can be no exception to that, and at this level it is highly irregular to say the least.

    So, the IPE needs to tell folks what is on the test, tell them how many questions are on the test, give them an opportunity to test on a standard computer, and before an examiner who is taped. These are pretty standard things, that the IPE and the NBME are currently completely rejecting to the dishonor of the NBME in general.

    The NBME is not four people. The NBME stands for the very best. Even their receptionists understand this problem. Why can't the IPE and the NBME.

    Finally, take a look at some of the things that make you a disruptive doctor on the article above. Two of them regard telling patients about their poor care. There should be 650000 letters from Physicians complaining about that. How sick is that?

    Conflict of Interest:

    None declared

    Joseph O. Boggi8 June 2006
    Who cares about this?

    Dear Annals

    Let's get to the heart of the matter. Medicine is run by corporations or large federal institutions. There is next to no interest in improving the prevailing rate of malpractice, and no effective program to address it. If payments were made for all of the Medical Malpractice, we would have to pay the patients for the privilege of working in Medicine.(1)

    As with all large entities, the only real incentive is to suppress. That is most evident in the treatment of folks with mental illness who have never hurt a patient. As an example folks with ADHD cannot get hospital privileges. At the recent ACP meeting, I asked the expert what to do about a prospective doctor with ADHD. He told me not to tell anyone that the candidate has ADHD. He went on to say that any specific question requesting direct information about a mental illness is illegal and hence the question should be answered as if there was no history of ADHD. Really. That assumes a stable patient of course.

    As a member of the ACP with ADHD, I cannot disgree with that advice, I am not sure if it is legal however. Who knows?

    As I return to practice, I have encountered the IPE. I have this to say about the IPE. There is no transparency of testing at the IPE. If you can take a 60 question per minute test you will do fine, they won't tell you about the rate in advance. It goes on.

    In general, I am a big proponent of ongoing testing of doctors. I think that random doctors should be run through the IPE on a yearly basis so that all of them go in a ten year period.

    My path to the IPE started when I actually tried to fire federal civilian employee physician from a protected class of individuals. That is not an easy thing to do. There is no whistleblower protection, and if you call the JCAHO that is the very first thing that they told you. It is even harder if you have ADHD. Honor, family name, and the fear of God almost always give way to the pressure of the corporation or the Federal Institution to toe the line.

    You see, Medical Malpractice can become rare. I am sure. Tolerance of folks who are paying attention but appear distracted can become part of our culture. In general changes like these take two generations.

    Before Medical Malpractice becomes rare, more of it will have to be revealed. Perish the thought. Before folks with Mental illness can be tolerated many reforms need to be instilled. The first of which is that standards of medical practice have to apply to licensure of doctors, and their discipline. That is not currently the case.

    Will this ever change? Articles like this at least talk about the issue. Much more than talk needs to be done. We just have to look to Dr. Deming and use his tenets for good and not politics.(2) A little fear of God, consideration of honor, and concern about your good family name will start to bring the meaning of Medicine back to us all.

    Best Regards

    Joseph O. Boggi D.O. MACP


    1.Brennan et al. Incidence of adverse events and negligence in Hospitalized Patients. NEJM 324: 370-376

    2. Crospby, Phillip Quality is still free Oct 1,1995.

    Conflict of Interest:

    None declared

    Duncan M. Kuhn9 February 2006
    Missing the More Important Problem?

    Leape and Fromson should be commended for addressing physician performance failures (1). 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, my and others experience has been no matter how incompetent the trainee, program directors and department heads are loathe to effectively discipline the individual. Concerns of legal action are often cited, which seem disingenuous Ð 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: it is to the advantage of the host departments, in terms of time (dealing with deranged rotation and call schedules) and money (e.g. Medicare funding of the trainees position) to keep individuals on. Anyone who has been exposed to community hospital residency programs can testify that filling slots often takes precedent over the quality of the candidates.

    Practicing physicians are engulfed in paperwork and requirements, which are only likely to increase, with questionable results (3). It seems unlikely additional testing (on top of residency in-service tests, multiple board exams and re-certifications, and CME requirements) will be of significant utility, but will add to the growing sense of intrusion. 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: e.g. physicians practicing in rural areas cannot be held to the same knowledge standards as counterparts in an urban academic setting; nor should surgeons handling high-risk patients be expected to have similar outcomes to community practitioners.

    The confrontational tone and anecdotal nature of sections of the article are disturbing, since 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" appears a) unsupported by data, b) discounts that most physicians will not practice during their compromise, and c) is over-dramatized by italics. While 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).

    1. Leape, LL and Fromsom JA. Problem Doctors: Is there a system- level solution? Ann Int Med 2006; 144: 107-115. 2. Papadakis MA et al. Disciplinary action by medical boards and prior behavior in medical school. NEJM 2005; 353: 2673-82. 3. Krasner J. Plan would tie copayments to doctorsÕ rankings. The Boston Globe. Jan 27 2006: A1. 4. Gifford DR, Crausman RS, McIntyre BW. Reflections from a State Medical Board. Ann Int Med 2006 ( 5. Talbott GD and Benson EB. Impaired physicians: the dilemma of identification. Postgrad Med. 1980; 68: 56-64.

    Conflict of Interest:

    None declared

    Jeffrey Fisher13 February 2006
    Immodest Proposals

    February 4, 2006

    To The Editor:

    In my opinion, the forecast of a continued decline in primary care physicians¹ is just the tip of the iceberg of problems in medical education and medical economics. Contemporary medicine is experiencing the best "“and worst of times. While scientific and technologic advances make the headlines, so does fraud and the burden of soaring medical errors. How can great science and poor care coexist? Easy. We allow it. Over the near-century since the Flexner report, every successive generation of physicians has been taught more science and less bedside medicine. We teach to test and so quality educational hours have been spent prepping for licensing exams at the expense of "hands on" time. Medical students and residents born of the computer age spend endless hours online checking lab results and ordering tests, and the "team" approach has replaced proprietary responsibility. Are we training today's physicians that the foundation of every medical encounter lies in a complete history, complete physical examination (when was the last time you heard a trainee mention the fundi "“ the window to the body?), assessment of routine laboratory tests, creation of a problem list (why was Weed weeded out?) with a differential diagnosis for each problem? Medical educators have not been explicit in expectations, nor have they adequately supervised our trainees. This has created the epidemic of "Hyposkillia" - trainees deficient in basic medical skills². The foundation of medical care is a dynamic, long-term patient-physician relationship which is based on a thorough psychosocial and clinically sound medical assessment, mutual respect and trust, as championed by Dr. Marcus Welby. The depth to which our profession has sunk in the public's eye (and the victory of science over art) is that television's new Marcus Welby is Dr. Gregory House. Why are physicians abandoning primary care? Because we are not educating them properly and, compared to their peers, we are paying them poorly. Can we fix the flaws? I believe so.

    Some Immodest Proposals:

    If we continue our present tack, things will continue to get worse. We need radical changes in medical education and medical economics. It's time for another American Medical Revolution.

    I. Overhaul Medical and Pre-Medical Education.

    Currently, our medical and pre-medical education is geared to creating medical scientists, at the expense of practical clinical training. While medical scientists are our hope for the future, properly trained clinicians are the foundation of the Ivory Tower. Many of our primary care physicians have been overtrained in science, and undertrained in bedside medicine and office management. They have not been given the appropriate skills, nor have they been selected for the altruism of Maimonides or the equanimity of Osler, to prepare for a career which is most rewarding when it is a passion, not a job, a calling and not a career. We need to re-instill in the profession the importance of attitude, to select trainees who will be gratified by their selected profession, and provide them with an education which best prepares them for the road that they have chosen. In my opinion, a working group should be established to create a nationwide change in both medical and pre-medical education. I propose that there be three distinct medical school tracts: the medical scientist, clinical scientist, and clinician. The first two- year basic science education should be overhauled and made clinically relevant. Those in the medical scientist tract would take additional training during first and second year elective periods, supervised by research scientists. Third year clinical clerkships and fourth year sub-internships would be requirements, but those in the medical scientist tract would take appropriate electives and time in the laboratories, while those in clinical scientist tracts would take electives in statistics and research methodology. Those in clinical tracts would take more electives in appropriate language skills such as Spanish, and spend time on home visits and in doctors' offices. The National Board examinations would reflect the new clinically oriented core curriculum, and all students would need to pass it. In addition, students can qualify for the M.D. degree with distinction in medical science, distinction in clinical science and distinction in clinical medicine, based upon a separate examination in which they can demonstrate acquisition of appropriate knowledge and skills. Internal medicine residency programs would seek a mix of graduates to ultimately fill appropriate positions on their faculty. Residency programs would similarly offer appropriate elective study. Creating three M.D. tracts would change pre-medical education. Students anticipating careers in medical science would be best prepared with an engineering, "hard science" or extensive life sciences background, while those interested in clinical investigation would have additional training in statistics and research methodology. Students anticipating as clinicians would take courses in psychology, sociology, anthropology, child development and management. Extracurricular activities for the medical scientist tract would involve participation in laboratory research, and reading and writing scientific papers. Clinical scientist candidates would have additional training in performing and analyzing clinical studies and writing clinically oriented papers. Those interested in a clinical tract in medical school would have extracurricular service commitments which would demonstrate their passion for helping others. Students should be exposed in high school to the existence of different careers in medicine, so that they could obtain an appropriate pre-medical curriculum in college.

    II. Medical Economics

    Our present system is worse than schizophrenic. It has multiple personalities which are hard to count. Primary care physicians waste precious time and are not reimbursed for paperwork and non-face-to-face patient care. Our system needs to pay our physicians for both time spent with patients and time spent caring for their needs when they are not physically there. We need to create a national health care system that is equitable. The President and CEO of United Healthcare had a 2005 salary with stock options of $1.125 billion dollars³. Simply stated: for-profit health care is an oxymoron. Another radical proposal: national universal healthcare "“ progressive/income-based. Every citizen would have a credit card with a picture. Every swipe of the card would lead to a deposit of both an income-related co-pay and fee from the patient's medical account, collected by the federal government. Physicians would be paid at the time of service. This program would have to be removed from congressional jurisdiction, to avoid capricious cuts, and administered by physicians and health care economists. These funds would be placed in, dare I say it, a "lockbox", prohibited from being decreased on a yearly basis, but increased instead by cost-of-living adjustments. In addition to establishing acceptable fees for service provided by their members, each college of physicians or superiors would create an encounter form with each reimbursable service. Time spent in non-face-to-face patient care could be logged into the system and reimbursed once appropriate documentary codes were entered into the system. Assessment of performance would be obtained by educating patients as to each college's expectations for interactions, and assessing patients' feedback. Physicians would be issued report cards, based on a number of performance indices, and both professional and economic incentives could be created, if desired. In summary, in order to be able to provide enough high-quality primary care physicians for the next century, we must alter the way we are educating them and paying them. While we want to continue to recruit genius doctors with super-high IQ's to be our medical and clinical scientists, our society is best served by having A-/B+ students with high emotional quotients become our primary care physicians. These clinicians would be granted an extraordinary privilege: that of the responsibility of caring for the life and well-being of another. Each college of physicians or superiors needs to create a national system of record keeping, so that our practitioners know at what level the bar is being set. There can be no questions about what the expectations are. By revitalizing medical education, we will select physicians more likely to be intellectually and emotionally gratified by primary care. We can restore the thrill of making diagnoses to clinicians and away from radiologists, and return our primary care physicians to the patient and away from the computer. They would be clinicians, not paper-pushers, and primary care medicine will be a calling, not a default position. Finally, in a nation so economically and intellectually rich as ours, we must create a climate where someone paying a large amount of money for several years of post- collegiate education who provides excellent care to his or her patients receives a wage commensurate with their peers. If we don't make primary care medicine intellectually exciting and financially acceptable, then our Ivory Towers will rest on faulty foundations.

    Jeffrey D. Fisher, M.D. 311 East 72nd Street New York, NY 10021


    1. Sox, H.C. Leaving (Internal) Medicine [Editorial]. Annals of Internal Medicine 2006; 144: 57-58

    2. Fred, H.L. Hyposkillia "“ Deficiency of Clinical Skills [Editorial]. Texas heart Institute Journal 2005; 32: 255-257

    3. Forbes. November 28, 2005; p. 122

    Conflict of Interest:

    None declared

    David R. Gifford1 February 2006
    Reflections from a State Medical Board

    While we agree with Leape and Fromsom's call for action about the need to address physician performance failures (1) , we believe that their strategy of relying on the hospital credentialing process, will not adequately address this vexing problem for several reasons. First, many physicians do not have admitting privileges to any hospital, Second, among those that do, most admit very few patients (2). Third, with the advent of hospitalists and a greater shift of health services to the ambulatory setting hospital credentialing committees only oversee a fraction of the practicing physicians' delivery of service. Lastly, as the authors summarize, many of the remedial programs are run by the state medical boards 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, assessment services for physicians with behavioral health problems, including sexual boundary violation, gambling, sexual and Internet addictions, and disruptive behaviors. Additionally, our Board is involved with the Practitioner Remediation and Enhancement Pilot Project [PREP] with the Citizen's Advocacy Center through a Health and Human Services grant [3]. Thus, 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 Board's of licensure and Discipline, our medical boards must evolve into Board's of licensure, discipline and remediation. This will require legislative change and much better reporting of potential physician performance failures or physicians at risk for such failures (e.g. suspected drug abuse) by hospitals, insurers, and the physician community. For example, in RI most referrals to the BMLD come from patients, comparatively fewer from other physicians or licensed health care facilities such as hospitals. Our experience also supports Leape and Fromsom's argument to identify these physicians prior to performance failures. Most physician performance failures had a history leading up to the event or a number of suspicious colleagues but 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 reorientation from the traditional disciplinary approach. This by necessity will require further legislative change and some degree of malpractice reform.

    We are also intrigued that Leape and Fromsom did not discuss (A) the role the individual physician has in working to change the system that contributes to medical errors, (B) the responsibility physician administrators play in identifying and addressing system problems as well as physician performance failures or physicians at risk of committing such failures and (C) the potential role health insurers and managed care plans might play in reviewing and reporting physician performance in outpatient settings..


    David R. Gifford MD MPH Director, RI Dept of Health Associate Professor of Medicine, Brown Medical School

    Robert S. Crausman MD, MMS FACP Chief Administrative Officer, Board of Medical Licensure & Discipline Associate Professor of Medicine, Brown Medical School

    Bruce W. Mcintyre JD Deputy Legal Council, RI Department of Health

    1. Leape, LL and Fromsom JA., Problem Doctors: Is there a system- level solution? Ann Int Med 1006;144:107-115.

    2. Miller ME, Welch WP, and Englert E. Physicians practicing in hospitals: implications for a medical staff policy. Inquiry. 1995;32(2):204-10.


    Conflict of Interest:

    None declared

    Martin T Donohoe30 January 2006
    Drug testing not the solution to problem doctors

    The explosive growth of pre-employment and random, not-for-cause drug testing (PERNFCDT) 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, business interests (Institute for a Drug-Free Workplace, pharmaceutical and drug-testing companies), and the public relations campaigns of a multi-billion 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)

    The cost of PERNFCDT to find one otherwise hidden drug abuser is estimated at $700,000 to $1.5 million for the federal government's program.(3) No solid data show that PERNFCDT deter drug use.(3) The National Academy of Sciences has concluded that frequently cited estimates of lost productivity due to drug use are based on flawed data.(4) PERNFCDT are subject to sabotage, false-positive and -negative results, and can negatively impact workplace moral, reduce productivity, and hinder recruitment of skilled workers. While no court has held an employer legally liable for not having a drug-testing program, employers have incurred substantial legal costs defending their programs against workers' wrongful dismissal claims.(1) It is impossible to completely safeguard that information obtained through drug testing programs will not be shared with other entities. The Canadian Human Rights Commission recently disallowed PERNFCDT of public employees, calling them human rights violations under the Canadian Human Rights Act.(1)

    In 1999, 2/3 of 44 randomly selected large teaching hospitals had formal physician drug testing policies. Many involved PERNFCDT.(5) Most were vague on procedural details; only half mentioned confidentiality. Substantial numbers of practicing physicians, residency program directors, and medical students oppose PERNFCDT.(1)

    To improve patient safety and enhance quality of care, the medical profession should improve substance abuse education and training; identify and refer impaired doctors for treatment; appropriately discipline impaired and incompetent providers; promote reference checking; increase attention to job- and life-satisfaction (depression and marital discord); enhance procedural training and oversight; support mandatory recertification, periodic hospital re-credentialing, and frequent skills appraisal and impairment testing (vision, reflexes, and coordination) to uncover substance abuse, physical disabilities, mental illness, and sleep deprivation; encourage reporting and analysis of errors; utilize computerized ordering systems to reduce prescribing errors; hire ancillary staff to assist residents in non-educational tasks; improve sign out protocols; and stop downsizing registered nurses in favor of less well- trained (but less expensive) licensed practical nurses and nursing assistants.(1)

    1) Donohoe MT. Urine trouble: practical, legal, and ethical issues surrounding mandated drug testing of physicians. J Clin Ethics, 2005;16(1):69-81. 2) Lundberg GD. Mandatory unindicated urine drug screening: still chemical McCarthyism. JAMA 1986;256(21):3003-05. 3) Matlby LL. Drug testing: a bad investment. 1st ed. New York: American Civil Liberties Union; 1999. Available from: URL: Accessed 5/18/00. 4) Normand J. Under the influence? Drugs and the American workforce. Washington, DC: National Academy Press; 1994. 5) Montoya ID, Carlson JW, Richard AJ. An analysis of drug abuse policies in teaching hospitals. J Behav Services & Res 1999;26(1):28-38.

    Conflict of Interest:

    None declared

    Mark S. Gold26 January 2006
    Random Mandatory Drug Testing: A Potential System Level Solution?

    We read with great interest the recent Improving Patient Care paper by Leape and Fromson on the issue of problem doctors(1). Substance abuse and dependence are significant problems among physicians and have negative impact on the individual physicians, their families and their patients. We have evaluated, treated, and reported on impaired physicians for more than three decades. While alcohol abuse and dependence are no more common among physicians than similarly matched controls, prescription misuse, opiate abuse and dependence and suicide appear to be more common among physicians. Physicians, however, may not be a single homogenous group. Our recent work has shown that anesthesiologists, surgeons, and emergency room physicians are over-represented among physician opioid addicts (2). We have reported on drug testing as a treatment for impaired physicians and think drug testing should be considered part of a system developed to improve patient care(4). Drug testing is also a method of case finding before an overdose or patient injury. However, as Leape and Fromson describe, few doctors are subjected to drug testing as a condition of employment (1). Physicians who are subject to pre-employment or random drug testing include those employed by the VA, military, physicians who are being monitored by state impaired professional programs and some new model programs at teaching hospitals(5). Our experience and research on impaired physicians suggest that pre-employment, for cause and random drug testing should be considered for all physicians. Testing complements prevention, education, early intervention and treatment initiatives. However, while being a physician is a risk group, we strongly recommend that specialties with greatest access and at greatest risk of occupational exposure (anesthesiology, surgery, emergency medicine), are the first priority for monitoring.

    References 1. Leape LL, Fromson JA. Problem doctors: is there a system-level solution? Ann Intern Med. 2006 Jan 17;144(2):107-15. 2. Gold MS, Byars JA, Frost-Pineda K. Occupational Exposure and Addictions: case studies and theoretical implications. Psychiatr Clin North Am. 2004 Dec;27(4):745-53. 3. Gold MS, Melker RJ, Dennis DM, Morey TE, Bajpai LK, Pomm R, Frost- Pineda K. Fentanyl Abuse and Dependence: Further Evidence for Second Hand Exposure Hypothesis. J Addict Dis. 2006; 25(1):15-21. 4. Jacobs, WS, Repetto M, Vinson S, Pomm R, Gold MS. Random Urine Testing as an Intervention for Drug Addiction. Psych Ann 2004; 34(10 781-785 2004. 5. Department of Veterans Affairs. Drug-Free Workplace Program: VA Directive 5383. Washington, DC: Department of Veterans Affairs; 2004.

    Conflict of Interest:

    None declared