Transcript The Role and Function of the Physicians` Well

THE ROLE AND FUNCTION OF THE
PHYSICIANS’ WELL-BEING COMMITTEE
CAMSS
43rd ANNUAL
EDUCATION FORUM
AND BONUS DAY
Sacramento, California
May 7-10, 2014
DEMOGRAPHICS
 42% of the nation's 1 million physicians are
older than 55 and 21% are older than 65,
according to the American Medical Association.
 Up from 35% and 18%, respectively, from 2006.
http://wvvw.kaiserhealthnews.org/Stories/201 2/December/1 1 /aging-doctors-face-greaterscrutiny.aspx
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AGING PHYSICIANS AND
BEHAVIOR
 Older doctors more prone to 4 D's:dementia, drugs,
drink, depression (Peisah, 2007).
 In an Australian study, impaired older doctors suffered
cognitive impairment (54%), substance abuse (29%)
depression (22%); 17% had 2 comorbid psychiatric
conditions (Peisah, 2007).
 Doctors minimize their health problems, don't take time
off, poorly understand and distrust of occupational health
services, self-diagnose and self-prescribe (Pitkanen,
2008).
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AGING DOCTORS FACE
GREATER SCRUTINY
“The public thinks that physicians’
health and competence is being
vigorously monitored and assessed. It
isn’t,”
William Norcross, 64, Founding Director of Physician Assessment
and Clinical Education (PACE) at University of California at San
Diego
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AGING DOCTORS FACE
GREATER SCRUTINY
“Norcross, who evaluates 100 to 150
physicians annually, estimates that about
8,000 doctors with full-blown dementia are
practicing medicine. (Between 3 and 11
percent of Americans older than 65 have
dementia.)”
Sandra G. Boodman, Aging Doctors Face Greater Scrutiny, Dec 10, 2012,
Kaiser Health News
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THE EFFECTS OF AGING
“Doctors with cognitive and neurological
problems almost never have insight into
their problems.” (William Norcross)
Sandra G. Boodman, Aging Doctors Face Greater Scrutiny, Dec 10,
2012, Kaiser Health News
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AGING PROCESS
“A small but growing number of hospitals . . .
University of Virginia Health System, Stanford
Hospital and Clinics and Driscoll Children’s
Hospital in Corpus Christi, Texas . . .have recently
adopted policies requiring doctors over a certain
age (70 at U-Va. and Driscoll, 75 at Stanford) to
undergo periodic physical and cognitive exams as
a condition of renewing their privileges.”
Sandra G. Boodman, Aging Doctors Face Greater Scrutiny, Dec 10, 2012,
Kaiser Health News
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AGING PROCESS
“John Schorling, a professor of medicine who
heads U-Va’s Physician Wellness Program, said
the policy adopted last year was prompted by
“general concerns” about patient safety and is
modeled on aviation industry practices. ‘Pilots
have people’s lives in their hands, and so do
doctors,’ he said.”
Sandra G. Boodman, Aging Doctors Face Greater Scrutiny, Dec 10,
2012, Kaiser Health News
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AGING PROCESS
“At Stanford, Weinacker, chief of the 1,800-member
medical staff, says that reaction to the policy. . . has been
mixed. Several doctors . . . have decided to retire instead
of undergoing testing. ‘I think the main thing I stressed with
people was that this policy is intended to be supportive,’ not
punitive.”
Sandra G. Boodman, Aging Doctors Face Greater Scrutiny, Dec 10, 2012,
Kaiser Health News
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AGING PROCESS
“At U-Va., Schorling said that 28 of the 35
doctors older than 70 completed screening
and passed easily. The other seven
decided against participating and no longer
have hospital privileges there, although they
are free to practice elsewhere.”
Sandra G. Boodman, Aging Doctors Face Greater Scrutiny, Dec 10,
2012, Kaiser Health News
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MANDATORY
RETIREMENT AGE?
 Not recommended
– Inability to definitively conclude that age, in
and of itself, is a risk factor for incompetence.
– Would further negatively impact the physician
shortage in the US.
– Would lead to the loss and wisdom of many
capable physicians.
J of Medical Regulations, Vol 99, No 1, 2013
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THE WIDESPREAD PROBLEM OF
DOCTOR BURNOUT
“Analyzing questionnaires sent to more than 7,000 doctors, researchers
found that almost half complained of being emotionally exhausted,
feeling detached from their patients and work or suffering from a low
sense of accomplishment. The researchers then compared the
doctors’ responses with those of nearly 3,500 people working in other
fields and found that even after adjusting for variables like gender, age,
number of hours worked and amount of education, the doctors were
still more likely to suffer from burnout.”
Pauline W. Chen, M.D., The Widespread Problem of Doctor Burnout,
August 23, 2012, 3:50 pm, The New York Times
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BURNOUT AND MENTAL
DISTRESS
“Major medical errors self-reported by American surgeons are strongly related
to both burnout and depression. Those findings appear today in the online
edition of Annals of Surgery. The Mayo Clinic-led study included collaborators
from Johns Hopkins and the American College of Surgeons.
In the confidential study, nearly 9 percent of U.S. surgeons responding said
they made a major error in the three months prior to being surveyed. Over 70
percent attributed the error to themselves rather than a systemic or
organizational cause. Results showed that the components of surgeon
burnout; emotional exhaustion, depersonalization and perception of their
personal accomplishments were related to errors, as was surgeons mental
quality of life including depression.”
Mayo Clinic News Network, Discussion: Burnout and Mental Distress Strongly
Related to Errors by U.S. Surgeons
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BURNOUT AND MENTAL
DISTRESS
“Of the 7,905 surgeons participating in the survey, 8.9
percent or 700 reported making recent medical errors that
they considered major.”. . . “Researchers say they found no
relation between errors and the work setting, method of
compensation, number of nights on call per week, or
number of hours worked.”
Mayo Clinic News Network, Discussion: Burnout and Mental Distress Strongly
Related to Errors by U.S. Surgeons
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PHYSICIAN SUICIDE LINKED TO
WORK STRESS
“Suicide among physicians appears to follow
a different profile than in the general
population, with a greater role played by job
stress and mental health problems.”
Crystal Phend, Physician Suicide Linked to Work Stress, Perelman
School of Medicine MedPage Today, Nov 14, 2012
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PHYSICIAN SUICIDE LINKED TO
WORK STRESS
“Point out that problems with work were
three times more likely to have contributed
to a physician’s suicide than a
nonphysician’s”
Crystal Phend, Physician Suicide Linked to Work Stress, Perelman
School of Medicine MedPage Today, Nov 14, 2012
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WHY AREN’T DOCTORS
DRUG TESTED?
New York Times op-ed in print on March
13, 2014, on page A27
Daniel R. Levinson is the inspector general
and Erika T. Broadhurst is a special agent
for the Department of Health and Human
Services.
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“They're often described as the best workers in the hospital," he says. "They'll
overwork to compensate for other ways in which they may be falling short, and to
protect their supply. They'll sign up for extra call and show up for rounds they don't
have to do." Physicians are intelligent and skilled at hiding their addictions, he says.
Few, no matter how desperate, seek help of their own accord.
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IMPAIRMENT
Concerning prescription drugs, Hughes and colleagues [19] found that
11.4% of physicians had used benzodiazepines in the past year in an
unsupervised fashion, whereas 17.6% had engaged in unsupervised
use of opioids. Clearly, this results in part from the enhanced access
physicians have to these substances as compared to the general
population. At a minimum, these data suggest that a substantial
minority of physicians are using these medications in what would often
be considered to be a clinically inappropriate fashion. In contrast, this
study showed that physicians were less likely than the general
population to have used tobacco and a variety of illicit substances,
including marijuana, cocaine, and heroin, than community controls.
Valliant, [47] in an editorial commenting on the Hughes article says, 'the
most important finding by Hughes et al is that, compared with controls,
physicians are five times as likely to take sedatives and minor
tranquilizers without medical supervision.'
19
Oreskovich MR; Kaups KL; Balch CM; Hanks JB; Satele D; Sloan J et al.
Prevalence of alcohol use disorders among American surgeons. Archives of
Surgery 147(2): 168-174, 2012. (50 refs.)
Objectives: To determine the point prevalence of alcohol abuse and dependence
among practicing surgeons. Design: Cross-sectional study with data gathered
through a 2010 survey. Setting: The United States of America. Participants:
Members of the American College of Surgeons. Main Outcome Measures: Alcohol
abuse and dependence. Results: Of 25,073 surgeons sampled, 7,197 (28.7%)
completed the survey. Of these, 1112 (15.4%) had a score on the Alcohol Use
Disorders Identification Test, version C, consistent with alcohol abuse or
dependence. The point prevalence for alcohol abuse or dependence for male
surgeons was 13.9% and for female surgeons was 25.6%. Surgeons reporting a
major medical error in the previous 3 months were more likely to have alcohol
abuse or dependence (odds ratio, 1.45; P < .001). Surgeons who were burned out
(odds ratio, 1.25; P = .01) and depressed (odds ratio, 1.48; P < .001) were more
likely to have alcohol abuse or dependence. The emotional exhaustion and
depersonalization domains of burnout were strongly associated with alcohol abuse
or dependence. Male sex, having children, and working for the Department of
Veterans Affairs were associated with a lower likelihood of alcohol abuse or
dependence. Conclusions: Alcohol abuse and dependence is a significant problem
in US surgeons. Organizational approaches for the early identification of
problematic alcohol consumption followed by intervention and treatment where
indicated should be strongly supported.
20
Berge KH; Seppala MD; Schipper AM. Chemical dependency and
the physician. Mayo Clinic Proceedings 84(7): 625-631, 2009. (26
refs.)
Although the nature and scope of addictive disease are commonly
reported In the lay press, the problem of physician addiction has
largely escaped the public's attention. This Is not due to physician
Immunity from the problem, because physicians have been shown to
have addiction at a rate similar to or higher than that of the general
population. Additionally, physicians' addictive disease (when
compared with the general public) Is typically advanced before
Identification and Intervention. This delay In diagnosis relates to
physicians' tendency to protect their workplace performance and
Image well beyond the time when their life outside of work has
deteriorated and become chaotic. We provide an overview of the
scope and risks of physician addiction, the challenges of recognition
and Intervention, the treatment of the addicted physician, the ethical
and legal Implications of an addicted physician returning to the
workplace, and their monitored aftercare. It is critical that written
policies for dealing with workplace addiction are In place at every
employment venue and that they are followed to minimize risk of an
adverse medical or legal outcome and to provide appropriate care to
the addicted physician.
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SCREENING
Breath Alcohol, 12-Panel Forensic Urine, Hair Drug Test
12-Panel
Forensic Urine
Hair Drug Test

Alcohol

Amphetamines

Amphetamines

Cocaine

Barbiturates

Opiates

Benzodiazepines

Extended Opiates

Cannabinoids

Phencyclidine

Meperidine

Cannabinoids

Methadone

Oxycodone

Opiates 2000

Phencyclidine

Propoxyphene

Cocaine
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CONCERNS
Dr. Kurt Zangerle, Med. Dir. Occ. Health Interview:








Client identification
Federal standards for chain of custody
Federal accepted substance testing techniques
Phone interview for positive tests to rule out prescription
meds
Urine: 3-4 days, water versus fat soluble
Hair: up to 90 days
Additional specificity tests possible
False positives – zero incidence
 Confirmation above threshold of detection
 Marijuana illegal per federal law
 Codeine is not in OTC meds
Concerns
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ROLE & FUNCTION OF PWBC
Hospital licensing requirements – Title 22, CCR 70703(d)
(d) The medical staff by-laws, rules, and regulations shall include,
but shall not be limited to, provision for the performance of the
following functions: executive review, credentialing, medical
records, tissue review, utilization review, infection control, pharmacy
and therapeutics, and assisting the medical staff members
impaired by chemical dependency and/or mental illness to
obtain necessary rehabilitation services. These functions may
be performed by individual committees, or when appropriate, all
functions or more than one function may be performed by a single
committee. Reports of activities and recommendations relating to
these functions shall be made to the executive committee and the
governing body as frequently as necessary and at least quarterly.
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ROLE & FUNCTION OF PWBC
 TJC Standards, MS.11.01.01: “The medical
staff implements a process to identify and
manage matters of individual health for
licensed independent practitioners which is
separate from actions taken for disciplinary
purposes.”
– Purpose is rehabilitation rather than
discipline.
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ROLE & FUNCTION OF PWBC
TJC process design addresses:
1.
Education of licensed independent practitioners and other
organization staff about illness and impairment recognition issues
specific to licensed independent practitioners (at-risk criteria).
2.
Self referral by a licensed independent practitioner.
3.
Referral by others and maintaining informant confidentiality.
4.
Referral of the licensed independent practitioner to appropriate
professional internal or external resources for evaluation,
diagnosis, and treatment of the condition or concern.
5.
Maintenance of confidentiality of the licensed independent
practitioner seeking referral or referred for assistance, except as
limited by applicable law, ethical obligation, or when the health
and safety of a patient is threatened.
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ROLE & FUNCTION OF PWBC
6.
Evaluation of the credibility of a complaint, allegation, or concern.
7.
Monitoring the licensed independent practitioner and the safety of
patients until the rehabilitation is complete and periodically thereafter, if
required.
8.
Reporting to the organized medical staff leadership instances in which a
licensed independent practitioner is providing unsafe treatment.
9.
Initiating appropriate actions when a licensed independent practitioner
fails to complete the required rehabilitation program.
10.
The medical staff implements its process to identify and manage matters
of individual health for licensed independent practitioners.
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THE BRIGHT LINE
 PWBC DOES NOT perform corrective action
investigations or participate in disciplinary actions
 If the performance, conduct, behavior or lack of
cooperation of the MD leads the PWBC to conclude that
the MD presents a danger to patients or others, the
matter must be referred to the COS or MEC
 Nothing (minutes, records, testimony about the PWBC)
is to be furnished in the absence of authorization from
the MD.
 Essential element of trust
 Avoidance of liability
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CONFIDENTIALITY
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


Evidence Code section 1157
Bylaw provisions
Policies and procedures
Authorization as part of the evaluation process
Sharing of Information
– Authorized but not mandated
– What is to be shared? With whom?
– Use of Sharing of Information Policy
– Special issues with Hospital Systems
– Immunity from Liability for Sharing
– Use of Authorizations
 Minutes of meetings – content, custody, control
 “Private” notes
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INITIAL PWBC INVOLVEMENT
 In aftermath of abolition of MBC Diversion
Program, what to do?
– Assist the physician by providing collegial guidance
and external resources for assessment and
assistance.
– Assist the MEC by serving as a coordinator and
conduit between MEC and external private resources
that can fill the function of former Diversion Program.
– CPPPH
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INITIAL PWBC INVOLVEMENT
 Monitoring, and referral for disciplinary (or
corrective) action (if and when indicated);
typical first steps:
– Gather information
• Meeting with chief of staff, other medical staff leaders
• Interview others with pertinent information – nurses, techs,
etc
• Meeting with MD (after other information obtained is best, if
meeting can wait)
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INITIAL PWBC INVOLVEMENT
Initial impressions and assessment of next steps:
 Is evaluation warranted? (not always – there must be a
threshold of reliable information before formal evaluation
should be recommended.)
 If “no,” make recommendations for assistance – e.g.,
stress management classes, counseling, etc.
 If “yes,” – can strongly urge evaluation as a
condition for the opportunity to continue to work
with the PWBC (rather than being referred to the
MEC for a formal investigation).
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EXTERNAL EVALUATION
ISSUES
Finding the right evaluator
 MD’s personal physician vs. the right
outside expert?
 Compiling a list of external health
evaluators (location, areas of expertise,
services they will provide, and fees)
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EXTERNAL EVALUATION
ISSUES
What kind(s) of evaluation(s)?








Addiction Medicine
Psychiatric
Psychological
Neuropsychological
Neurological
Internal medicine
Pain management
Other (e.g. for symptoms of visual malfunction or other
problems)
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EXTERNAL EVALUATION
ISSUES
Who Pays?
 Often, the MD – but caution: make sure
that you will get the product you need –
might be worth having the medical staff
pay – depending upon the severity of the
concerns and the circumstances of the
matter.
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EXTERNAL EVALUATION
ISSUES
How to get what you need from the
evaluation:
Letter of understanding or agreement with
evaluator
Information to be provided to evaluator
Authorization from the MD regarding disclosure
and use
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EXTERNAL EVALUATION
ISSUES
Generic purpose of evaluation:
 E.g., “We are seeking this evaluation due to
reliable concerns raised that this practitioner has
appeared disoriented and confused and has, on
one or more occasions, provided inappropriate
responses to nursing questions, failed to
perform daily rounds, rounded in the middle of
the night, been unavailable to other members of
the healthcare team for consultation as to his
patients, and exhibited apparently unwarranted
outbursts of anger.”
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EXTERNAL EVALUATION
ISSUES
More specific information to come.
 E.g., “Upon receipt of legally appropriate
authorizations, we will provide you with
additional information regarding our concerns.”
Can then provide any personal health
information etc. that might factor into current
concerns (e.g. history of head injury, former
psychiatric hospitalization, former rehab
experience, etc.).
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EXTERNAL EVALUATION
ISSUES
Information needed from evaluation – what do you need to know?
 Does this MD have an addiction-related impairment or harmful use
issue?
 Does this MD have any psychiatric or psychological impairment that
could interfere with his/her ability, (as a family practitioner, surgeon,
etc. – to the extent that specialty might be an important factor) to
diagnose and treat patients in the hospital setting?
 Is this MD able to communicate and interact with peers, nurses, and
other members of the healthcare team effectively and appropriately?
 E.g., can this neurosurgeon (with known monovision) perform any
aspect of neurosurgery without compromising patient safety or
quality of care?
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EXTERNAL EVALUATION
ISSUES
Is this MD “safe to practice”?
 How severe is any identified impairment and what
prognosis can be expected?
 As to any identified health impairments, what treatment
and/or other measures would you recommend in order
for this practitioner to be able to practice safely?
 Is further health evaluation indicated currently? In the
future?
 Responsibility of refraining from practice
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EXTERNAL EVALUATION
ISSUES
 Requirement for written evaluation and answering of all
questions presented.
 Authorization by MD to provide report to MEC if referred for
corrective action.
 Deadline for receipt of report.
 Additional options:
– Require evaluator’s agreement to refrain from agreeing to become
MD’s treating professional.
– Require evaluator’s agreement to refrain from being retained, at any
time, as an expert witness for or on behalf of MD as any current or
future dispute with the medical staff and/or hospital.
– Require evaluator to agree to testify at any medical staff hearing that
might involve to any extent questions regarding MD’s health issues.
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PWBC FUNCTIONS AFTER
RECEIPT OF EVALUATION

Follow-up – recommended self-improvement and/or treatment?

MD – buy-in and commitment

Letter of expectations for working with the PWBC

Provisions might include, among others:
– MD’s acknowledgement of problems and desire to work with PWBC.
– Expectations for treatment (including any expected counseling or therapy).
– Agreement for alcohol and drug testing (as appropriate).
– Agreement to refrain from use of addictive substances –e.g. drug/alcohol.
– Expectations of attendance at support group meetings.
– Agreement to undergo further evaluation or continue treatment in the manner
determined reasonable and necessary by the PWBC.
– Agreement to execute further authorizations for full and free 2-way sharing of all
health information.
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PWBC FUNCTIONS AFTER
RECEIPT OF EVALUATION
PWBC must not drop the ball
 Important to follow-up diligently.
 Make sure to communicate with any treating providers to
ensure that the individual is compliant and doing well.
 Important to meet with the MD on a periodic basis to
“check in”.
 Can adjust requirements as appropriate.
 Must report on all PWBC activities to MEC and Board at
least 1x per quarter (TJC Standards).
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PWBC FUNCTIONS AFTER
RECEIPT OF EVALUATION
 Remember patient safety is primary!
*** Report to chief or MEC if MD is noncompliant and/or if corrective action is
needed, for any reason, to ensure
patient safety. ***
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FINAL THOUGHTS
 Role of Committee – Increasing
Importance to the Facility and the
Physician
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FINAL THOUGHTS
 Composition of the Committee – Requires
Thoughtful Attention
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FINAL THOUGHTS
 Guidance of the Committee Through
Policies, Procedures Specific Enough to
Provide Direction, Flexible Enough to be
Responsive
(CPPPH)
(MS 01.01.01.)
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FINAL THOUGHTS
 Resources Should be Researched,
Compiled, Shared
(CPPPH)
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FINAL THOUGHTS
 Support of the Committee Must be
Adequate – Line Item Budget Allocation?
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FINAL THOUGHTS
 Increased Activity May Encounter Legal
Challenges
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QUESTIONS?
Tom Curtis
Nossaman LLP
18101 Von Karman Avenue,
Suite 1800
Irvine, CA 92612
(949) 833-7800
[email protected]
Mary Antoine
Nossaman LLP
621 Capitol Mall,
25th Floor
Sacramento, CA 95814
(916) 442-8888
[email protected]
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