can the aaos and its compliance program do more? the disruptive and impaired physician the...
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Can The AAOS And Its Compliance Program Do More?
The Disruptive and Impaired Physician
Edward V. Craig MD, MPH
AAOS Judiciary Committee
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Symposium: Disruptive and Impaired Physician
Edward V. Craig MD, MPH
I have no potential conflict with this presentation
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AAOS Compliance Program And Standards Of Professionalism
Background: How We Got Here
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Where Did The Standards (SOP) Come From?
• For Years– AAOS Heard From Members
• Through Professional Liability Committee
• Need to Address Fraudulent and Misleading Testimony
• Fellow Support---Sanction Based Program
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Background---2002
• BOC—Advisory Opinion To AAOS Board
• Resolution—Florida Orthopaedic Society
• Need----Professional Conduct Program Regarding Expert Witness Testimony
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Background --2005
• AAOS Bylaws Established Professional Compliance Program
• Appointed Committee on Professionalism (COP) and Judiciary Committee To Resolve Disputes ----The Grievance Process
• Standards Of Professionalism (SOP)—First Three Approved
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Standards of Professionalism
• Based Upon AAOS Code of Medical Ethics and Professionalism for Orthopaedic Surgeons
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First Three Standards
• Musculoskeletal Services To Patients
• Professional Relationships
• Expert Witness Testimony
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Additional SOPs Adopted
• 2006 – Research and Academic Responsibilities
• 2007Advertising by Orthopaedic Surgeons
• 2007Orthopaedic Surgeon-Industry Conflicts of Interest
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Grievance Process
• One AAOS Fellow Can File Grievance Against Another
• Violation Of Any Standards
• Multilevel Process---Culminate AAOS Board
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Allocation of Board Time---Program
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. Program Operating Expenses
• Professional Compliance Program Budget includes: – 2011 budget - $1M for litigation expenses– Initial proposed 2012 budget
$1M for litigation expenses
Program: Time Consuming and Expensive
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Official Disciplinary Actions Reported To:• National Practitioner Data Bank
(Suspensions and Expulsions Only)• State Licensing Boards• ABOS • State Medical Societies
and Associations
Grievance Process--Sanction Based Program
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Professional Compliance Program
….and Reported to Fellowship:
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Judiciary-Non SOP :Loss Of Medical License by Fellows
• AAOS Surveillance System• Fellow—Need To Have License
Unencumbered, No Restrictions ( State Action: Impairments- Drugs, Alcohol)
• Any State Disciplinary Action—Considered A Restriction, Subject to Compliance Action—Including For Disruptive Behavior
• Usually Suspension
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Medical License Loss- Substance Abuse
• Most Difficult For Judiciary---Illness, Volitional, in Treatment or Not, Complying With Aftercare, etc.
• Each State has Differing Response--- Judiciary Can Consider
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Extent Of The Problem—Among Physicians
• 8-12% Will Develop Substance Abuse Problem at Some Point Career
• At Any Given Time Up To 1 in 20 (3%- 7%) are Active Substance Abusers
• Left Untreated 17% Mortality Rate
Independent—Age Range,Geography
Urban/Rural
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Incidence By Medical Specialty
• No Specialty Immune
• Emergency Medicine, Psychiatry, Anesthesiology Slightly Higher Incidence—
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Archives of Surgery (2012)—Survey 27,000
• 15.4% had a Score on Alcohol Abuse Identification Test ( Abuse or Dependence)
• Correlation –Alcohol Abuse or Dependence– Major Medical Error Prior 3 Months– Surgeons Who Were Burned Out– Surgeons Depressed– Emotional Exhaustion
• Having Children, Working for VA—Lower Likelihood
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Risk factors
• Parallel General Public–Strong Familial Association–Psychological or Psychiatric Disorders
• Unique to Physicians–Self Treatment with Prescription Meds–High Stress or Long Hours–Access to Controlled Substances
Cicadas—Substance Abuse Among Physicians
Hospital Medicine, 2003
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Other Risk Factors
• Smoking One or More Packs/day• Multiple Affairs or Marriages• History Multiple Jobs in Multiple
Communities• Academic Medicine
Cicadas—Substance Abuse Among PhysiciansHospital Medicine, 2003
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Archives of Surgery- 2012• Alcohol Abuse and
Dependence “ a Significant Problem”
• Suggested Organizations-ACS, AAOS Develop Early Warning and Intervention Programs
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Are We Doing Enough?
• If Statistics Correct---
In USA: 2,500-3,700– Current Orthopaedic Surgeons will Develop Alcohol or Substance Abuse Problems—At Some Point in Career
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Physician Health Programs ( PHP)
• Most States Have—Identification, Treatment , Support—Non Disciplinary
• Confidentially: Deal With Abuse Issues
• 17% Orthopaedic Surgeons Practice in States That do not Have PHP ( 5,308 surgeons)
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Consequences—Depend On State Where Fellow Practices
• PHP states—often not come to state licensing board ( Confidential-Treatment)
• Non PHP States– state licensing board, discipline, license loss, public disclosure, AAOS Compliance
• Potential exists for groups to be treated differently by AAOS
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Judiciary Committee Actions• Disciplinary Action- Guiding Principles
and Special Considerations
• Generally Not “Second Guess” State Licensing Boards
• Special Cosiderations- No Compliance Action Pending Treatment Program—Therefore Not Reported
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Should AAOS Do More ?
• Recognize Widespread Nature—
• More Publicly Acknowledge and Discuss
• Education—Fellows, Residents
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AAOS---Education on SOP
• Annual Meeting- ICL, Symposia• Publications—AAOS Now, OKU• On Line Module- Requirement For
Membership• Module—Residency Training
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Disruptive Physician Behavior
• Medical errors• Adverse
outcomes• Cost• Personnel Loss• Litigation
Orthopaedics—4th Highest Field Prevalence
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Problems
• AMA—established definition Disruptive Behavior
• Surgeons—Disagree What Disruptive Behavior is in Practice ( Interpretation)
• Survey 110 Surgeons– 9 behaviors disruptive by national organization– 4 classified as disruptive by surgeons
JBJS 93 A Orthopaedic Forum, 2011
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Does Compliance Program Deal With Disruptive Physician?
• State Licensing Surveillance: Disciplinary Action—Disruptive
• S.O.P.--Professional Relationships
• S.O.P.--Musculoskeletal Services To Patients
One Fellow Must Bring Complaint Against Another
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Potential Problems—The Slippery Slope
• Hospital By Laws—Code of Conduct• Complaints– Peer Review Process• Potential ” Sham Peer Review”• “Disruptive Physician” Code Word—
Vendetta, Competition— Potential Weapon• State—Disciplinary Action—NPDB, AAOS
considers License restricted
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Aggressive Anger Outbursts
Profane/Disrespectful Language
Throwing Objects
Demeaning Behavior
Physical Aggression
Sexual Comments or Harassment
Racial/Ethnic Jokes
PassiveAggressive
Derogatory comments about
institution, hospital, group, etc.
Refusing to do tasks
Passive
Chronically late
Not responding to call
Inappropriate or inadequate chart
notes
Spectrum of Disruptive Behaviors
FSPHP April 23-26, 2012
Williams BW, Swiggart WH, Ghulyan MA, Vickers, K, Williams MV
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AAOS—Documents Limited Disruptive and Impaired
• Acknowledge Issues
–Code of Medical Ethics
–Standards Of Professionalism»Musculoskeletal Services»Professional Relationships
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AAOS--Comprehensive Position Statement( Disruptive Physician Behavior)
• Defining Disruptive Physician Behavior• Facilitate Reporting Protocol• Ensure Fair Evaluation and
Management
Standard— Medical Centers—Increase Patient SafetyJBJS 93 A Orthopaedic Forum, 2011
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Summary
• PCP is An Ethics Compliance Program• SOP’s Define Levels of Acceptable
Conduct• What To Do With Impaired and
Disruptive Physician Issues ?• Goal – Achieve/Maintain a High Level
of Professional Behavior by AAOS Members---How? Role of Education?
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Thank You
• Rick Peterson--AAOS• Melissa Young--AAOS• Murray Goodman—Chair, COP• Richard Schmidt—Chair, Judiciary• Michael Parks—Past AAOS Board
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