Prevention system sought to boost quality care

At some point in their careers, one-third of physicians will have a condition that impairs their ability to practice medicine safely, putting patients in harm's way, two medical experts say.

Despite the large number affected, most doctors receive little help for mental illness, substance abuse and other problems. The serious conditions often are handled poorly at the hospital and practice level, according to the experts' article in the Jan. 17 Annals of Internal Medicine.

The authors are urging development of a national monitoring and prevention system to identify and help those whom they call problem doctors, to act before patient safety is affected.

"There are problems with doctors whose performance isn't where it ought to be. That's a system problem," said patient safety expert Lucian L. Leape, MD, adjunct professor of health policy at the Harvard School of Public Health. "We don't have good methods for identifying them, and we don't have good resources for getting them rehabilitated."

Dr. Leape and Massachusetts physician health expert John A. Fromson, MD, wrote the article to spark national debate about finding systematic solutions to problem doctors. Few organizations have formal programs to spot these doctors or monitor physician performance, the article said. And there are few national or state measures for checking performance or standards of conduct or competence.

Underlying causes for performance problems include mental and behavioral issues. For example, depression might be higher among physicians than the general population, and physicians have a higher suicide rate. About 8% to 13% of doctors have alcohol problems compared with 13.5% of the adult population. And 3% to 5% of physicians will exhibit disruptive behavior such as making sexual comments or throwing charts.

"The problem isn't the sensational cases you read about in the newspaper. It's really good doctors who are slipping for understandable and human reasons," Dr. Leape said.

Taking a proactive approach

Drs. Leape and Fromson said the current reactive approach should be replaced with a proactive monitoring system that uses measures to focus on clinical and behavioral performance. The system would require better ways to spot doctors who need help and better programs for providing aid. Hospitals would be the likely starting place for the initiative.

An institution would adopt performance standards of competence and behavior, and physicians would be required to abide by the standards to receive hospital privileges. Adherence to standards would be monitored annually through formal evaluations by colleagues and others. If problems are found, physicians could receive counseling or be referred to assessment and treatment programs.

"This calls for a much more preventive model to help the whole profession," said Dr. Fromson, assistant clinical professor of psychiatry at Harvard Medical School and chair of the American Psychiatric Assn.'s committee on physician health.

State medical boards, specialty boards and the Joint Commission on Accreditation of Healthcare Organizations are best-suited to lead the effort, the authors said. Specialty boards are working on standards for competence.

JCAHO Senior Vice President Paul M. Schyve, MD, said the article addresses issues his group is examining. For example, JCAHO and members of other groups are trying to revise medical staff credentialing and privileging standards. Proposed revisions address performance monitoring to assess competence and constant professional practice evaluation.

James Thompson, MD president and CEO of the Federation of State Medical Boards, agrees that a new mechanism is needed to identify doctors not practicing quality medicine. He said there also needs to be a nonpunitive plan to place such doctors in quality improvement programs. "The remedies are not unreasonable, but it requires a major shift in the culture of the profession," he said.