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PubMed2003

A prescription for the rogue doctor: part II ready, aim, fire.

As discussed in Part I of this series, rogue doctors have serious sociopathic behavioral deficiencies which may be the result of a defect of character or a flaw in ethics. Under these circumstances, unacceptable behavior patterns will arise. For years, counseling, coaching, training, supervising, transfers to less critical disciplines, disciplinary warnings, and offering opportunities to resign have been the typical approaches in dealing with rogues; the outright firing of residents and doctors has been relatively taboo. However, preserving a rogue's professional status as a practicing doctor has become increasingly problematic. In Part II of this two-part series, implementation of a performance management system to remove rogues from the system is discussed. This paper will detail exactly how such a system can work.

Documentation↗
PubMed2006

Disciplinary careers of drug-impaired physicians.

Alcohol and drug abuse are among the leading reasons for disciplinary action against physicians by state licensing authorities in the United States. I use event history models to describe the longitudinal patterns in disciplinary actions taken against physicians' licenses by state medical boards in the United States, 1990-2000. Adverse licensure action episodes that included discipline for drug or alcohol abuse were more likely to be followed by license restoration than episodes that did not. However, those restorations were also more likely to be followed by subsequent disciplinary action than episodes that did not include discipline for drug abuse. Furthermore, disciplinary licensure actions for drug abuse were the category most likely to be followed by a subsequent action for the same reason over the longer term (4-11 years). The increased risk of repeat disciplinary action associated with drug abuse may result in part from intensive surveillance of physicians who complete impaired physician programs, through mechanisms that include urine screening. However, it is also likely that the chronic nature of addiction leads to continued risk of relapse even among physicians receiving appropriate treatment.

Databases as Topic↗
PubMed2005

Disciplinary action against physicians: who is likely to get disciplined?

PURPOSE: We sought to determine the characteristics of disciplined physicians at-large and the risk of disciplinary action over time and to report the type and frequency of complaints and the nature of disciplinary actions against allopathic physicians in Oklahoma. METHODS: Descriptive statistics, Kaplan-Meier analysis, and Cox proportional hazards modeling of publicly available data on physicians licensed by the Oklahoma Board of Medical Licensure and Supervision. RESULTS: Among 14,314 currently or previously licensed physicians, 396 (2.8%) had been disciplined. Using univariate proportional hazards analysis, men (P <0.04), non-whites (P < 0.001), non-board-certified physicians (P < 0.001), and those in family medicine (P < 0.001), psychiatry (P < 0.001), general practice (P < 0.001), obstetrics-gynecology (P < 0.03) and emergency medicine (P < 0.001) were found to be at greater risk of being disciplined than other medical specialty groups. Foreign medical graduates had a higher risk of disciplinary action compared to US medical graduates (P < 0.001), although this finding was not confirmed by multivariate analysis. Kaplan-Meier analysis revealed that the proportion of physicians disciplined increased with each successive 10-year interval since first licensure. Complaints against physicians originated most often from the general public (66%), other physicians (5%), and staff (4%), and the complaints most frequently involved issues related to quality of care (25%), medication/prescription violations (19%), incompetence (18%), and negligence (17%). CONCLUSION: To improve physician behavior and reduce the need for disciplinary action, medical schools and residency training programs must continue to emphasize both patient care and medical professionalism as critical core competencies.

Employee Discipline↗
PubMed1989

Attitude toward and experience of industry-based alcohol recovery programmes: a survey of 161 Scottish organizations.

This paper reports the results of a survey of 161 Scottish organizations which asked questions in four areas: attitudes of employers toward alcoholism, present disciplinary practice on alcohol-related behaviours, structural features of firms relevant to their policy in discipline in this matter, and employers' views on support available in implementing a work-based alcohol-recovery programme. Results indicated (a) favourable attitudes toward the treatment of alcoholism generally but some doubt as to the practicalities of work-based programmes, (b) a proportion of firms (25.5%) with some form of alcoholism policy, (c) written programmes being associated with firms employing a more skilled workforce and possessing a large personnel department, (d) a willingness by employers to use external voluntary agencies in a recovery programme.

Alcoholism↗
PubMed2003

The professional nurse and regulation.

The regulation of nursing began as a simple registry process to protect the nursing title and the public. Today, the primary purpose is still the protection of the public through defining nursing practice, approving nursing education, and overseeing the competence of nurses through licensing and disciplinary rules and regulations. State Boards of Nursing are legislatively given the authority to license and discipline the nursing profession. The RN is responsible for the care given to assigned patients. Issues of staffing, delegation, and reporting of incompetent or impaired nurses are a concern of nurses today with regard to their license. Each nurse must understand the regulations, which vary from state to state, that directly and indirectly affect his/her daily practice. As the health care environment is met with several challenges, pressures are increasing to modernize the licensing and competency assessment of nurses. Ultimately, the safety of patients must remain at the center of the regulatory debate.

Certification↗
PubMed2005

Ability, incentives, and management feedback: organizational change to reduce pressure ulcers in a nursing home.

OBJECTIVE: Quality improvement (QI) processes in nursing homes are highly variable and often ineffective. This study evaluated an innovative QI process to reduce pressure ulcers (PUs) in a nursing home with a high rate of PUs. DESIGN: This was a 48-week, longitudinal study comparing the incidence of PUs during 12-week baseline and intervention and post-intervention periods. SETTING: Not-for-profit, 136-bed nursing home in urban Western Pennsylvania. PATIENTS OR OTHER PARTICIPANTS: All residents and all staff at the nursing home participated in this study. INTERVENTIONS: The intervention consisted of 3 components: Ability enhancement, incentivization, and management feedback. To enhance ability, all staff members completed a computer-based interactive video education program on PU prevention and were mandated to use penlights to promote early detection. Incentivization included $75 for each staff member if the desired reduction in PU incidence was achieved. Management feedback provided real-time information of staff"s adherence to the mandated training. MAIN OUTCOME MEASURES: Outcome measures consisted of staff's adherence to mandated training and the incidence of new PUs during the baseline period compared to the intervention and post-intervention periods. RESULTS: Management responded to noncompliance with training with both rewards and stepped discipline. Adherence to protocol, as measured by training compliance, was 100%. There was a significant reduction (P < .05) in the incidence of stage 2 or worse PUs during the intervention period. During the post-intervention periods, the effect was lost. CONCLUSION: An innovative QI initiative resulted in a significant decrease in PUs in 1 facility. This intervention was not sustainable when the 3 components of the QI intervention were no longer actively maintained.

Aged↗
PubMed2005

Domains of unprofessional behavior during medical school associated with future disciplinary action by a state medical board.

BACKGROUND: In a previous study, we showed that unprofessional behavior in medical school was associated with subsequent disciplinary action. This study expands on that work by identifying the domains of unprofessional behavior that are most problematic. METHOD: In this retrospective case-control study, negative comments were extracted from student files for 68 case (disciplined) and 196 matched control (nondisciplined) physicians. Comments were analyzed qualitatively and subsequently quantified. The relationship between domains of behavior and disciplinary action was established through chi-square tests and multivariate analysis of variance. RESULTS: Three domains of unprofessional behavior emerged that were related significantly to later disciplinary outcome: (1) poor reliability and responsibility, (2) lack of self-improvement and adaptability, and (3) poor initiative and motivation. CONCLUSIONS: Three critical domains of professionalism associated with future disciplinary action have been defined. These findings could lead to focused remediation strategies and policy decisions.

California↗
PubMed2001

Returning to competence after discipline.

Nursing regulatory boards have long taken disciplinary action against licensees who have violated Nursing Practice Acts. License suspensions are a common penalty for such violations, but rehabilitation and regaining competence also must be considered. The North Carolina Board of Nursing has developed and implemented two courses, Legal-Ethical Decision Making, and Pharmacology, which may be required of licensees as part of the disciplinary process. Developed by board staff, the courses are taught by independently contracted nurse instructors located throughout the state. During the courses, the licensees must acknowledge their specific violation and explore the reasons for occurrence and strategies for prevention. Upon completion of the course, instructors submit required course materials that are used for consideration of relicensure decisions. This article describes the development and implementation of the instruction program, as well as descriptive data on the licensees.

Clinical Competence↗
PubMed2003

The suspensions scandal.

The process by which senior hospital doctors are disciplined within the National Health Service is analysed. The mechanisms used are discussed and a number of faults are identified. Many of these faults give an unfair advantage to management and are contrary to the rules of 'Natural Justice'. These faults lead to an excessive number of doctors being wrongfully suspended for an unnecessarily long period. The process is oppressive to doctors as well as being contrary to the Human Rights Act. A number of risk factors are identified; race, sex, speciality and obstetricians appear to be particularly vulnerable. The process causes significant morbidity as well as having a 2% mortality. The process is also remarkably inefficient with management, despite all the in built advantages, unable to prove that the suspended doctor is at fault in the majority of cases. It is also very wasteful of the NHS's financial resources.

Employee Discipline↗
PubMed2003

Characteristics of physicians disciplined by the State Medical Board of Ohio.

Although physicians have been disciplined for a variety of offenses by state medical boards across the United States, limited information is available about the characteristics of these physicians. To assess the characteristics of, offenses committed by, and resulting disciplinary actions taken against a consecutive series of disciplined physicians in the state of Ohio, the authors conducted a case-control study of all 308 physicians publicly disciplined by the State Medical Board of Ohio (SMBO) from January 1997 to June 1999. Subjects were matched with two groups of control physicians--one matched by location only, and the second matched for location, gender, practice type, and self-designated specialty. The main outcomes measured were disciplinary actions, offenses leading to state medical board actions, and the characteristics of disciplined physicians. Of 340 physicians disciplined during these 30 months (approximately 0.37% per year), 308 committed 477 offenses requiring 409 actions by the SMBO. The most common offenses were impairment due to alcohol and/or drug use (21%), inappropriate prescribing or drug possession (14%), previous state actions (15%), negligence or incompetence (7%), and drug-related charges (7%). Although offenders were significantly less likely to be women (P < .05; odds ratio [OR], 0.46; 95% confidence interval [CI], 0.28-0.75), the authors found no difference in the severity of disciplinary action taken against offenders by gender (OR, 1.23; 95% CI, 0.54-2.82) or by type of medical training, ie, between osteopathic physicians and allopathic physicians (OR, 0.70; 95% CI, 0.39-1.26). Compared with controls matched for location, gender, practice type, and self-designated specialty, offenders were significantly less likely to be board certified (OR, 0.65; CI, 0.46-0.92) and significantly more likely to have been in practice 20 or fewer years (OR, 1.51; 95% CI, 1.08-2.13). Disciplinary actions in Ohio were more frequent, more severe, and more often in response to impairment due to alcohol and/or drug use and previous state actions than previously reported. No difference in the severity of disciplinary action was noted between men and women or between osteopathic and allopathic physicians.

Adult↗
PubMed2005

Disciplinary action by medical boards and prior behavior in medical school.

BACKGROUND: Evidence supporting professionalism as a critical measure of competence in medical education is limited. In this case-control study, we investigated the association of disciplinary action against practicing physicians with prior unprofessional behavior in medical school. We also examined the specific types of behavior that are most predictive of disciplinary action against practicing physicians with unprofessional behavior in medical school. METHODS: The study included 235 graduates of three medical schools who were disciplined by one of 40 state medical boards between 1990 and 2003 (case physicians). The 469 control physicians were matched with the case physicians according to medical school and graduation year. Predictor variables from medical school included the presence or absence of narratives describing unprofessional behavior, grades, standardized-test scores, and demographic characteristics. Narratives were assigned an overall rating for unprofessional behavior. Those that met the threshold for unprofessional behavior were further classified among eight types of behavior and assigned a severity rating (moderate to severe). RESULTS: Disciplinary action by a medical board was strongly associated with prior unprofessional behavior in medical school (odds ratio, 3.0; 95 percent confidence interval, 1.9 to 4.8), for a population attributable risk of disciplinary action of 26 percent. The types of unprofessional behavior most strongly linked with disciplinary action were severe irresponsibility (odds ratio, 8.5; 95 percent confidence interval, 1.8 to 40.1) and severely diminished capacity for self-improvement (odds ratio, 3.1; 95 percent confidence interval, 1.2 to 8.2). Disciplinary action by a medical board was also associated with low scores on the Medical College Admission Test and poor grades in the first two years of medical school (1 percent and 7 percent population attributable risk, respectively), but the association with these variables was less strong than that with unprofessional behavior. CONCLUSIONS: In this case-control study, disciplinary action among practicing physicians by medical boards was strongly associated with unprofessional behavior in medical school. Students with the strongest association were those who were described as irresponsible or as having diminished ability to improve their behavior. Professionalism should have a central role in medical academics and throughout one's medical career.

College Admission Test↗
PubMed1987

Perceptions and attitudes toward nursing impairment.

Perceptions and attitudes toward nursing impairment held by 1,047 registered nurses were examined. Factor analysis of the 32 Likert-type items in an original survey questionnaire revealed an underlying structure of nine dimensions characterizing attitudes toward impairment. Analyses of variance and covariance gave evidence that supervisors were more likely than staff nurses to perceive a need for disciplinary action in responding to cases of nursing impairment; staff nurses were more likely to view impairment as treatable. Significant differences were found among attitudes toward drug abuse, alcohol abuse, and emotional distress as forms of impairment.

Adult↗
PubMed1997

What consequences should result from failure to meet internal standards?

This paper tries to approach a difficult problem, namely how to deal with a resident who has failed to meet the internal standards of a residency training program. First the problems of the definition of a standard and the associated problems of its reproducibility, documentation, teaching, update, and internal variability inside the same teaching program are dealt with. Consequently the question needs to be answered that constitutes a failure to meet the standard. The results of a survey of residents' attitudes are quoted as are some responses to a survey among the chiefs of teaching programs. Considering the attitudes of residents on how to handle breaches of standard the basic message was that residents want to be told that they do not function. Both parties want the collaboration of senior staff members on this topic. Whereas residents want to re-train, exercise and talk they do not want sanctions. Chiefs, however, want much less re-training, exercising and talking but earlier sanction. The difficult point of dealing with a true failure is discussed in the light of the German legal situation and the actual possibilities of how to handle the case. Before it comes to the point of discontinuing the training of a resident, it needs to be agreed upon what would be a classical situation of failure in which both the chiefs responsible for training and the residents agree that training is better discontinued. The author describes his experience with the real course of events in 7 cases he witnessed in 22 years.

Attitude of Health Personnel↗
PubMed1991

Bringing the abusive employee back.

In many health care settings, some dispute resolution process exists which limits the discretion of the employer to simply terminate an employee suspected of inappropriate or abusive behavior. On occasion, the working of such disciplinary processes results in an employee, who is viewed by management as having broken a fundamental trust, being returned to the workplace. In managing the return of these individuals, provider agencies must develop strategies to reduce the likelihood of any future client injury and to increase the chances of returning the employee to a productive functioning level. We surveyed employees returned to work after an abusive incident along with their supervisors to determine what specific supports each group saw as necessary for a successful return. As a result, an individualized, structured program was developed to deal with such returns and piloted. The authors' results indicate that the program might serve as one possible model for wider use.

Aggression↗