Impaired Physicians Part II - Insight

There are two psychological traits that are important to the successful practitioner; empathy and insight. Empathy allows us to identify with the suffering of others; it motivates us to perform at a high level. Insight allows us to process uncomfortable realizations regarding our ineffective, harmful or embarassing actions. "Good judgment comes from experience, and experience comes from bad judgment;" but only if there is motivation to get it right, and insight to allow honest assessment of when we do (and don't) get it right.

Unfortunately, neither empathy nor insight are required to succeed in medical school and residency. In training, empathy can be replaced by fear; fear of disapproval or dismissal. And insight can be replaced by external direction; the non-insightful are frequently good at following instructions. At least, those that aren't (true sociopaths and the like) don't usually make it into medical practice.

Of the two, insight is far and away the more important. Empathy can be imperfectly substituted by pride or ambition; we all (as patients and colleagues) know clinicians like that. And too much empathy will drive a practitioner to distraction and depression; there's just too much suffering around us to internalize all of it.

The first step, then, in assessing an affected practitioner is the simple question, "does he have insight into what happened." The answer is most frequently, yes. The practitioner will say, "that was a mistake," "I had a bad day," or "I'll never do THAT again!" A sincere apology is a sure sign of insight; usually, you see those practitioners once in a great while (because they don't become "affected practitioners"), and they are fine with some advice and encouragement.

Physicians without insight however, are generally dangerous. There is an old adage, first told to me by a former boss, Mike Roizen; "One guy beeps at you, he's an asshole. Two guys beep at you, you're the asshole..." Even practitioners with no insight understand that the consensus opinion of a committee can't be argued with; therefore, they rationalize. Normally, they will pick somebody on the committee who they decide "has it in" for them, and then they'll reason that that person has somehow persuaded everyone else, against their own better judgments, to go along. This is so improbable a denial mechanism, that if I hadn't seen it time and again, I wouldn't believe it possible. Of course, such a practitioner is typically headed for serious trouble.

Angry practitioners lacking insight always hide behind their patients; the doctor that screams at the nursing station "this unit is killing my patient!" loud enough for the whole ward to hear is merely trying to "discipline" the nurses. The surgeon who refuses to write a brief history and physical on the patient going to OR with an acute abdomen does not want to waste "critical minutes," even though he took two hours getting over to see the patient in the first place, and so on.

There aren't that many physicians lacking insight, but those that do occupy an inordinate amount of administration and leadership time. I used to remind my MEC that we were spending many hours of valuable physician time discussing the same 8 or 10 physicians over and over, sometimes for years at a stretch.

Fair Hearings are a wonderful tool if used correctly, and a disaster if not; and most of that hinges on the medical staff coordinator and CEO. I know of fair hearings that have been allowed to turn into mini-trials, with hour-after-hour of testimony, witness calling, and dueling attorneys. That's just wrong, and abusive of the time of the volunteer committee members. A fair hearing is not an adversarial legal proceeding; it is a medical staff disciplinary proceeding, its recommendations are non-binding, and the complete due-process obligations are spelled out in the bylaws and don't extend beyond the bylaws, no matter what an attorney says; it's just not court. Ideally, the fair hearing committee takes a careful look at the circumstances, and makes recommendations for redemptive interventions. When I preside over a fair hearing, the attorneys are not permitted to speak, but are certainly allowed to observe to ensure fairness. Good attorneys, who understand the process and their role in it, are never a problem. Attorneys who want to show their client how tough they are usually damage their client's situation, since their aggressive manner alienates the committee members.

The best attorneys recognize when their clients don't have a clue, and seek to help their clients understand their transgressions, and what needs to be done to return them to effective practice. I have hammered out reasonable arrangements over the years between hospital attorneys (who are invariably on the ball) and good affected practitioner attorneys. These are the most satisfying cases to be involved with.

In any case, short of mal-intent or obvious willful negligence, the job of leadership is to provide a "redemptive pathway" for affected practitioners that keeps patient and community well-being clearly in the forefront. Sometimes, the way back is tough; it may involve some fellowship style retraining, psychiatric evaluation and care, or a long-term monitorship/mentorship agreement. Of course, a suspension without a prescribed redemptive pathway is a revocation of privileges without saying so.

Next post (Part III) I will discuss the regulatory climate of physician discipline, and competence issues.