Lance Armstrong and parallels with physician discipline

I read the headlines in the paper today "Armstrong stripped of seven Tour titles."  I had just read his personal position on Facebook.  For those who have not followed this issue, the US Anti Doping Agency (USADA) has been trying to say that Armstrong violated doping regulations by using banned substances despite a significant amount of objective evidence in his favor.  The objective evidence in his favor was to such a degree that the Department of Justice dropped a 2 year investigation of him.  The USADA is not a branch of law enforcement branch but it does have the power to ban athletes, ban them for life, and apparently remove any awards that they have won in a retrospective manner even though they were under intense scrutiny at the time.  In my reading the USADA also apparently believes that their test results are infallible which makes their spin on those results even more confusing.  As Armstrong points out - during competition he had to submit for testing 24/7 at at no time did the USADA say that he had a positive test result or pull him from competition.  I am not going to review the pros and cons of the decision - only to say that at this point it has been politicized and a stunning amount of objective evidence has been ignored.  My interest in the process is how it resembles similar processes that are conducted against physicians.

The "disruptive physician" concept seems to have been the driving force behind a lot of these initiatives.   Disruptive physicians to me would be physicians who have not violated the medical practice statutes in their states.  They would be basically physicians that somebody doesn't like because of their behavior or personality.  The Joint Commission has a position statement:

"Intimidating and disruptive behaviors including overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks were quietly exhibiting uncooperative attitudes during routine activities. Intimidating and disruptive behaviors are often manifested by healthcare professionals in positions of power. Such behaviors include reluctance or refusal to answer questions, return phone calls or pages, condescending language or voice intonation, and impatience with questions or it overt and passive behaviors undermine team effectiveness and can compromise the safety of patients. All intimidating and disruptive behaviors are unprofessional and should not be tolerated."

They go on to cite research suggesting that these behaviors are widespread as high as 40% in some settings. The research is survey research and there are no concerns about its potential quality or biases. My concern and working in a number of medical settings for the past 30 years is that I have witnessed it exactly once. An attending physician personally verbally attacked me several times after he learned I was going to be a psychiatrist at least until I outguessed him on the correct diagnosis of acute abdominal pain.  I think that behavior would clearly qualify.

On the other hand, I have become aware of many physicians being disciplined and even losing their jobs over trivial situations in the workplace. Apparently the threshold for a complaint against a physician is that the complainant feels as if they were "disrespected".  In today's healthcare environment that complaint plus a personal dislike from a department chairman is enough to get you fired or at least live a miserable existence until you decide to quit.  That is true irrespective of the number of people who would testify on your behalf, service to the department, patient satisfaction ratings,  ratings by residents and medical students, and other professional accomplishments.  If you are a physician these days all it takes is the subjective opinion from someone who does not know you or your personal motivation or reasons for doing things to file a complaint and potentially destroy your career. Even if you are not fired outright, there could be a lingering process of accumulating demerits and reviews by other physicians who are not sympathetic to your plight before you are ultimately let go.

At least Lance Armstrong can say that a ton of objective evidence was ignored in order to make this decision. The decision against a physician can be based on a single subjective complaint irrespective of how reliable or credible the complainant is and what sort of evidence exists.

That is all it takes to be a disruptive physician.

George Dawson, MD. DFAPA

Physician oversight or intimidation?

The Board of Medical Practice in the state of Minnesota regulates 20,000 physicians. Most of them are employees in large healthcare companies. That means they have to undergo the credentialing process within those organizations as well as collateral organizations in addition to renewing their state license every year. There are about 800 complaints against physicians with the board of medical practice every year and the board takes serious actions based on those complaints at the rate of about 1.29 serious actions per 1000 physicians.

In Minnesota, anyone can complete a formal complaint against any physician. A specialist at the board sends a letter with the complaint to that physician's office and they have two weeks to respond to the complaint. That generally involves a specific letter to address the complaint as well as all of the associated medical records.  Frequently several physicians or clinics are part of the complaint in the process cannot go forward until all of the responses have been received by the Board.  The physician must respond literally to the complaint as written by the complainant.   The complaint is never interpreted by the Board.  The Board renders a decision based on the information it receives.

Like many states there is a move by politicians and the news media to suggest that doctors are not regulated tightly enough and they are not punished thoroughly enough in the state of Minnesota. The local press has been beating that drum for the past month.

There is now a clear case to be made that some of these complaints have little to do with medical practice and more to do with politics.  Many of us have seen it happen to our colleagues. I am familiar with several cases where a physician was accused of having a problem with other staff. The descriptions of those problems varied from being "disrespectful" to "snubbing" another staff member. Even in the case of unsubstantiated complaints there are protocols available in the Twin Cities that allow for physicians to be fired, written up, or rehabilitated based on purely subjective complaints. That is a far cry from the concerns about "disruptive physicians". It is apparent that in many settings purely subjective and essentially political complaints are being made on physicians and advanced by their administrative hierarchies.

Before anyone plays the "you're just defending physicians" card consider this. There is no physician I am aware of who would not agree with disciplining a physician who is physically abusive, verbally abusive, or otherwise out of control. There is no physician I am aware of who wants to see an incompetent physician practicing anywhere regardless of the source of their incompetency.  The people who escape criticism in the issue of physician discipline are not physicians but anyone who stands to gain from the proposition that there continue to be physicians who endanger public safety and there are widespread undetected numbers of them out there practicing.

Clearly the media has a stake in this process. The letter by Dr. Langland points out that the media in this case certainly could have done a better job investigating the major points of their contention that the medical board is failing in its public safety mandate. At a national level, Public Citizen obviously has a lot to gain by its ranking of medical boards and suggesting that ranking has a lot more meaning than it really does. Politicians at all levels get a lot of mileage out of keeping professionals accountable. That is true whether they are teachers or physicians. The irony is that politicians at all levels are clearly some of the least accountable people out there. I have also posted clear evidence that their approach to holding teachers "accountable" with an emphasis on standardized test score results is exactly the wrong approach to improving student test scores.

There are clearly a lot of people with a lot to gain in pushing this agenda and that conflict of interest is never discussed. The objective evidence is also never discussed. But I want to draw attention to a key paragraph in Dr. Langland's letter and that is the paragraph below:

"The Star Tribune also expresses concern that a majority of 74 doctors whose privileges were suspended or revoked by hospitals or clinics did not receive disciplinary action. Again, I am very familiar with these situations, most of which do not involve substandard patient care. Often they result from personality conflicts, turf battles and competitive issues. The board has correctly not let itself be drawn into these battles." (see reference 1)

This is a rather stunning revelation. It suggests that some organizations that are punishing physicians for what are essentially subjective or political complaints are also filing those complaints with the Board of Medical Practice and looking for them to be legitimized. While it is good to know that the current board has been able to see those complaints for what they are, there is no guarantee that will always be true. With the increasing influence of businesses and their agenda to control doctors, at some point in the future we may see these trivial complaints suddenly become complaints that threaten a physician's license and livelihood.

That is a heavy price to pay for the cost of doing business.

George Dawson, MD

1.  James Langland.  State Medical Board is Sound.  StarTribune March 5, 2012

2.  Star Tribune Editorial Board.  Medical Board Fails Quality Examination.  StarTribune February 25, 2012

3.  Medical Board actions against doctors, per 1,000 doctors, 2010.  StarTribune  February 6, 2012.

4.  Glenn Howatt and Richard Merryhew. State panel: Public deserves more information about physician misconduct.  StarTribune February 27, 2012.

5.  Glenn Howatt and Richard Merryhew. Doctors who err escape penalties.  StarTribune February 5, 2012.