Nature of Human Error – Implications to Surgical Practice Alfred Cuschieri Scuola Superiore SAnna di Studi Universitari Pisa, Italy.
Presentation on theme: "When Good Doctors Go Bad"— Presentation transcript:
1 When Good Doctors Go Bad Lucian L. Leape, MDAmerican Surgical AssociationBostonAugust 21, 2006
2 Failure to ensure that all of our colleagues are competent and safe is ethically indefensible.
3 ACS Code of Professional Conduct Maintain competence throughout our surgical careersRespect the knowledge, dignity, and perspective of other healthcare professionalsParticipate in self regulation by setting, maintaining, and enforcing practice standards
4 Types of Performance Problems 1. The Psychopathic physician2. The impaired physicianSubstance abuse - alcohol / drugsMental illnessPhysical illness3. Declining Competency4. Behavioral ProblemsDisruptive physician- Refuses to follow rules- Abusive behaviorAbusive with patients
5 Types of Performance Problems 1. The Psychopathic Physician ? 0.1%2. The impaired physicianSubstance abuse - alcohol / drugs 15%Mental illness %Physical illness %3. Declining Competency
6 Recertification Exam Failure Rates (2004) Board No % FailedAm. Bd. SurgeryGeneral surgery %Subspecialties %Am. Bd. PediatricsGeneral pediatrics %Subspecialties %Am. Bd. Internal MedInternal Medicine %Specialties %Am. Bd. Family Med %
7 Types of Performance Problems 1. The Psychopathic Physician. 1% 2 Types of Performance Problems 1. The Psychopathic Physician ? 0.1% 2. The impaired physician Substance abuse - alcohol / drugs 15% Mental illness % Physical illness % 3. Declining Competency %4. Behavioral ProblemsDisruptive physician
8 What do surveys reveal about disruptive behavior? NURSES:Nurses witnessing or receiving it 95%Verbal abuse every 2-3 months 64%Believe it is a cause of nurses leaving 37%Percent of doctors exhibiting it 5.7%HOSP EXECS: %
9 Types of Performance Problems 1. The Psychopathic Physician. 1% 2 Types of Performance Problems 1. The Psychopathic Physician ? 0.1% 2. The impaired physician Substance abuse - alcohol / drugs 15% Mental illness % Physical illness % 3. Declining Competency %4. Behavioral ProblemsDisruptive physician ? 5%Refuses to follow rulesAbusive behaviorAbusive with patients ? 5%
10 All causes considered, 30-40% of all physicians will have a problem at some time in their career that will impair their ability to practice medicine safely.For a hospital staff of 100, this means that at any one time 1 or 2 physicians need help.
11 Why are doctors reluctant to act? Distasteful to judge peersEmotionally difficult – “family”“Glass house” syndromeFear of retributionNo good mechanism
12 We have a “Non-System” Implicit Personal Punitive It’s “all or nothing”
13 We define performance problems as disciplinary problems “Hung up” on punishing- Want to “weed them out”Safety objective: prevention
14 What would we like to do? 1. Identify doctors with problems early 2. Do something about it3. Do it in a timely fashionWe need a system
15 What are the essential characteristics of an effective professional accountability system? Objective - based on data, not opinionFair - applies to everyoneResponsive – prompt and effective treatmentGOAL: to enable the physician to continue to practice medicine
16 What would an effective professional accountability system look like? Adopt performance standardsAdherence is a condition of appointment to staffAdherence is monitored (everyone)Feedback of results and action as neededBroad repertoire of methods for remediation
17 Sub par performance can be objectively defined Routine monitoring of all members of the medical staff is necessary to detect problems fairly and earlyThe response to deficiencies should be prompt, constructive, and sustained
18 What is needed?StandardsMeasuresAssessment and remediation programs
19 ACGME / ABMS Competency Standards Compassionate, appropriate, and effective patient careMedical knowledge and its application to patient carePractice-based learning and improvementInterpersonal and communication skillsProfessionalism and ethical behaviorSystems-based practice
20 Example of a Behavioral Standard “Treat Co-workers with Respect”Hostile behavior is forbidden (raised voice, insults, public reprimands)No demeaning behavior or humiliation of residents and nursesNo derogatory comments about colleagues – oral or writtenWork in meaningful teamsAccept challenges to authority
21 What measures are available? ABMS competency measures are being developedABIM competency testing nowGerald Hickson’s analysis of patient complaintsPAR “360” multitrait evaluations
22 What about:Annual physical examsDrug testingCognitive testing
23 What is needed?StandardsMeasuresAssessment and remediation programs
24 How will we develop programs for assessment and remediation? Need a collaborative effortABMSFSMBJCAHO
25 Are we willing to support recovering doctors? Who pays for assessment and remediation?How is his/her income maintained?Are we willing to make refresher positions available in all of our residency programs?Are we willing to mentor and supervise retrained doctors?Will we let them care for our patients?