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Can The AAOS And Its Compliance Program Do More? The Disruptive and Impaired Physician The Disruptive and Impaired Physician Edward V. Craig MD, MPH AAOS.

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Presentation on theme: "Can The AAOS And Its Compliance Program Do More? The Disruptive and Impaired Physician The Disruptive and Impaired Physician Edward V. Craig MD, MPH AAOS."— Presentation transcript:

1 Can The AAOS And Its Compliance Program Do More? The Disruptive and Impaired Physician The Disruptive and Impaired Physician Edward V. Craig MD, MPH AAOS Judiciary Committee

2 Symposium: Disruptive and Impaired Physician Edward V. Craig MD, MPH I have no potential conflict with this presentation

3 AAOS Compliance Program And Standards Of Professionalism Background: How We Got Here

4 Where Did The Standards (SOP) Come From? For Years– AAOS Heard From MembersFor Years– AAOS Heard From Members Through Professional Liability CommitteeThrough Professional Liability Committee Need to Address Fraudulent and Misleading TestimonyNeed to Address Fraudulent and Misleading Testimony Fellow Support---Sanction Based ProgramFellow Support---Sanction Based Program

5 Background BOCAdvisory Opinion To AAOS BoardBOCAdvisory Opinion To AAOS Board ResolutionFlorida Orthopaedic SocietyResolutionFlorida Orthopaedic Society Need----Professional Conduct Program Regarding Expert Witness Testimony Need----Professional Conduct Program Regarding Expert Witness Testimony

6 Background AAOS Bylaws Established Professional Compliance Program AAOS Bylaws Established Professional Compliance Program Appointed Committee on Professionalism (COP) and Judiciary Committee To Resolve Disputes ----The Grievance ProcessAppointed Committee on Professionalism (COP) and Judiciary Committee To Resolve Disputes ----The Grievance Process Standards Of Professionalism (SOP)First Three ApprovedStandards Of Professionalism (SOP)First Three Approved

7 Standards of Professionalism Based Upon AAOS Code of Medical Ethics and Professionalism for Orthopaedic SurgeonsBased Upon AAOS Code of Medical Ethics and Professionalism for Orthopaedic Surgeons

8 First Three Standards Musculoskeletal Services To PatientsMusculoskeletal Services To Patients Professional RelationshipsProfessional Relationships Expert Witness TestimonyExpert Witness Testimony

9 Additional SOPs Adopted 2006 – Research and Academic Responsibilities 2006 – Research and Academic Responsibilities 2007 Advertising by Orthopaedic Surgeons 2007 Advertising by Orthopaedic Surgeons 2007 Orthopaedic Surgeon- Industry Conflicts of Interest 2007 Orthopaedic Surgeon- Industry Conflicts of Interest

10 Grievance Process One AAOS Fellow Can File Grievance Against AnotherOne AAOS Fellow Can File Grievance Against Another Violation Of Any StandardsViolation Of Any Standards Multilevel Process---Culminate AAOS BoardMultilevel Process---Culminate AAOS Board

11 Allocation of Board Time--- Program Allocation of Board Time--- Program

12 . Program Operating Expenses Professional Compliance Program Budget includes:Professional Compliance Program Budget includes: –2011 budget - $1M for litigation expenses –Initial proposed 2012 budget $1M for litigation expenses Program: Time Consuming and Expensive

13 Official Disciplinary Actions Reported To: National Practitioner Data Bank (Suspensions and Expulsions Only) State Licensing Boards ABOS State Medical Societies and Associations Grievance Process--Sanction Based Program

14 Professional Compliance Program Professional Compliance Program ….and Reported to Fellowship:

15 Judiciary-Non SOP :Loss Of Medical License by Fellows AAOS Surveillance System AAOS Surveillance System FellowNeed To Have License Unencumbered, No Restrictions ( State Action: Impairments- Drugs, Alcohol) FellowNeed To Have License Unencumbered, No Restrictions ( State Action: Impairments- Drugs, Alcohol) Any State Disciplinary ActionConsidered A Restriction, Subject to Compliance ActionIncluding For Disruptive Behavior Any State Disciplinary ActionConsidered A Restriction, Subject to Compliance ActionIncluding For Disruptive Behavior Usually Suspension Usually Suspension

16 Medical License Loss- Substance Abuse Most Difficult For Judiciary--- Illness, Volitional, in Treatment or Not, Complying With Aftercare, etc. Most Difficult For Judiciary--- Illness, Volitional, in Treatment or Not, Complying With Aftercare, etc. Each State has Differing Response-- - Judiciary Can ConsiderEach State has Differing Response-- - Judiciary Can Consider

17 Extent Of The ProblemAmong Physicians 8-12% Will Develop Substance Abuse Problem at Some Point Career8-12% Will Develop Substance Abuse Problem at Some Point Career At Any Given Time Up To 1 in 20 (3%- 7%) are Active Substance AbusersAt Any Given Time Up To 1 in 20 (3%- 7%) are Active Substance Abusers Left Untreated 17% Mortality RateLeft Untreated 17% Mortality Rate IndependentAge Range,Geography Urban/Rural

18 Incidence By Medical Specialty No Specialty ImmuneNo Specialty Immune Emergency Medicine, Psychiatry, Anesthesiology Slightly Higher IncidenceEmergency Medicine, Psychiatry, Anesthesiology Slightly Higher Incidence

19 Archives of Surgery (2012)Survey 27, % had a Score on Alcohol Abuse Identification Test ( Abuse or Dependence)15.4% had a Score on Alcohol Abuse Identification Test ( Abuse or Dependence) Correlation –Alcohol Abuse or DependenceCorrelation –Alcohol Abuse or Dependence –Major Medical Error Prior 3 Months –Surgeons Who Were Burned Out –Surgeons Depressed –Emotional Exhaustion Having Children, Working for VALower LikelihoodHaving Children, Working for VALower Likelihood

20 Risk factors Parallel General PublicParallel General Public –Strong Familial Association –Psychological or Psychiatric Disorders Unique to PhysiciansUnique to Physicians –Self Treatment with Prescription Meds –High Stress or Long Hours –Access to Controlled Substances CicadasSubstance Abuse Among Physicians Hospital Medicine, 2003

21 Other Risk Factors Smoking One or More Packs/daySmoking One or More Packs/day Multiple Affairs or MarriagesMultiple Affairs or Marriages History Multiple Jobs in Multiple CommunitiesHistory Multiple Jobs in Multiple Communities Academic MedicineAcademic Medicine CicadasSubstance Abuse Among Physicians Hospital Medicine, 2003

22 Archives of Surgery Alcohol Abuse and Dependence a Significant ProblemAlcohol Abuse and Dependence a Significant Problem Suggested Organizations-ACS, AAOS Develop Early Warning and Intervention ProgramsSuggested Organizations-ACS, AAOS Develop Early Warning and Intervention Programs

23 Are We Doing Enough? Are We Doing Enough? If Statistics Correct---If Statistics Correct--- In USA: 2,500-3,700– Current Orthopaedic Surgeons will Develop Alcohol or Substance Abuse ProblemsAt Some Point in Career In USA: 2,500-3,700– Current Orthopaedic Surgeons will Develop Alcohol or Substance Abuse ProblemsAt Some Point in Career

24 Physician Health Programs ( PHP) Most States HaveIdentification, Treatment, SupportNon DisciplinaryMost States HaveIdentification, Treatment, SupportNon Disciplinary Confidentially: Deal With Abuse IssuesConfidentially: Deal With Abuse Issues 17% Orthopaedic Surgeons Practice in States That do not Have PHP ( 5,308 surgeons)17% Orthopaedic Surgeons Practice in States That do not Have PHP ( 5,308 surgeons)

25 ConsequencesDepend On State Where Fellow Practices PHP statesoften not come to state licensing board ( Confidential-Treatment)PHP statesoften not come to state licensing board ( Confidential-Treatment) Non PHP States– state licensing board, discipline, license loss, public disclosure, AAOS ComplianceNon PHP States– state licensing board, discipline, license loss, public disclosure, AAOS Compliance Potential exists for groups to be treated differently by AAOSPotential exists for groups to be treated differently by AAOS

26 Judiciary Committee Actions Disciplinary Action- Guiding Principles and Special ConsiderationsDisciplinary Action- Guiding Principles and Special Considerations Generally Not Second Guess State Licensing BoardsGenerally Not Second Guess State Licensing Boards Special Cosiderations- No Compliance Action Pending Treatment Program Therefore Not ReportedSpecial Cosiderations- No Compliance Action Pending Treatment Program Therefore Not Reported

27 Should AAOS Do More ? Recognize Widespread NatureRecognize Widespread Nature More Publicly Acknowledge and DiscussMore Publicly Acknowledge and Discuss EducationFellows, Residents EducationFellows, Residents

28 AAOS---Education on SOP Annual Meeting- ICL, SymposiaAnnual Meeting- ICL, Symposia PublicationsAAOS Now, OKUPublicationsAAOS Now, OKU On Line Module- Requirement For MembershipOn Line Module- Requirement For Membership ModuleResidency TrainingModuleResidency Training

29 Disruptive Physician Behavior Medical errorsMedical errors Adverse outcomesAdverse outcomes CostCost Personnel LossPersonnel Loss LitigationLitigation Orthopaedics4 th Highest Field Prevalence

30 Problems AMAestablished definition Disruptive BehaviorAMAestablished definition Disruptive Behavior SurgeonsDisagree What Disruptive Behavior is in Practice ( Interpretation)SurgeonsDisagree What Disruptive Behavior is in Practice ( Interpretation) Survey 110 SurgeonsSurvey 110 Surgeons –9 behaviors disruptive by national organization –4 classified as disruptive by surgeons JBJS 93 A Orthopaedic Forum, 2011

31 Does Compliance Program Deal With Disruptive Physician? State Licensing Surveillance: Disciplinary ActionDisruptiveState Licensing Surveillance: Disciplinary ActionDisruptive S.O.P.--Professional Relationships S.O.P.--Professional Relationships S.O.P.--Musculoskeletal Services To PatientsS.O.P.--Musculoskeletal Services To Patients One Fellow Must Bring Complaint Against Another

32 Potential ProblemsThe Slippery Slope Hospital By LawsCode of Conduct Hospital By LawsCode of Conduct Complaints– Peer Review ProcessComplaints– Peer Review Process Potential Sham Peer ReviewPotential Sham Peer Review Disruptive Physician Code Word Vendetta, Competition Potential WeaponDisruptive Physician Code Word Vendetta, Competition Potential Weapon StateDisciplinary ActionNPDB, AAOS considers License restrictedStateDisciplinary ActionNPDB, AAOS considers License restricted

33 Aggressive Anger Outbursts Anger Outbursts Profane/Disrespectful Language Profane/Disrespectful Language Throwing Objects Demeaning Behavior Demeaning Behavior Physical Aggression Physical Aggression Sexual Comments or Sexual Comments or Harassment Harassment Racial/Ethnic Jokes Racial/Ethnic Jokes PassiveAggressive Derogatory comments about institution, hospital, group, etc. Refusing to do tasks Passive Chronically late Not responding to call Inappropriate or inadequate chart notes Spectrum of Disruptive Behaviors FSPHP April 23-26, 2012 Williams BW, Swiggart WH, Ghulyan MA, Vickers, K, Williams MV33

34 AAOSDocuments Limited Disruptive and Impaired Acknowledge IssuesAcknowledge Issues –Code of Medical Ethics –Standards Of Professionalism »Musculoskeletal Services »Professional Relationships

35 AAOS--Comprehensive Position Statement( Disruptive Physician Behavior ) Defining Disruptive Physician BehaviorDefining Disruptive Physician Behavior Facilitate Reporting ProtocolFacilitate Reporting Protocol Ensure Fair Evaluation and ManagementEnsure Fair Evaluation and Management Standard Medical CentersIncrease Patient Safety JBJS 93 A Orthopaedic Forum, 2011

36 Summary PCP is An Ethics Compliance Program SOPs Define Levels of Acceptable Conduct What To Do With Impaired and Disruptive Physician Issues ? Goal – Achieve/Maintain a High Level of Professional Behavior by AAOS Members---How? Role of Education?

37 Thank You Rick Peterson--AAOSRick Peterson--AAOS Melissa Young--AAOSMelissa Young--AAOS Murray GoodmanChair, COPMurray GoodmanChair, COP Richard SchmidtChair, JudiciaryRichard SchmidtChair, Judiciary Michael ParksPast AAOS BoardMichael ParksPast AAOS Board

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