Case Scenario

I am part of a group practice in which physicians commonly see each other's patients. When I see a particular colleague's patient, the patient's health maintenance is often not up to date, and I do not trust that the physician has followed up on clinical issues. When I see something troubling in a patient chart, I bring it to the physician's attention in a friendly, collegial way; however, the pattern has continued. The physician has an adequate knowledge base, but she is not as thorough and systematic as the other physicians in the practice. Other colleagues have noticed similar problems when treating her patients, and our practice manager has had a formal discussion with her about it. Most of the issues are minor, none have led to major harm to a patient, and I could even see myself making some of the same errors on rare occasions. However, some of her omissions could have potentially caused harm or liabilities. All physicians make mistakes, and I do not want to create a culture where the physicians in the practice are unsupportive when a clinical error occurs. Also, patients like the physician. What is the right balance in this situation?

Commentary

The dilemma in the scenario concerns a colleague who displays a pattern of failing to perform the group's best practices. She does not keep up with health maintenance protocols, and although she sometimes has written plans or orders, her charts often do not include evidence of follow-up. The physician has received informal feedback from her colleagues, and the practice manager has confronted her about the concerns. Although no one has formally proved that the physician is providing substandard care or that a patient has been harmed, the colleague is legitimately anxious about the physician's behavior.

This is an opportunity to develop group policy on feedback, quality assurance, and dealing with uncomfortable issues among colleagues. The next step in the scenario is to review the facts of the situation. Although the colleagues want to keep this physician in the practice, her performance does not meet the standards of the group. The colleagues should clarify what they know, acknowledge assumptions, and identify goals. What specific mistakes were made? How were deficiencies exposed? What are the practice's collective and corrective policies for clinical errors?

Finally, action must be taken. There may be a temptation to avoid confrontation; however, inaction or unsuccessful action undermines the colleagues' commitment to patients and puts the colleagues at legal and professional risk. Before taking action, well-researched and referenced documentation should be collected. Resources are available to help physicians respond to incompetent colleagues.^1–5

The following tips may help the physicians in the scenario with peer interaction:

• Be sure a policy is developed that is fair, equally applied to all physicians in the practice, and focused on understanding and correcting the concerns.

• Decide who will confront the problem physician. Make sure that at least two colleagues are involved in the conversation. Choose colleagues who you know will reinforce the practice's commitment to corrective action and retention of the physician. If needed, a professional facilitator can guide and mediate the conversation.

• Do not dwell on the psychological and metaphysical “whys” of the situation. If the physician wants to reveal personal factors that may help explain her behavior, it is her responsibility to bring them up or to seek assistance. The colleagues' focus should be on guiding the physician in making better medical choices.

• Expect that emotions will run high. Prepare for the possibility that there will be anger or the threat of litigation. Perhaps you can ask a local therapist for role-playing suggestions.

• Prepare the physician by letting her know the planned agenda. Reiterate your intentions, and mention her positive contributions to the practice. Give her reasonable time to respond to the concerns.

• Plan several sessions. Spend the first session listening, not trying to resolve every issue; the goal is to develop a feasible plan of action. Include the physician and her colleagues in proposing and implementing suggestions to resolve the issue. The group should agree on sanctions for this physician and for other physicians in the practice if similar problems arise in the future.

• Implement a plan to deal with legal problems or threats to practice morale when efforts do not resolve risk management issues. The physician's problems put the group at risk of enabling unacceptable professionalism, procrastination (which lowers member morale), and substandard patient care. In addition, there is always the possibility that the target physician may react by leaving or filing suit against the practice.

• Monitor the progress of the physician's behavior, and reward her success. Incorporate the peer-review and corrective-action policies into your practice bylaws. Make sure quality assurance methods are adhered to and applied fairly.

• Commit to a high-integrity culture that is reasonable, fair, and humane. For example, plan a group event that is social, warm, and supportive of a healthy group culture.