I was reading the newspaper and came upon an article that described a physician with a history of mistakes. For those that enter into the medical system, or need to trust that their family will be safe in the hands of physicians, this has to be an absolutely terrifying article. And it is not the first to describe events in which providers were either terribly inept or corrupt. There is also a podcast called Dr. Death that has already had two seasons. I find myself ardently hoping that the production team will not find the material for a third season, but if the podcast is popular then I bet they will find more material. Perhaps they will use the new article for their next case. But there have been other instances of providers doing procedures on patients so they could make money.
The good news is that I don’t believe that Dr. Death represents most physicians, particularly the second season which focuses on a greedy doctor doing chemotherapy on people without cancer. There are other instances of physicians doing this sort of thing, but thankfully this is the exception.
The news article and the first season of Dr. Death represent something more worrisome. These are doctors who are truly incompetent. These cases represent the extreme of problematic physicians, but they show how difficult it seems to be to address even the most obvious cases. If we cannot manage the physicians who are this obvious how can we assure the public that we can manage the less serious cases?
This brings me to the hospital peer review process. Done well, this process can help us find and address physicians who are having competence problems. Events that result in patient harm or other instances in which delivered care may represent a deviation from standard, can be sent to the hospital peer review committee. This committee should have a multidisciplinary group of providers as well as those who are experts in the case being reviewed. This is meant to be a non-punitive quality process that is protected from litigation. The care is reviewed and a determination is made as to whether a standard of care was delivered. Committees need to try to avoid reviewing care with the hindsight that comes from knowing how the case ultimately turned out. The committee can consider systems issues that may have contributed to any bad outcomes. A single bad outcome does not mean that a provider isn’t competent. Doctors are human and will make mistakes. What the committee needs to address is the provider that has multiple bad outcomes within a limited period of time. If this occurs, then the provider can be placed on a focused peer review process in which a variety of cases can be reviewed. If concerns are found then opportunities can be presented for the provider to be retrained so they can regain skills.
This process as described is easy to describe but it is hard to do in practice. Physicians do NOT like having their care questioned. What we do is deeply intertwined with our identity and questioning our care is questioning who we are. Also, if a decision is made to limit a providers privileges while they are being retrained, then they may need to be reported to their state medical boards. This will impact their license. Though it is not the intent of the peer review process, from the doctor’s perspective this will seem punitive. Hard though it may be, we do have a responsibility to the patients we serve and we need to identify physicians who cannot perform at expected levels. We can’t ignore this and we cannot pass problematic providers on to other places. We an approach that is supportive but still with expectations that competent care must be established, it is possible to help providers and keep patients safe. No one need to have their hospital in the news or on a terrifying podcast.