Poor Physician Performance: Causes and Remedies.

As with all professions, poor performance of doctors is a critical component to poor otucomes for patients in the health care system.

The major categories are: incompetence, age-related degeneration, alcohol-abuse, drug abuse, hostility.

I include in the category of competency a number of factors: straight-up incompetence, poor physical skill, lack of knowledge, and too fast through-put of patients. One thing that is pervasive and is generalized throughout health care and everything else is: the amount of information in health matters is complex, getting more complex, there is a failure rate in everything for a multitude of reasons, and sometimes simply bad outcomes happen.

Most of the factors are however controllable, but it generally relies on senior administration taking a vigilant role in protecting patients. This has generally not been done well anywhere.

The legal system has been a major impediment- incompetent doctors can sue the employer, and employers don't want the bad PR, expense or stress. So the fall back has been, as with gun control, 'thoughts and prayers', hoping somehow the problem will just go away. Poor manual skills pertains to physicians doing operative procedures, jus like painting, making a dress, or other physical skills, some people are very good, many are average, and a sizable percent 10-30% are simply just not technically good. Historically, a number of patients have overcome this issue by knowing a doctor in that health care system and asking "if it were you, who would you see". Most patients however are not that fortunate to have a friend physician in the health care system in question. Administration vigilance in the findings of Morbidity and Mortality (M and M) conferences would correct much of this issue. Too my knowledge, this has generally not been vigorously pursued. Added to the above list, it is also time-consuming to pay attention to trends. This obviously has to be improved.

Lack of knowledge at least has been addressed in a blunt instrument way by many state medical societies insisting that physicians show evidence of maintaining learning through years of practice,with Continued Medical Education types of programs. This has some real benefit, the problem is there is no guarantee that the CME training a doctor is performing has has any relevance on what they are doing, and also does not generally verify that the doctor has learned actually anything. But nonetheless effort is made into this.

Some of the more tragic cases of too fast patient through put are surgical removal of the wrong thing. The most common of these probably has been the removal of the wrong leg. Less common but more deadly, removal of the wrong lung: eg: taking out the healthy lung and leaving behind the lung with cancer that was supposed to be removed. Transplanting incompatible lungs, heart, liver, etc. Inadequate or incorrect cleaning of instruments. All of these are mainly related too trying to work too fast and being sloppy. Over the last decade one important implementation in surgery is having a time out period of a minute or so, before committing to doing the surgical procedure, eg: making sure you are cutting off the correct leg. In addition other stupidity preventing measures such as pre-operatively labelling the leg as the leg to cut off.

Age-related dementia/ degeneration in general is related to incompetence, but is different, insofar-as the physician may at one time been competent, but now because of the development of dementia, tremors, mental health, other forms of physical and mental loss of competency, they are no longer competent to treat patients. The most common important scenario is where surgeons have now developed a severe tremor, and should not operate, or severe dementia, and again should not operate. A major case of this recently reported in Florida. Some institutions have used a blunt instrument to deal with this issue. Duke for example does not pay for medical insurance in physicians older than 65 to practice medicine. Clearly the major lacking protection for patients is the hesitancy to report on a colleague, or higher station health care worker, for fear of retaliation. This fear is unfortunately well placed, because the assumption is generally correct, it is more likely that the individual reporting poor performance by another colleague is disciplined, or worse, fired, than the actual perpetrator.

Alcohol abuse is one of the most preventable of the poor physician performance (P3) factors, and yet is controlled for with variable level of administrative interest among centers. In part it is not uncommon that the physicians who are alcohol impaired at work are among the most senior in the medical system. Historically and to the present day, there has been great hesitancy among administration to do much about it. Probably cronyism, in its timeless good old fashion way is the principle cause, in addition to the lesser evils of not wanting conflict, especially if it a friend, and the more modern, not wanting to get sued. In some areas of medicine maybe have some alcohol on board may help the physician, eg: psychiatry, but in fields that involve direct patient surgical care and entering the body with some devise, no level of alcohol is acceptable. In my estimation this is the most important cause of P3 that is readily preventible. There have been many errors committed, and covered up because doctors operated drunk., My understanding that the University of California system has a SWAT team strategy where if a health care worker suspects someone is impaired by alcohol or drugs they can call a number and a SWAT team will quickly go to the scene and test the health care worker in question. Approximately 20 years ago the Centers for Medicare and Medicaid enacted legal action against universities for not having attending physicians doing the procedures, importantly surgical/ interventional procedures, but rather having the physicians in training, for example surgical residents., doing most or all of the procedures. From my present vantage point, having developed a fair amount of knowledge of the occurrence of alcohol impairment in attending physicians, the unintended consequence of this change in. practice, is more patients may now be operated on by drunk senior doctors and have worse outcomes. One career objective I have (beyond GDD) is to make a major impact in the turning a blind eye to doctors operating drunk, mainly by focusing on holding senior administration accountable.

Drug impairment is less of a problem than alcohol impairment in physicians in general. The one exception being anesthesiologists, simply because they have direct access to the most potent drugs, such as fentanyl. A SWAT team approach would manage this problem.

Hostility is a huge problem in Medicine as it is in all aspects of modern US society. In all areas of modern life hostility has become a major impediment to quality outcome. By far the greatest perpetrators are men of all cultures. There are 3 basic personality disorders that contribute to hostility: 1. hostile personality disorder; 2. narcissistic personality disorder spectrum, including sociopathy, 3. psychopathy.

Among the 3 hostile personality disorder is the most common, with the most common phenotype presently, the gun-loving, trigger point explosive anger male. There is presently in US society the great concern that it is difficult to know when they go from simply a gun-loving, hostile, solitary, nut, to a killing spree devil. Not only these more overt types, but there is a large silent mildly misogyniist herd of males, which are often herd-like especially when young and physicians-in-training, and more often solitary predators when older. These are the now infamous characters that have been in the news as gynecologists, though are not hostile personality types but narcissists: essentially cultured in the male patriarchy of medicine from decades ago that still persists today. Perhaps the strongest control of this has been happening, incidental to trying to combat it, the more women in Medicine the smaller the opportunity for female harassment and assault. These still occur and must be vigorously pursued. Here again the critical point is to hold senior management equally responsible for the abuse to the ground floor perpetrators. Narcissists and sociopaths do not look to inflict harm on others, they are simply indifferent to it, Physicians with hostile personality disorder act like a poison to the entire work place environment. They must be eliminated quickly form the health care system, when their conduct is recognized, so as not to compromise the care of the entire department.

Psychopaths carry the greatest allure, simply because true evil is somehow mesmerizing to the public. Unlike sociopaths, true psychopaths are looking to cause harm and death in patients. True psychopaths in medicine are rare, because although they are frequently intelligent, their thinking is often so involved in causing destruction and inflicting harm they lack the patience to be able to study for so many years and get such high grades to become medical doctors.. It is exceedingly difficult to compartmentalize those two distinct patterns of thought. That is why the champions of psychopathic killing of patients are held by nurses, where training is neither so lengthy, arduous or require as high grades. So the recent psychopath nurse in northern US states who killed more than 100 patients, and the German nurse from a few years back who also killed more than 100 patients, likely hold the gold medals in number of deaths killed by psychopaths in medicine,. Nurses also have the advantage in murdering in that they have longer contact with patients, and are much more often alone with them. Despite my highly compassionate nature, the most sever of punishment must be dealt to the perpetrators. Also it is critical that severe punishment must be dealt to the administrators who either turned a blind eye to it, or who covered it up.

The above provides a brief summary of the types of poor physician performance.. Among all of them, probably the largest silent killers are drunk doctors, age-degenerated physicians, and hostile personality disorder doctors. The failing in health care, as in all other professions, has been that the role of inattentive, ignoring or covering-up senior administrators has been overlooked and not addressed. What needs to happen is senior administrators need to be held fully accountable for the poor performance of the faculty. Legal suits against them and prison time, the latter especially when they have allowed patients to be killed, and have overlooked The critical present step is to hold senior administration fully accountable, when poor physician performance has gone unchecked. All systems need to adopt a SWAT team approach, that impaired physician be caught on the spot in the hospital system.

Richard Semelka, MD