A sad-eyed pediatrician sits in a sparsely furnished office in a Denver suburb, hoping to resuscitate a career that has spun wildly out of control. Suspended from his practice after a series of medical errors in a case that ended with the death of a child, the middle-aged physician is the latest reluctant client of the Institute for Physician Evaluation, the nation's biggest salvage yard for problem doctors seeking redemption.
After nearly three days of tests and evaluations, Dr. X-who practices in a large city in the Western U.S.-will receive a customized plan for rehabilitation that includes a yearlong regimen of mentoring, retraining and extra education. Once the program is successfully completed, the doctor can return to his practice with a clean bill of health.
The 2-year-old institute-comprising a cluster of six small offices in one corner of a modern office building in Aurora, Colo., a large suburb west of Colorado's capital city-is not empowered to punish bad doctors, suspend their licenses or force them from practice. Instead, its somewhat controversial mission is to help physicians recapture the skills necessary to practice good medicine, a goal designed to serve both the doctor and society as a whole, institute officials say.
Indeed, this early intervention makes perfect sense for hospitals and other providers that refer problem doctors in a last-ditch effort to avoid career-threatening disciplinary action, says the institute's executive director, Elizabeth Korinek.
"It's a question of whether they can salvage a relationship with a physician and maintain an important resource in the community at the same time they're keeping patients safe," Korinek says. "We're trying to provide a win-win solution here."
The institute, which has evaluated about 70 physicians during its second full year in existence, is the model for a proposed nationwide network of similar programs that will work closely with hospitals, medical groups and insurers to identify and help doctors whose clinical skills or judgment are called into question. Officials with the National Board of Medical Examiners and the Federation of State Medical Boards, which have joined in a partnership with the institute, believe there's enough demand to warrant as many as four or five sites across the country.
"We think we have the opportunity to create partnerships (with hospitals) in early intervention before patterns arise," says Tom Henzel, program manager with the Philadelphia-based NBME. "But we need to get past this punitive issue-we want to get to the point where the hospital and doctors are really working together. Recertification is becoming more and more common. All sorts of other forms of checkups for doctors are coming right behind. The institute is just another type of checkup."
In a way, it's like a drug-rehabilitation program, providing the impaired client with a way to re-establish a normal life. But it's not wholly voluntary. These doctors are sent to this institute and others like it for a clear reason: They've done something wrong in their practices. In most cases, though, their transgressions aren't serious enough to warrant public action by a state medical board-as long as they complete a course of remedial education.
Still, some critics wonder whether the institute treats only the symptoms and not the disease, helping bad doctors sidestep the most severe forms of discipline and essentially escape any real punishment. About one of every four clients of the institute is referred by state medical boards, which have wide discretion to impose much tougher punitive measures than a course of remedial education, including revocation of a doctor's license to practice.
"The idea is that the doctors are educable, and that you can teach them (to be better doctors)," says Sidney Wolfe, M.D., director of Public Citizen's Health Research Group, Washington. "Well, where's the evidence? This kind of a program is worrisome because, in some ways, it seems to avoid disciplinary actions by having you take this course (of additional education). If a doctor is doing something so seriously wrong that it bespeaks the need for education, you really need to demonstrate that you've learned something. It's one thing to do it on paper; it's an entirely different thing to put it into practice with patients."
Critics such as Wolfe, who has argued for years that state medical boards are grossly ineffective, say these kinds of programs will only contribute to the perception that state overseers are rarely aggressive in meting out punishment to incompetent doctors. Wolfe, for one, thinks educational programs are little more than a slap on the wrist to doctors whose misdeeds often merit much harsher sanctions.
In 2000, for example, state medical boards imposed a total of 3,951 punitive actions against the 676,522 licensed practicing physicians in the U.S., according to an annual survey prepared by the Euless, Texas-based Federation of State Medical Boards. Some of those involved multiple actions against individual physicians. All told, state medical boards stripped the licenses of just 1,725 physicians, or about one-quarter of 1% of all licensed doctors.
Dale Austin, the federation's chief operating officer, vigorously defends the work of state medical boards, saying they protect the public by disciplining doctors who are clearly unfit to practice medicine. Institutes such as the one outside Denver, he says, help supplement the oversight of doctors who fall into a "gray zone."
"Medical boards do an excellent job in dealing with the really bad characters-those individuals who should have their licenses revoked or suspended," Austin says. "With this (evaluation and education) program, we can identify what a physician needs to perform the job. I don't think that's protecting physicians or shirking the responsibility of the board (of medical examiners). That's zeroing in on the problem, making the rehabilitation specific to that individual. Of course, it doesn't feed into this 'notch-in-the-belt' mentality that you have to have an X number of actions or revocations in order to prove you're doing what you're supposed to do to protect the public. It's not the goal of medical boards to revoke licenses."
Austin and officials at the Institute for Physician Evaluation are confident that mounting concerns about quality of care will only reinforce the need for early-intervention programs.
A recent study in Canada, for example, indicated that as many as 10% of all practicing doctors need some type of a comprehensive evaluation of their educational and clinical skills. No similar study has yet been conducted in the U.S., institute officials say. But even if only 3% of the practicing doctors in the U.S. need some sort of fine-tuning, that would amount to about 21,000 physicians, each one a potential customer of the institute or its progeny.
Martha Illige, M.D., the institute's medical director, won't hazard a guess about the specific numbers of doctors in the U.S. who might need some level of remedial education. But she says it's definitely higher than the relatively small number of clients who have trickled into the institute during the past two years.
"However, you might guess at the true need for this kind of a process," she says. "This one center alone could never meet it."
Austin says he's sensing a growing recognition of the effectiveness of this assessment tool by hospitals, managed-care organizations and medical groups judging the process as a way to help individuals "long before they get in trouble with the medical board."
Assessing the patient
In the case of Dr. X, a managed-care organization suspended him from practice in his group and ordered him to undergo the comprehensive evaluation after a series of mistakes. In one case, a child he was treating died after he missed a diagnosis of a rare condition.
The physician will undergo 21/2 days of tests, interviews and clinical assessments in the most important crucible of his professional life. Asked what he expects of his forced involvement in the program, Dr. X pauses briefly, then replies, "Hopefully, an unbiased look at how well I practice."
His mood and reaction are fairly typical of most doctors forced to endure what is generally regarded as a humiliating and punitive inquiry into their professional skills. He agreed to be interviewed and observed during his evaluation on the condition that he remain anonymous.
"The stakes are high," Korinek says. "Very rarely does anybody come here because they want to. They're usually here because there's a very good reason. They come in either a little defensive or very defensive. But many of these doctors leave saying they feel they've been treated fairly."
Underscoring concerns raised by Wolfe and other critics, Korinek acknowledges that only a small percentage of the doctors who enter the program are ultimately removed from practice.
"This is an educational intervention," she says. "If we see a doctor who we feel is a danger to patients, we'll report (him or her). We've done it three of four times."
On average, she says, about 10% to 20% of the physician-participants are given the green light to continue practicing medicine without any supplemental educational program at all. About 30% to 35% are found to have slight deficiencies in a few areas of medical knowledge, requiring a modest level of remediation, while another 30% to 35% need a much more in-depth educational plan to address "broader-based" concerns about their clinical skills, Korinek says. In about 10% to 15% of the cases, she says, the institute's examiners determine that the physician has "global deficiencies" in most areas and should either leave medicine or enter a residency program. But the ultimate decision on the physicians' fate is left to the referring agency.
"A lot of organizations do outside peer review," Korinek says. "That is not our purpose. (Clients) seek our assessment and try to find a solution to the problem that is not litigation."
Korinek freely acknowledges that the institute is not designed as a vehicle for disciplining doctors. The program itself and the follow-up education are both voluntary.
In the case of a physician in private practice, usually referred either by his fellow doctors or an insurer, a refusal to attend the assessment program would likely end in dismissal and a referral to state officials; a state medical board, meanwhile, will initiate its own action against a physician who refuses to report to the program. In one recent case, for instance, a physician referred to the institute by his group practice in western Colorado rejected the remediation plan, quit the group and formed his own private practice. The state medical board reportedly is conducting an inquiry.
"We would investigate this like any other case," says Susan Miller, program administrator of the Colorado State Board of Medical Examiners. "And if our investigation confirms substandard care, we would take action." Miller is prohibited from providing details of an ongoing case.
The results of any evaluation, meanwhile, are not reported to any official authority, including the National Practitioner Data Bank in Washington, the nation's most comprehensive compilation of disciplinary actions against doctors.
"We have never been an advocate for physicians," Korinek says. "But we're set up to help physicians. If a hospital has information that a physician shouldn't be practicing, then don't send them here. This is a place to help them remain in practice. Our role is to have expert witnesses render opinions."
A few other providers
The institute isn't the only organization of its kind to focus on substandard physicians. Others that spotlight clinical skills are based at the University of Florida's Harrell Center for Professional Development in Gainesville; the State University of New York's Health Science Center in Syracuse; the University of California at San Diego; and the Oregon Medical Association, which operates the Individualized Physician Renewal Program in Portland. Last year, the Brody School of Medicine at East Carolina University in Greenville, N.C., shut down a clinical-enhancement program that had operated for about eight years, in part because it was not cost-effective.
The University of Wisconsin School of Medicine launched one of the first physician-assessment programs in 1965, providing evaluations along with a tailored remediation plan.
Unlike the increasingly common physician-health programs, which deal with drug and alcohol abuse, this handful of organizations, like the institute, is designed to help deficient doctors update or upgrade clinical skills.
The idea is to get these essentially good doctors back to work, fixing the problem before it becomes unmanageable.
Richard Roberts, M.D., a family practitioner in Belleville, Wis., and the board chairman of the American Academy of Family Physicians, worked with the Wisconsin program for several years, examining the medical records of problem doctors. In many cases, he says, the best way to deal with marginal doctors is to provide enough education and mentoring to improve their skills.
"The public makes a huge investment in doctors, in terms of how public tax dollars go into training them," he says. "A community comes to depend on doctors. It doesn't serve the public well to simply yank a guy's license. Doctors want to do better. I have yet to meet a doctor who aspires to incompetence. Are you going to throw them away at the first sign of a problem? These kinds of assessment programs represent a natural evolution of improving physicians' performance."
Created in April 2000, the institute operates in conjunction with Colorado Personalized Education for Physicians, a not-for-profit program formed in 1990 by a coalition of medical groups. It created a new alliance in April 2000 with the two national organizations of medical boards that perform various assessment and licensing functions for physicians, including testing every medical school graduate through the United States Medical Licensing Exam.
The institute, together with the CPEP program, stretches over 2,300 square feet of space in an office that employs six employees who work full time at both programs. The institute assessed 44 doctors in its first year. That number is expected to increase to slightly more than 70 for the second year, an indication, Korinek and others say, of a growing market.
"We think we're very much underutilized," Korinek says.
Those numbers are lower than once forecast, but Austin remains confident that demand will ultimately lead to a network of four or five similar independent, not-for-profit institutes. It's not clear at this time whether this prospective network might include one or more of the existing programs at places such as the University of Wisconsin.
But Austin's optimistic view is not shared by Roberts, who believes there is a limited need for such expensive, elaborate programs.
"I don't know that the frequency (of clients) or the economics will pan out," he says. "You don't need a bazooka to shoot a fly. I do feel it's a good thing. But when you do a reality check, there might not be a market."
The Denver-area program isn't cheap. The price tag for the assessment is $7,500, not including costs associated with the follow-up educational plan, and these can vary widely. But the total tab, Illige says, seems like a bargain compared with the often hefty sums involved in the long legal processes aimed at dealing with problem doctors. Proponents of the institute's framework believe that persuading a physician to participate in an assessment and re-education program will almost always help avert costly litigation.
Says Austin: "Typically, how this ends up playing out (with a problem doctor) is that they come before an executive committee of the medical staff and lawyers. It might be wiser, early on, to have that physician referred, and spend the money to have the assessment done and get a true, clear picture: Can this problem be fixed or not?"
Richard Wade, spokesman for the American Hospital Association, says the institute's framework "has a lot of strengths" as long as it does not undermine the role of state boards of medical examiners in disciplining bad doctors. "This could be enormously helpful for hospitals," he says.
The institute evaluates physicians in four areas: medical knowledge, communication skills, problem-solving and patient documentation. In addition to a battery of examinations and interviews during the two- to three-day assessment, which includes computerized motor-skills tests, physicians such as Dr. X are videotaped and graded during simulated office visits with actors who portray patients with medical problems.
Participants also must provide experts with 18 to 20 of their own medical charts, which are systematically reviewed during a series of 90-minute question-and-answer sessions. Evaluators use the charts to modify symptoms and circumstances, asking the participant how they might deal with these changes.
"It's a tense situation," says Robert Lederer, M.D., the institute's associate medical director for assessment. "It's not like their oral boards. This is a dialogue on how you would manage a patient. It's very easy for our consultants to pick up quality-issue deficiencies."
For his part, Dr. X remained defensive and angry throughout his assessment. In an interview near the end of his evaluation, he told Modern Healthcare, "I don't think I deserve to be here. I missed a diagnosis on something that is extremely rare. I'd never seen it before. And the patient did die. Whether the patient would have died anyway, I don't know."
He called himself a grudging participant in the critical assessment of his clinical skills, trying to make the best of what he clearly viewed as a very bad situation.
"My reaction: Let's get on with the process," he says. "I don't want to be here, but if we've got to do it, we've got to do it. I consider myself a good doctor."
Like most of the physicians in the program, Dr. X is not severely punished or disciplined despite the missed diagnosis that may have led to the death of a young patient. There is no record of any disciplinary action ever being taken against him by the state board of medical examiners.
Yet, after the evaluation, Dr. X is found to be lacking a "deep knowledge base" about a number of key clinical issues. To rehabilitate his practice, he is asked to undergo a yearlong educational program that involves twice-monthly reviews of his cases by a preceptor. That person was chosen by Dr. X but approved by officials at the institute. They say that any bias in the choice would be uncovered during reviews by outside experts who routinely review the cases. Dr. X, who also must take continuing medical-education classes, has chosen to try to improve his skills by working a series of shifts at a pediatric hospital near his home. After three months, the prognosis looks good, institute officials say.
Like many participants, Dr. X is left with a grudging appreciation of the "tiring, emotionally charged" evaluation process, along with the huge impact it will have on his own life and career.
"Sure, I was defensive," he says. "It was a little awkward. But I don't disagree with the overall process. Having been an administrator, I can see how this could be a useful tool. At least it's as objective as you can get in something that is not an exact science. And I don't think medicine is a science to the point that you can practice perfectly. There are things that happen that are totally unexpected. Hopefully, you make as few mistakes as you can. I challenge any physician to tell me the unexpected hasn't happened to them."