The head of the intensive care unit comes to see you as head of your department, concerned that one of your staff has a high treatment complication rate. They want you to immediately restrict the staff’s privileges. How do you ensure that the criticisms are correct and what is the appropriate response to the allegations?
Competency of physicians is one of the most difficult areas to establish with certainty. Unfortunately, complications and adverse events, the most frequent precipitating concern(s), are all too common in medicine. Furthermore, even competent physicians are prone to situational biases that may lead to poor decisions with terrible outcomes that are not often, or necessarily indicative of, incompetence. The issue of determining competence is further complicated by institutional desire for open reporting of serious safety patient events (with the hope of learning and improvement in safety). Open reporting of events is likely to be seriously impeded if investigation of competence becomes a frequent outcome of reporting. Despite these issues, and while infrequent, incompetent physicians may exist and institutions have an obligation to respond to this possibility.
Several triggers may prompt consideration of competence, including adverse outcomes identified through morbidity and mortality rounds and/or safety reports, patient or staff complaints/concerns, multi-source feedback and/or serious safety patient-incident investigations. There are several steps you need to take before an issue is raised. First, institutions need to formalize what constitutes a “trigger” for an investigation. Next, the process for investigation needs to be explicit. Finally, specify potential responses to the outcome of any investigation clearly. Patient safety is paramount and if patients are potentially at risk, the physician’s practice may need temporary, partial or full restriction until the investigation is complete. While there should be a low threshold for suspension of privileges (or a clinical service if the concerns are for an entire group), this step should not be taken lightly. Any policy must consider what constitutes reasonable grounds for suspension, who is involved in the decision to suspend, who makes the final decision, what aspects of clinical activity are to be suspended (e.g. inpatient and/or outpatient), how the decision is communicated to staff and patients and finally, what is/are the actions required to lift the suspension?
Legitimate concerns about competency require an investigation. The process for investigation of potential incompetence needs to consider the context of the event or events. As noted above, the investigation also needs to consider possible situational biases leading to the poor decision(s). This latter point often revolves around the question of whether other clinicians in similar circumstances might make a similar decision or take similar action. The investigation, can be internal, but often should be conducted by individuals external to the organization to get an unbiased view. If the concerns are major or litigious, then an external review is compulsory. The clinician being investigated must have appropriate assistance, including emotional support and legal advice. In the process of the investigation, issues of competency, such as substantial abuse and/or mental illness may arise. Such issues require separate processes (look out for my blog post, dealing with the subject of Capacity). Provide clear guidance for the reviewers with the terms of reference, specifically scope for the review process. Reviews may focus on a particular concern, but important information to inform an investigation might include morbidity and mortality rates, patient complaints with random chart reviews. Finally, any events that cause concern should be examined in terms of peer and external benchmarks.
If the investigation concludes that the clinician is incompetent in some regard, the initial focus should be on remediation in areas identified as deficient, such as knowledge, skill and/or judgment. Major incompetence may require temporary (to allow remediation) or permanent (if remediation not possible) restrictions of privileges to protect patients. With restriction of privileges often comes an institutional responsibility to report to licensing bodies.
In summary, incompetence is a rare issue that requires formal attention. Focus needs to be on protection of patients and remediation of the individual.