Preventive Medicine and the Seven Deadly Sins: Avoiding Discipline Against your Medical License

Each of these sins reminds me of some truly outlandish investigations, and anger is no exception. Anger rages in a variety of styles. Some cases are predictable, some are eccentric, and a few, with only the names changed to protect the innocent, could be made into movies starring Anthony Hopkins and Jodie Foster.

Let me provide a few examples:

  • A physician became angry with his accountant and hired a hit man to murder him. At the time the undercover police officer consummated the deal, the physician had a change of heart and decided he merely wanted the officer to break the accountant's legs.
  • A surgeon became infuriated with a scrub nurse and hurled blood on her during an operation.
  • Another surgeon graciously offered his services as an assistant during his wife's operation. He sutured his wife's vagina completely closed.
  • A physician under peer review investigation by a hospital surreptitiously (or so he thought) wandered around the hospital parking lot keying the cars of hospital administrators.
  • A surgeon purposely slashed his assistant's hand with a scalpel.
  • An emergency room physician arrested for drunk driving told the officer that if he showed up in the doctor's ER, the doctor would let him die.
  • An attending surgeon grew impatient with a fledgling resident and began throwing instruments in the operating room.

Most of the examples cited above also were criminal violations of law for which the physician was convicted and sanctioned criminally. When physicians are arrested and charged with a felony, or convicted of a felony, the Medical Board is notified. The Medical Board then will investigate pursuant to Business and Professions Code section 2236, which defines the conviction of a crime as "unprofessional conduct."

Specifically, section 2236 reads:

(a) The conviction of any offense substantially related to the qualifications, functions, or duties of a physician and surgeon constitutes unprofessional conduct within the meaning of this chapter. The record of conviction shall be conclusive evidence only of the fact that the conviction occurred.

(b) The district attorney, city attorney, or other prosecuting agency shall notify the Division of Medical Quality of the pendency of an action against a licensee charging a felony or misdemeanor immediately upon obtaining information that the defendant is a licensee. The notice shall identify the licensee and describe the crimes charged and the facts alleged. The prosecuting agency shall also notify the clerk of the court in which the action is pending that the defendant is a licensee, and the clerk shall record prominently in the file that the defendant holds a license as a physician and surgeon.

(c) The clerk of the court in which a licensee is convicted of a crime, shall, within 48 hours after the conviction, transmit a certified copy of the record of conviction to the board. The division may inquire into the circumstances surrounding the commission of a crime in order to fix the degree of discipline or to determine if the conviction is of an offense substantially related to the qualifications, functions, or duties of a physician.

(d) A plea or verdict of guilty or a conviction after a plea of nolo contendere is deemed to be a conviction within the meaning of this section and section 2236.1. The record of conviction shall be conclusive evidence of the fact that the conviction occurred.

-- BUSINESS AND PROFESSIONS CODE SECTION 2236

When a physician is convicted, an investigation customarily will involve obtaining the criminal charging and conviction documents and police reports. We then will invite the physician to attend an interview to provide their side of the event. This information is assimilated into a package that then is forwarded to the Office of the Attorney General where a determination is made whether administrative charges should be filed.

What happens in the above-cited examples when a conviction does not accompany the act that brought the physician to our attention? When it comes to anger, the board has another mechanism by which to insure public safety: the mental/physical examination. This happens frequently in cases where a physician is arrested, but not convicted, for domestic violence. Often the victim of the abuse does not wish to cooperate with law enforcement authorities. Business and Professions Code section 820, however, allows for the board, when good cause exists, to compel a physician to be examined. Section 820 reads: "Whenever it appears that any person holding a license, certificate or permit under this division or under any initiative act referred to in this division may be unable to practice his or her profession safely because the licentiate's ability to practice is impaired due to mental illness, or physical illness affecting competency, the licensing agency may order the licentiate to be examined by one or more physicians or psychologists designated by the agency. The report of the examiners shall be made available to the licentiate and may be received as direct evidence in proceedings conducted pursuant to section 822.

"If the examiners conclude the licentiate's ability to practice his or her profession safely is impaired because the licentiate is mentally ill, or physically ill affecting competency, the licensing agency may take action against the license. This action may include revoking the license, suspending it, placing the licentiate on probation or taking such other action in relation to the licentiate as the licensing agency, in its discretion deems proper."

In many instances, the examining psychiatrist will indicate a physician needs therapy or medication management. The question we then pose is, can the physician practice safely without therapeutic or other types of intervention? If the answer is yes, the matter is closed. If the answer is no, then the board files an accusation so that this condition can be imposed in order to insure patient safety.

Anger has even invented a new classification of doctors, the "disruptive physician." This term has become so commonplace that it yielded about 986,000 hits on a Google search. The disruptive physician is the one who blames everyone except him or herself for everything that goes awry. This is the physician who has tantrums, the one who lambasts nurses for calling with concerns about patients; the one who throws instruments. These individuals can and do impact patient care. They subject themselves, and others, to liability for creating a hostile work environment. They can intimidate nurses, for example, from contacting the physician with a concern about a patient. We've seen several cases where nurses were afraid to contact an obstetrician about a worrisome fetal monitor strip for fear of being ridiculed or chastised. Some of these cases resulted in fetal and/or maternal demise.

I recently investigated a case where the subject was alleged to be caustically abusive to O.R. staff, and especially to the residents he was charged with mentoring. I had no difficulty establishing that this physician was remarkably proficient in spewing insults and bruising egos. My job, however, was to determine whether or not his volatile personality traits imposed on his ability to treat patients safely. In that sense, no correlation could be made. I found it interesting, though, that during the interview, the physician suggested his behavior with residents imparted his prodigious work ethic. He sincerely believed he was teaching the residents to care as much as he did. He admitted he could be harsh but he believed his tactics yielded conscientious and hard-working practitioners. I questioned whether the turmoil he caused in the O.R., the fear his outbursts generated, and the stress of deflecting (or absorbing) his acerbic critiques extracted the best performance from those he was teaching.

As with every sin, we all experience anger. What makes us different is how we respond to it. Could you be considered a disruptive physician? What is interesting about this phenomenon is that those who are disruptive often don't recognize it. I suppose that component of denial can be attached to the unique personality of the disruptive person, but I also believe it derives from the failure of colleagues and friends to communicate honestly when observing behavior that passes beyond the threshold of good taste and decorum. We are often reluctant to confront inappropriate behavior, no matter how destructive it is.

There are numerous anger management courses available to the general public, but the University of California, San Diego has a unique course that addresses anger management for healthcare professionals. It is offered at their Physician Assessment and Clinical Education Program (PACE) and participants receive Category 1 continuing medical education credits. Instituted in February 2005, approximately 48 physicians have participated, most of whom were referred by Medical Executive Committees. If you or someone you know might benefit from this course, additional information can be obtained from PACE's Web site: ucpace@ucsd.edu.

Coming up next: Gluttony.