Doctor/Doctor Relationship
REPORTING IMPAIRED PHYSICIANS
Physicians have as much of a duty to report an impaired physician as they do to report
child abuse. Although enormously confrontational, there is no discretion in terms of avoiding
reporting an impaired physician when the impairment is clear. If you know that another
physician is not functioning normally and may be a danger to patients, the privacy of the
physician is less important than the safety of his patients. This is true whether the impairment
is from substance abuse, a psychiatric disorder, Alzheimer s disease, or an emotional
disturbance.
You should report physicians and students-in-training to their local supervisor first;
report a resident to his program director or department chair; and report a medical student to
his dean or course director. You should report attending physicians to the department chair or
division head. If the attending physician is a self-employed physician in private practice, t en
there is no department chair or division head to which you can make a report. You should
report physicians in the community in private practice to the state board of medical conduct
or the state health or education department. The key is to go to whoever might have authority
over that physician. The lines of supervision are much clearer in the hospital or m medical
school, where there are clear supervisors.
For example, Dr. Smith is an attending in endocrinology that is doing a month as
the attending on the general medical service at King’s County Hospital in Brooklyn.
Unfortunately, his house staff finds him getting lost on the way to the bathroom m the
hospital. In addition, he has no knowledge of general medical practice and he can’t
remember the cases after the residents present them The senior resident on service
mentions this to you and asks your advice about what to do given that Alzheimer’s
might be developing. What should you tell him?
The resident has a duty to report the potentially impaired physician to the department
chair. This will allow for a private, confidential intervention with the attending physician. It
can allow for an evaluation that can determine if the physician is truly impaired. It is possible
that an impaired physician could have a correctable problem that might not otherwise come
to light without this report. In addition, the rates of substance abuse for physicians are the
same as the rates of substance abuse for the general population. Reporting the impaired
physician may be the only way of getting a doctor into treatment for his substance abuse.
Catching substance abuse before patient harm occurs prevents malpractice. The physician
can be successfully rehabilitated and returned to practice.
You only have a duty to report behavior that affects patient care. If a physician goes out
to wild parties but there is no detectable impairment of patient care, this is not something to
report. If a physician likes to get tattoos, use bad language, and ride in a motorcycle gang on
the weekend, this is not something to report. Your duty to report is based exclusively on
behaviors found to have an adverse effect on patient care.
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The bottom line is that it is your mandatory duty to report an impaired physician who
may potentially be a danger to patients. You have the same protections for yourself on
reporting as you do in child abuse, which is that there is no penalty if the report is found to be
untrue as long as the report is made in good faith without malice.
PHYSICIAN DISAGREEMENTS
If an attending physician disagrees with a residents improper management, there is little
problem because the attending physician has the authority to overrule the resident. It is much
more problematic if the resident disagrees with the attending physician.
If the resident finds what may be an error in management with the attending physician,
the USMLE first wants you to answer “discuss”, “confer” or “try to reach consensus with
evidence-based medicine.” If these discussions are not satisfactory, then bring the issue to
whatever is the version of a higher authority locally. The key words are “higher” and
“locally.” Do not go straight to the state medical board, licensing board, or governing body
without first trying to have a discussion with the division head or department chair. In
addition, do not answer “Inform the patient.”
What if the resident is wrong? Disagreements between physicians are handled in much
the same way as the reporting an impaired physician is handled, except that you should
always first pursue discussion with the person with whom you are disagreeing. You cannot
make changes in patient’s care without the attending physician knowing and approving the
changes. The attending physician ultimately has all the responsibly for the patients and has
an absolute right to direct the care of the patients and know what is going on.