August 1999 Bulletin

Focus on 'troubled physician'

Workbook, monitoring focuses on residency training

There was no doubt about his skill as an orthopaedic surgeon; no doubt at all about his technical skills. But his behavior was something everyone questioned.

He ranted and raged at office staff and operating room personnel, denigrated his colleagues, inappropriately promoted himself and may not have always been truthful.

He's a hypothetical example of a so-called "troubled physician" whose personal and professional behavior not only affects his practice, but also gives a "black eye" to the entire profession.

"It's a problem of the affective domain," says Scott B. Scutchfield, MD, chairman of the Academy's Task Force on the Troubled Physicians. "It's honesty; dependability; interrelations with other doctors, staff and patients; responsibility. It stops short of sociopathic behavior."

The problem often surfaces in residency training and carries on throughout a career. Dr. Scutchfield dismisses a suggestion that it may be the result of the pressures of residency training. "It's probably a personality defect in certain individuals, who are very smart, but lack ethics."

The task force called it "a significant problem" which could involve up to 10 percent of those completing a residency program. To find solutions to the problem, the task force was formed with members from the American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Academic Orthopaedic Society and Orthopaedic Residency Review Committee (RRC).

While the problem is recognized during residency training, the task force said solutions are extremely difficult because of the lack of knowledge of remedial action and due process and the legal ramifications.

The fear of a legal challenge for removing a resident from a program, barring a physician from certification or admission to a professional organization is a potent ally to the troubled physician.

The task force said the residency application process is ineffective in identifying problem physicians, and "residency education is not effective in emphasizing the need for ethics and appropriate behavior and is certainly far from uniform." Educational resources are available, but the task force said the resources are not being used effectively.

"There appears to be no method to hold orthopaedic residency programs accountable for the problem residents who complete their training in their particular program," the task force said. "There appears to be no mechanism for tracking the problem nor follow-up on alterations in the system directed to correct the problem. Because of the many difficulties in dealing with this problem, no one wants to assume responsibility for its management."

The task force recommended the development of a workbook in conjunction with the Academic Orthopaedic Society for distribution to program directors. Dr. Scutchfield said the workbook would inform directors of the best way to screen applicants; methods to evaluate residents, particularly in the first two years of a program; remedial actions to take to correct a problem; and, if not successful, how to remove the resident from the program "legally."

A monitoring program involving the membership committee of the American Association of Orthopaedic Surgeons (Association), American Board of Orthopaedic Surgery (ABOS) and RRC also was recommended. The membership committee would monitor statistics on residency programs that produce problem residents. The ABOS, once it received legal clearance, would establish a monitoring program that would be coordinated with the membership committee's monitoring program. The RRC would respond to information from the monitoring programs by informing specific residency programs there is a problem.

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