Can The AAOS And Its Compliance Program Do More?

1. Can The AAOS And Its Compliance Program Do More? The Disruptive and Impaired Physician Edward V. Craig MD, MPH AAOS Judiciary Committee

2. Symposium: Disruptive and Impaired Physician Edward V. Craig MD, MPH I have no potential conflict with this presentation

3. AAOS Compliance Program And Standards Of Professionalism Background: How We Got Here

4. Where Did The Standards (SOP) Come From? • For Years– AAOS Heard From Members • Through Professional Liability Committee • Need to Address Fraudulent and Misleading Testimony • Fellow Support---Sanction Based Program

5. Background---2002 • BOC—Advisory Opinion To AAOS Board • Resolution—Florida Orthopaedic Society • Need----Professional Conduct Program Regarding Expert Witness Testimony

6. Background --2005 • AAOS Bylaws Established Professional Compliance Program • Appointed Committee on Professionalism (COP) and Judiciary Committee To Resolve Disputes ----The Grievance Process • Standards Of Professionalism (SOP)—First Three Approved

7. Based Upon AAOS Code of Medical Ethics and Professionalism for Orthopaedic Surgeons Standards of Professionalism

8. First Three Standards • Musculoskeletal Services To Patients • Professional Relationships • Expert Witness Testimony

9. Additional SOPs Adopted • 2006 – Research and Academic Responsibilities • 2007Advertising by OrthopaedicSurgeons • 2007OrthopaedicSurgeon-Industry Conflicts of Interest

10. Grievance Process • One AAOS Fellow Can File Grievance Against Another • Violation Of Any Standards • Multilevel Process---Culminate AAOS Board

11. Allocation of Board Time---Program

12. . Program Operating Expenses • Professional Compliance Program Budget includes: • 2011 budget - $1M for litigation expenses • Initial proposed 2012 budget $1M for litigation expenses Program: Time Consuming and Expensive

13. Official Disciplinary Actions Reported To: National Practitioner Data Bank (Suspensions and Expulsions Only) State Licensing Boards ABOS State Medical Societies and Associations Grievance Process--Sanction Based Program

14. Professional Compliance Program ….and Reported to Fellowship:

15. Judiciary-Non SOP :Loss Of Medical License by Fellows • AAOS Surveillance System • Fellow—Need To Have License Unencumbered, No Restrictions ( State Action: Impairments- Drugs, Alcohol) • Any State Disciplinary Action—Considered A Restriction, Subject to Compliance Action—Including For Disruptive Behavior • Usually Suspension

16. Medical License Loss- Substance Abuse • Most Difficult For Judiciary---Illness, Volitional, in Treatment or Not, Complying With Aftercare, etc. • Each State has Differing Response--- Judiciary Can Consider

17. Extent Of The Problem—Among Physicians • 8-12% Will Develop Substance Abuse Problem at Some Point Career • At Any Given Time Up To 1 in 20 (3%- 7%) are Active Substance Abusers • Left Untreated 17% Mortality Rate Independent—Age Range,Geography Urban/Rural

18. Incidence By Medical Specialty • No Specialty Immune • Emergency Medicine, Psychiatry, Anesthesiology Slightly Higher Incidence—

19. Archives of Surgery (2012)—Survey 27,000 • 15.4% had a Score on Alcohol Abuse Identification Test ( Abuse or Dependence) • Correlation –Alcohol Abuse or Dependence • Major Medical Error Prior 3 Months • Surgeons Who Were Burned Out • Surgeons Depressed • Emotional Exhaustion • Having Children, Working for VA—Lower Likelihood

20. Cicadas—Substance Abuse Among Physicians Hospital Medicine, 2003 Risk factors • Parallel General Public • Strong Familial Association • Psychological or Psychiatric Disorders • Unique to Physicians • Self Treatment with Prescription Meds • High Stress or Long Hours • Access to Controlled Substances

21. Other Risk Factors • Smoking One or More Packs/day • Multiple Affairs or Marriages • History Multiple Jobs in Multiple Communities • Academic Medicine Cicadas—Substance Abuse Among Physicians Hospital Medicine, 2003

22. Archives of Surgery- 2012 • Alcohol Abuse and Dependence “ a Significant Problem” • Suggested Organizations-ACS, AAOS Develop Early Warning and Intervention Programs

23. Are We Doing Enough? • If Statistics Correct--- In USA: 2,500-3,700– Current Orthopaedic Surgeons will Develop Alcohol or Substance Abuse Problems—At Some Point in Career

24. Physician Health Programs ( PHP) • Most States Have—Identification, Treatment , Support—Non Disciplinary • Confidentially: Deal With Abuse Issues • 17% Orthopaedic Surgeons Practice in States That do not Have PHP ( 5,308 surgeons)

25. Consequences—Depend On State Where Fellow Practices • PHP states—often not come to state licensing board ( Confidential-Treatment) • Non PHP States– state licensing board, discipline, license loss, public disclosure, AAOS Compliance • Potential exists for groups to be treated differently by AAOS

26. Judiciary Committee Actions • Disciplinary Action- Guiding Principles and Special Considerations • Generally Not “Second Guess” State Licensing Boards • Special Cosiderations- No Compliance Action Pending Treatment Program—Therefore Not Reported

27. Should AAOS Do More ? • Recognize Widespread Nature— • More Publicly Acknowledge and Discuss • Education—Fellows, Residents

28. AAOS---Education on SOP • Annual Meeting- ICL, Symposia • Publications—AAOS Now, OKU • On Line Module- Requirement For Membership • Module—Residency Training

29. Disruptive Physician Behavior • Medical errors • Adverse outcomes • Cost • Personnel Loss • Litigation Orthopaedics—4th Highest Field Prevalence

30. Problems • AMA—established definition Disruptive Behavior • Surgeons—Disagree What Disruptive Behavior is in Practice ( Interpretation) • Survey 110 Surgeons • 9 behaviors disruptive by national organization • 4 classified as disruptive by surgeons JBJS 93 A Orthopaedic Forum, 2011

31. Does Compliance Program Deal With Disruptive Physician? • State Licensing Surveillance: Disciplinary Action—Disruptive • S.O.P.--Professional Relationships • S.O.P.--Musculoskeletal Services To Patients One Fellow Must Bring Complaint Against Another

32. Potential Problems—The Slippery Slope • Hospital By Laws—Code of Conduct • Complaints– Peer Review Process • Potential ” Sham Peer Review” • “Disruptive Physician” Code Word—Vendetta, Competition— Potential Weapon • State—Disciplinary Action—NPDB, AAOS considers License restricted

33. Williams BW, Swiggart WH, Ghulyan MA, Vickers, K, Williams MV Spectrum of Disruptive Behaviors Aggressive Passive Anger Outbursts Profane/Disrespectful Language Throwing Objects Demeaning Behavior Physical Aggression Sexual Comments or Harassment Racial/Ethnic Jokes Passive Aggressive Chronically late Not responding to call Inappropriate or inadequate chart notes Derogatory comments about institution, hospital, group, etc. Refusing to do tasks

34. AAOS—Documents Limited Disruptive and Impaired • Acknowledge Issues • Code of Medical Ethics • Standards Of Professionalism • Musculoskeletal Services • Professional Relationships

35. AAOS--Comprehensive Position Statement( Disruptive Physician Behavior) • Defining Disruptive Physician Behavior • Facilitate Reporting Protocol • Ensure Fair Evaluation and Management Standard— Medical Centers—Increase Patient Safety JBJS 93 A Orthopaedic Forum, 2011

36. Summary PCP is An Ethics Compliance Program SOP’s Define Levels of Acceptable Conduct What To Do With Impaired and Disruptive Physician Issues ? Goal – Achieve/Maintain a High Level of Professional Behavior by AAOS Members---How? Role of Education?

37. Thank You • Rick Peterson--AAOS • Melissa Young--AAOS • Murray Goodman—Chair, COP • Richard Schmidt—Chair, Judiciary • Michael Parks—Past AAOS Board