Peer review: New program helps rehabilitate problem physicians

Hospitals can avoid messy revocation of privileges

A Colorado program that has proven successful in assessing problem physicians and helping them overcome their shortcomings now is being rolled out on a national basis, offering health care organizations an option short of revoking a physician’s credentials. Advocates of the program call it a constructive way to help physicians whose credentials are in question but whose careers might be saved with an in-depth assessment and retraining.

Physicians in Colorado have had this option available for 10 years, but in the past year it was incorporated in the Philadelphia-based National Board of Medical Examiners’ (NBME) Institute for Physician Evaluation (IPE). That means any physician in the country can participate, though the national rollout is still moving slowly. The NBME hopes to have the program available in several centers throughout the country, but for now physicians have to travel to the original site in Aurora, CO.

The program is intended to help physicians who need a thorough assessment of their medical education, practical skills, practice management, and overall clinical performance. For most, the program becomes an option when they are in danger of losing their privileges due to medical errors or complaints of incompetence or impropriety.

For a smaller number of physicians, the program can be useful when they are seeking to take on new responsibilities, such as a family practice physician who wants to move into pediatrics. The assessment can help the physician and privileging hospitals determine whether the physician is ready for that move.

In Colorado, the program is known as Colorado Personalized Education for Physicians (CPEP); the national program is the IPE. The IPE provides essentially the same services on a national scale that CPEP has offered for years, but under the auspices of the NBME.

The IPE program is not yet well-known among peer review professionals, but it should be of great interest, says Martha Illige, MD, medical director of the program and an assistant professor at the University of Colorado Health Sciences in Denver. She says the program fulfills a need for thorough assessments. "Medical practice is very complex, and no one single test with a pass/fail is going to tell you whether this person is competent or not," she says. "We have to look at medical knowledge, the ability to apply that knowledge, patient care documentation, communication skills, even interpersonal relationships. That’s when you’re going to get a real idea of what’s going on with this person."

The IPE program is more comprehensive than any other assessment program that has come before it, says Peter Scoles, MD, vice president for assessment programs at the NBME. The group hopes to make IPE a nationally recognized standard for assessing physicians, providing a uniform yardstick previously unavailable to peer review professionals.

Program is intense, not for everyone

The IPE assessment’s value comes from its thoroughness. Illige acknowledges that the two-day interview process and a review of relevant materials can be extremely uncomfortable for the physician. The two days can include role playing in which the physician interacts with simulated patients, plus a lot of questioning and discussion about current information in the specialty or field of practice.

Surgeons may be observed at work, and the referring organization can send whatever information might be relevant to the physician’s assessment. That includes any evidence of previous mistakes or impropriety. (For an example of how a physician would be assessed and educated, see "Physicians tested, observed, re-educated, if needed," in this issue.)

IPE does not recommend what should be done with the problem physician, but it does provide the health care organization with a complete report. "The findings range from this is a terrific physician with one bad outcome,’ to the incident that got your attention was only the tip of the iceberg,’" Illige says. "For about 20% of physicians, we say that they have strong skills but may want to brush up in some areas. No formal education program is necessary for them, and most hospitals would stop their questioning process there. For about 15%, we report that they do not have the basic skills to practice and look dangerous. We give information that details why that’s so and explain why they shouldn’t practice unsupervised."

For that 15%, the physician’s age often determines the ultimate outcome. Younger physicians will seek additional training, while older physicians often take that assessment as their signal to retire. "For the lump of people in the middle, about 65%, we report that they have some issues of concern but that they could work well under supervision, in a well-structured program," she says. "We offer the education services to help them improve while they remain in practice. Some hospitals will say yes, they can work under those conditions, and others will say no and let the physician go. That often depends on how much they need physicians in their area."

About 400 physicians have been through the program, and follow-up information indicates that about 80% are now practicing without restrictions. Those good results are partly the result of working only with physicians who can be helped by the program, and the IPE program is not for everyone. (For more on how to determine when it is a good option, see "Remedial program good for those who can improve," in this issue.)

Program saves a doctor’s career

Advocates of the IPE program stress that it is not punitive and should not be viewed as "the place where bad doctors go." Quite to the contrary, they say, the IPE program provides a fair and objective assessment for physicians in trouble and others who aren’t, then offers an opportunity to improve. That can be a good opportunity, says Bob Spencer, JD, an attorney in Greenwood Village, CO, who represents both physicians and hospitals in peer review. He previously was on the board of CPEP.

Spencer says physicians should welcome IPE as another option that doesn’t damage their careers. The assessment can work in the physician’s favor when it shows that he or she is well-qualified and the referring organization’s fears were overstated. "When there are legitimate problems, the medical executive committee or the peer review committee may suggest to a physician that a way to resolve the issue is to enroll with IPE for an evaluation," he says.

"If the physician does that and successfully completes the process, taking whatever steps are necessary to correct the issues, then my experience is that the hospital will work with that physician and not take steps like restricting privileges or revoking them altogether," Spencer adds.

Giving hospitals an option

That is an option the hospital might not have otherwise, Spencer says, especially in a smaller community where physicians are reluctant to assess a competitor’s skills for fear of anti-competitive conduct and the sheer awkwardness of the situation. IPE provides a reliable assessment for both parties, far removed from any personal relationships.

"It helps to get the monkey off the hospital’s back a little bit," he says. "The medical staff are always on the horns of a dilemma when faced with what to do with a peer. They want to protect patients but not destroy the career of someone they work with every day. Sometimes, that results in staff not taking aggressive action when perhaps they should." But Spencer emphasizes that sending a physician to the IPE is not letting him or her off easy. Spencer has seen many physicians go through the process, which he describes as grueling.

Peer review committees should position the IPE option as a good step for physicians — which it is. Many physicians are easily persuaded to seek the IPE assessment and education, but some will resist. Illige says many of the program participants are not happy to be there, but they understood that the alternative was much worse.

"When I’ve represented hospitals in these cases, some of the cases involved physicians who had been problems at a low level for a long time," Spencer says. "The physician had become difficult to deal with, resistant to anyone questioning his practice. In cases like that, we’ve had to go to the extreme and say this is no longer an option. You must do this or lose your privileges."

The IPE staff and consultants work directly with the physician, who must travel to Colorado for the initial assessment. Scoles says the hospital or other provider is encouraged to provide as much background as possible on why the physician was sent and what problems are suspected. The physician must provide written permission for IPE to discuss its findings with the hospital.

The IPE program costs $7,500 for the two-day assessment, Scoles says. If a follow-up education program is necessary, the fees include $900 for devising a plan and $350 per month for monitoring the physician’s progress, plus $2,300 for a post-education evaluation. The education program fees do not include any costs for preceptors, CME courses, texts, or educational activities that might be part of the plan. So for an assessment and a six-month education plan, the minimum cost would be $12,800.

That’s a substantial sum, but many hospitals would find it a bargain when compared with the alternative of restricting or revoking a physician’s privileges, Illige points out. The referring hospital or other organization usually picks up the tab or splits it with the physician. Few physicians come of their own accord and pay for the program themselves.

"We get a lot of fear that cost is a deterrent, but going through the adversarial process to restrict someone’s privileges will cost a minimum of $25,000," she says. "When you add up the lawyers’ time, the cost can go higher. And there’s a huge investment in terms of time."