The Disruptive Employed Physician and Medical Staff Bylaws
The delivery of cost-efficient, high quality and safe patient care requires the harmonious relationship between hospital administrators and the medical staff. The concept of a “disruptive physician” who is antagonistic to this relationship must be recognized and dealt with appropriately for the benefit of patients, physicians and staff. Recently, however, there are clear examples that may be too easily forthcoming and not properly investigated. Circumstances have occurred, especially with employed physicians, in which administrators reach conclusions and administer penalties regarding physician behavior without appropriate due process and investigation. This dangerous trend was recognized and brought to attention through the Council of State Neurosurgical Societies’ (CSNS) resolution process. The result was a neurosurgery-sponsored American Medical Association (AMA) resolution with powerful reaffirmation of the rights of all physicians to due process.
Physicians must understand the nature of their relationship with hospital administrations. Private practice and employed physicians are considered members of the medical staff. By virtue of their obligation to submit their credentials for acceptance, pay medical staff dues, participate in quality committees, take call, serve on committees, submit to peer and quality review, educate staff, etc., they deserve and obtain the rights of medical staff membership, even if employed. All physicians are obligated to conform to medical staff bylaws and rules and consequently, their conduct as physicians, must be judged according to accepted medical staff standards.
Review and Investigation
The question has been raised that, if employed, can a physician be characterized as “disruptive” by his employer and subsequently be disciplined? Although an employed physician is subject to the terms of an enforceable employment contract, one cannot be judged regarding medical conduct and behavior by non-physicians. Absent a specific waiver of due process rights the physician is entitled, as a member of medical staff, to a medical staff review.
Especially with regard to employed physicians, proper investigation regarding if a physician’s conduct is disruptive, inappropriate or intimidating requires an established and appropriate investigative process. Such a review must be conducted fairly and with an established procedure to ensure that a physician’s conduct is not mischaracterized, which can result in immediate (termination) and future harmful consequences.
Failure to follow recognized definitions, guidelines and procedures can result in harm to the relationship among physicians, medical staff and hospital administrations. Lack of a fair process can result in loss of trust, “hard feelings,” retaliatory behaviors and ultimately, dystopic physician-hospital relations. Decisions as to physician conduct can never be solely the province of a hospital administration. Such unilateral decisions represent a subtle form of coercion in which the physician may feel required to submit to administrative fiat. At worst, such behavior by an administration can be interpreted as an attempt to subtly modify, enforce or threaten future conduct.
In order to understand whether or not a physician falls short of appropriate conduct, clear guidance as to the characterization of accepted physician behavior is the first requirement. Definitions of preferred and inappropriate physician behavior have been established in the AMA Moral Code. In addition, this same code describes an appropriate procedure to investigate and adjudicate claims of misconduct.
The above issues, especially with regards to employed physicians, were brought to the attention of the AANS Caucus during the last CSNS meeting in Los Angeles (Resolution VI-2016-S “The ‘Disruptive Physician’ Label and Its Impact on Neurosurgery”). It was discussed that a resolution sponsored by the AANS to address this issue might be presented at the AMA meeting in Chicago, June 2017. As a result, a joint resolution by the AANS and Congress of Neurological Surgeons (CNS) was authored and accepted for consideration. The resolution was amended without substantive change and was unanimously adopted at the meeting of the AMA House of Delegates as Resolution – 012: “Promoting the AMA Model Medical Staff Code of Conduct and Its Application to Employed Physicians.” The critical part of the resolution states:
“[The] AMA actively educate state and specialty medical societies about the AMA Medical Staff Code of Conduct and promote its use. In addition, the resolution requests that the AMA advocate for employed physicians to be afforded 37 the same right of review as non-employed physicians in accusations where conduct is 38 characterized as “disruptive, intimidating or inappropriate.”
As a result of this neurosurgery-sponsored resolution, employed and private practice physicians now have the support of the AMA with regard to the characterization and process to be followed when dealing with issues of alleged disruptive or inappropriate conduct. Nevertheless, in order to secure the benefits of this resolution, physicians must proactively read their medical staff bylaws and, if necessary, amend and incorporate the AMA Model Medical Staff Code of Conduct into them. This will ensure that all physicians enjoy equitable treatment. A further benefit of AMA bylaws incorporation includes the process to be followed regarding “behavior which undermines a culture of safety and is directed against the organized medical staff or a medical staff member by a hospital employee, administrator, board member, contractor, or other member of the hospital community.”
Physicians must read and understand their medical staff bylaws. It is only with this appreciation that all parties will recognize their rights and obligations that must be observed in order to provide the highest quality medical care. Medical staff bylaws, therefore, are the exclusive means for review and discipline of medical staff members who fail to live up to this ideal.
2017 AANS/CNS Section on Pediatric Neurological Surgery
Nov. 28-Dec. 1, 2017; Houston
2nd Homburg ICP and Hydrocephalus Workshop
Nov. 28-30, 2017; Germany
22nd Instructional Course and 45th Annual Meeting of the Cervical Spine Research Society
Nov. 29, 2017 - Dec. 2, 2017; Hollywood, Fla.
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