Adverse behaviors and their effect on credentialing and licensure

Editor’s note: The following is the fourth in a series of excerpts from Being Well and Staying Competent: Challenges for the Surgeon, a guidebook issued in 2013 by what is now the Physician Competency and Health Workgroup of the Board of Governors Quality Pillar. The complete document is posted in the General Surgery Community. Log-in is required.

“I’ve been reported to the state medical board for alcohol/substance abuse. What do I do?”

“I have been reported for anger, sexual harassment, or disruptive physician behavior. What do I do?”

“I had my privileges restricted by my credentialing body. What are my options?”

“My license has been restricted/revoked. What are my rights?”

“I have completed a treatment program. How do I restore my license/privileges?”

“What do I disclose to the hospital, my colleagues, and my patients?”

These are some of the questions posed by our colleagues who have engaged in some form of adverse behavior, which led to the loss of their credentials and/or restriction of their medical license. Loss of credentials and licensure takes a toll on physicians and their patients. As professionals, we have made a significant investment in our education and careers, and it can be difficult to find another career that is as financially and professionally rewarding as surgery. For society, loss of licensed health care professionals can result in reduced access to the talents and care that surgeons provide. The goal of this article is to define the terms used among the licensing and regulatory bodies, as well as the credentialing committees, and outline steps for individuals to reinstate themselves as fully productive members of the medical community.

Definitions

Illness generally is defined as the presence of a disease, whereas impairment is a functional classification and implies that the person is affected by a disease that renders him or her unable to perform specific activities. Regulatory and credentialing bodies often use these terms synonymously; however, mental and physical illness, as well as substance abuse, can eventually lead to impairment if left untreated. As surgeons, we strive to recognize and treat surgical illness in our patients early, before they face significant impairment in their ability to function. Surgeons should look at their own issues in the same way.

Disruptive physician behavior, as defined by the American Medical Association, is a style of interaction with physicians, hospital personnel, patients, family members, or other individuals that interferes with patient care. More specifically, the physician’s behavior intimidates and demeans others, potentially resulting in a negative impact on patient care. It is not a diagnosis, but could reflect underlying personality disorders, substance-related disorders, or psychiatric illness.*

Another area of potential impairment for physicians is addiction. Addiction is a compulsive activity or a psychological dependence on a certain behavior, which can eventually consume the attention of the individual to the exclusion of the other aspects of an individual’s life and, thereby, create impairment. Addiction may include substance abuse disorder, as defined by the American Psychiatric Association’s Diagnostic and Statistical Manual of Disorders, Fourth Edition, or addictive illness.

Related bodies

The Federation of State Medical Boards (FSMB) is a national body that leads the licensing community by promoting excellence in medical practice, licensure, and regulation. The FSMB also functions as a resource and voice on behalf of the state medical boards in their protection of the public’s well-being. Another organization involved in supporting physician behavior is the Federation of State Physician Health Programs, which, as its name suggests, is an association of physician health programs (PHP) with knowledge and expertise specifically related to matters of physician health. These programs do not diagnose and treat physicians, but rather coordinate and monitor intervention, evaluation, and the treatment and the continuing care of an impaired physician, as well as those with potentially impairing illness. The PHPs have a primary commitment to uphold the mission of their state medical and osteopathic boards in order to protect the public.

The state medical board’s primary goal is to protect the public through the issuance of professional licenses, as well as the use of disciplinary action for those health care professionals who violate the state medical practice act. There are approximately 70 state medical boards, including 13 osteopathic boards; several states have dual boards. Unfortunately, many physicians finish their training with specialty certificates only to realize that it is not possible to practice medicine without meeting a certain standard in the state where he or she practices.

The issuance of a license attests to meeting a minimal standard of education and training. The United States Medical Licensing Examination (USMLE) is the product of a collaborative effort between the National Board of Medical Examiners, the FSMB, and the individual state licensing boards to develop uniform standards across the U.S. and Canada for the issuance of an initial license. In addition to the examination, other data are taken into consideration before the license is granted. For example, each state has its own rules and regulations regarding medical practice. The overall purpose of these guidelines is to protect the public through licensure, discipline, and assurance of a minimal level of education to issue a license. Many states now require additional education beyond medical school before a license is issued.

A large portion of a state medical board’s activity centers on measuring competency, particularly in the areas of illness and impairment, and restricting licenses and mandating treatment programs for those health care professionals who are demonstrating signs of impairment or illness. This is frequently done through the PHPs that work in conjunction with the state medical board and the state medical societies; however, PHPs should be insulated as much as possible from any political pressures and conflicting interests with the professional organizations.

Hospital credentialing

Credentialing is usually done at the local hospital or health care facility where the the physician seeks to practice. The FSMB has developed a centralized credentialing bank that stores an individual’s college, medical degree, initial licensure, USMLE scores, and basic demographic information. This database helps to facilitate new licensure applications as physicians move from state to state and into different positions and, at the same time, protects the public from exposure to physicians who are under investigation in another jurisdiction. The local hospitals and health care facilities issue credentials depending on the individual’s training and upon the needs and standards they have established. An unrestricted license is usually mandatory; however, for individuals who have had their licenses restricted, each individual credentialing body has to establish the rules and regulations under which their practitioner is going to operate in the facility. It is imperative that each individual, depending on the jurisdiction in which he or she practices, be familiar with the state medical practice act and the unique rules and policies regarding that legislation.

Next steps

Although most physicians want to help their colleague reinstate his or her license, there has to be an appropriate balance between the goals of protecting the public and the safety of their health care versus the recovery of the ill physician. From a practical standpoint, if a health care professional is subject to a formal complaint, either with their local credentialing body or the state board, it is important that they undergo self-examination of their illness or addictive behavior. Initially, these individuals should obtain the assistance of their treating physician, as well as colleagues who may assist them in their recovery. However, if a formal hearing, locally or statewide, is initiated, then it is imperative that these physicians obtain legal counsel from a lawyer who is familiar with administrative health laws, as the rules of evidence in these hearings are different than in a criminal court proceeding.

It is necessary that individuals who are facing disciplinary action act with complete transparency before the hospital administrative body or the state regulatory agency in the hearing. Documentation of efforts to correct the illness or the impairment in a forthright manner is essential to a favorable decision by these authorities.

In many cases, if a patient has not been adversely affected by the individual’s behavior, then the PHP can work in conjunction with the state regulatory agency in terms of monitoring appropriate intervention, evaluating the condition, and recommending treatment and the ongoing care for the impaired physician. If anger or disruptive behavior is an issue, programs are available to assist individuals in managing these problems. Ongoing monitoring and continuing reports to the appropriate authority will be mandatory. If a medical license is encumbered, specific restrictive conditions need to be fulfilled in order to achieve full reinstatement of an unencumbered license. Again, an experienced health care lawyer should be secured to assist in these proceedings.

Even when treatment and rehabilitation are successful, the road to recovery can be difficult. Recovering substance abusers often face discrimination, but they should be given the opportunity to prove themselves through careful monitoring. Most state regulatory agencies will restore a license with conditions outlined in a public document, which may be used as guidelines for the local credentialing body. For those health care professionals with substance abuse problems, either alcohol- or drug-related, the typical period of observation is five years without recidivism.

This journey can be long and arduous, but with determination, discipline, and self-awareness, complete rehabilitation is achievable. In some instances, the road to full rehabilitation may be particularly challenging, and the individual may have to establish a new, modified professional routine. The Federation of State Physician Health Programs and the American Society of Addiction Medicine are both excellent resources for accomplishing that goal.


*American Medical Association. Model medical staff code of conduct. 2013 revision. Available at: http://www.ama-assn.org/ams/pub/amawire/2013-january-30/2013-january-30-omss.shtml. Accessed August 26, 2014.

Federation of State Medical Boards of the United States, Inc. Policy on physician impairment. April 2011. Available at: http://www.fsmb.org/Media/Default/PDF/FSMB/Advocacy/grpol_policy-on-physician-impairment.pdf. Accessed August 18, 2014.

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