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TRANSCRIPT
Physician Health Impacting Patient Safety: The
Experience and Results of a National Fitness for
Duty Evaluation Program
Session Code: WE06
Date: Wednesday, September 21, 2016
Time: 10:30am - 12:00pm
Total CE Credits: 1.5
Presenter(s): David Bazzo, MD, FAAFP
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Physician Health Impacting Patient Safety – The experience and results
of a National Fitness for Duty Evaluation Program
David E.J. Bazzo, M.D. FAAFPClinical Professor of Family Medicine
Director, Fitness for Duty ProgramUC San Diego Physician Assessment and Clinical Education (PACE) Program
September 21, 2016, 10:30 AM – 12:00 PM – WE06
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Presenter Disclosures
Consultant/
Speakers bureaus
“No Disclosures”
Research funding “No Disclosures”
Stock
ownership/Corporate boards-employment
“No Disclosures”
Off-label uses “No Disclosures”
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• Founded in 1996
• Provides assessment of physician competencies and remediation of deficiencies
• Competency assessment of more than 1600 physicians
• Educational services to more than 5000 physicians
The UC San Diego PACE Program
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• Define “fitness for duty” and explore how the health of a physician can impact the delivery of safe healthcare;
• Describe the process of creating a meaningful fitness for duty evaluation;
• Identify potential accommodations that can be made to preserve patient safety and the physician’s continued practice;
• Analyze the results of specific fitness for duty evaluations and the composite of evaluations of a National assessment program.
Objectives
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• Patient care
• Medical knowledge
• Practice-based learning and improvement
• Interpersonal and communication skills
• Professionalism
• Systems-based practice
What to measure? The ACGME/ABMS 6 Core
Competencies
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Pre-Assessment Preview
• An intensive effort to gather as much information as possible (through questionnaires, telephone interviews, document review, etc.).
• Before the physician physically comes to PACE.
• Followed by a detailed presentation of these materials at the weekly Case Conference, to enable us to design a more effective and efficient individualized assessment program.
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• PULSE 360° Assessment
• Review of practice profile, physician background, demographic data
• MicroCog®
• Physical and mental health screening
• Review of randomly selected chart notes
• Oral Clinical Examination (OCE)
• Evaluation of performing an H&P on a mock patient
PACE Assessment (potential components)
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• Clinical Observation with UC San Diego Faculty
• Chart Stimulated Recall (CSR) Evaluation
• Standardized patient modules
• Post-Licensure Assessment Systems (PLAS) multiple choice question tests and computerized case simulations (PRIMUM CCS)
• Evidence-based medicine Project
PACE Assessment (potential components)
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• Participating physicians “shadow” faculty in their specialty, but are a part of the clinical team and may ask questions, participate in teaching activities, etc.
• Participating physicians have no responsibility for patient care. They do not perform procedures, make entries into medical records, or write prescriptions.
• 90% of participating physicians describe the clinical experience as “very good” to “excellent,” and state it is an excellent learning experience, even in procedural specialties
PACE Assessment: Clinical Experience
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PACE Assessment
(Clinical Skills Simulation)
• Center for the Future of Surgery• Anesthesiology Simulation
• Noelle High Stakes OB Simulator• Laparoscopic Surgical Simulation • Endoscopic Surgical Simulation
• SIM Man Emergency Medicine Simulator • “Low tech” simulation (suturing, etc.)• Customized Simulation Activity
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• Weekly multidisciplinary meeting where all cases are discussed and
subsequent determinations and recommendations are made.
• Attended (on average) by four PACE faculty, subspecialty faculty as
needed, and four experienced case managers
• Performance falls into 1 of 4 categories
1. Pass
2. Pass with minor recommendations
3. Pass with major recommendations
4. Fail
• PACE has assessed over 1600 physicians; of those, the “fail” rate is
between 10% and 15%
• Fail = unsafe to practice medicine
The PACE Case Conference
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• Conclusions:
o Based upon many items of data/information gathered during assessment and following an in depth discussion by the multidisciplinary PACE team members and faculty.
o Although we strive to use objective, reproducible, valid measures to the extent possible, subjective measures are also considered, and the ultimate determination often depends upon expert opinion.
How PACE Determines Risk
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The PACE Fitness for Duty Program (founded 2011)
• Similar to the Competency Assessment, but it is intended for physicians for whom it is suspected that a physical, mental, or cognitive illness may be impacting competence and clinical performance
• Usually will include one or more generalist and/or subspecialty health evaluations
• May also include competency components and/or simulations, depending on the physician’s specialty and reason for referral
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Definitions
• Fitness for Duty- Whether a person is physically and mentally capable of safely performing the essential functions of his/her job with or without reasonable accommodation.
• Fitness for Duty Evaluation- Evaluation by an impartial, independent health care professional with appropriate expertise in one or more of the following: medical conditions, psychological conditions, and/or conditions related to the use or abuse of alcohol or other substances.
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How the FFD Program Came To Be
• Robust health screening has always been part of the PACE competency assessmento The first 250 (or so) competency assessments
included a complete neuropsychological evaluation and H&P exam
o Eventually deemed excessive• First 1200 (or so) competency assessments have included
the MicroCog, self-report forms (PHQ-9, UCSD Family Medicine adult health history questionnaire), and a complete H&P
• Currently ~ 6-7% of competency assessments result in failure due to impairment (about 5-6 per year)
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• First Step: Establish whether evaluation will be FFD only or combined with competency
• Second Step: Determine who will receive results and whether agreement between UCSD and a hospital/medical group is needed
• Third Step: Obtain background information from referring agency and physician:o Information requested from referring agency:
� Reason(s) for referral in writing
� Timeline of events
� Job description if available and/or list of privileges
� Any additional relevant information
PACE FFD Program Processes
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o Information requested from physician:
�Personal health records
� Intake form
�Adult Health Questionnaire
�Patient Health Questionnaire (PHQ-9)
�CV
�Root cause analysis
PACE FFD Program Processes
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• Fourth Step: Review background information to determine scope of FFDE
o Only core component is background forms physician submits and an interview with FFD Program Director
o All other components are selected based on background information received
o If physician is a proceduralist, we will try to include functional simulation of skills at UCSD’s Simulation Center
• Fifth Step: Schedule FFD evaluation
PACE FFD Program Processes
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Fitness for Duty Evaluation:Common Elements
• Comprehensive medical examination• Toxicology screen• Neuropsychological testing• Neurologic evaluation• Ophthalmologic evaluation• Specialty medical evaluations• Functional Assessment• Simulated procedural/skills evaluation in the physician’s specialty• Chart reviews• Oral examinations• 360-degree workplace survey
UC San Diego Simulation CenterUC San Diego Simulation CenterUC San Diego Simulation CenterUC San Diego Simulation Center
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• Sixth Step: Review results and assign final grade
o Clearly fit for all aspects of duty
o Fit for some duties, but not others (fit with accommodations)
o Unfit for duty
• 7th and Final Step: write final report summarizing all aspects of FFDE
PACE FFD Program Processes
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Fitness for Duty (FFD) Program
• Although age is sometimes a factor, this is specifically notan “aging physician” assessment
• Although cognitive function is sometimes a factor, virtually any disease or disability can bring clinical performance into question
• Unlike our typical competence assessment, the FFD program requires a large amount of preliminary investigation by PACE staff and faculty to be able to understand the issues and design an effective individualized FFD assessment
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Potential Outcomes of PACE FFD
• Clearly fit, no evidence of disease
• Clearly fit; disease present, but treatment optimal and does not interfere with ability to practice; physician may need interval evaluation
• Disease present and may interfere with some, but not all, clinical duties; PACE will delineate findings and make recommendations about accommodations
• Disease present that interferes with most or all of clinical duties; accommodations not currently possible
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• *1 participant has been evaluated 4 times
Fitness for Duty Evaluation:
Total Number of Evaluations to Date = 46
YearYearYearYear # of Physicians# of Physicians# of Physicians# of Physicians
2011 5
2012 9
2013 3
2014 15
2015 11
2016 thus far 3 (7)
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West: West: West: West: 33333333
MidwesMidwesMidwesMidwest: 9t: 9t: 9t: 9
NortheaNortheaNortheaNortheast: st: st: st: 4444
Fitness for Duty Evaluation:
Total Number of Evaluations to Date = 46
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Fitness for Duty Evaluation:
Total Number of Evaluations to Date = 46
Hospital /
medical group 82%
State Physician Health Program
5%
Medical Board 7%
"Self"2%
Attorney4%
Referral Referral Referral Referral SourceSourceSourceSource
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Fitness for Duty Evaluation:
Total Number of Evaluations to Date = 45
SpecialtSpecialtSpecialtSpecialtiesiesiesies
Internal Medicine
20%
Other Surgeries
16%
Emergency Medicine
13%
Anesthesiology / Pain
Management9%
General & Vacular Surgery
9%
Radiology9%
Family Medicine / General Practice / Urgent Care
7%
Obstetrics and Gynecology
7%
Orthopedic Surgery
4%
Pediatrics4%
Psychiatry2%
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Who are our participants?
• 36 Male and 10 Female
o Average age of group = 65
� Oldest = 80
� Youngest = 29
• Average age of male physicians = 58
• Average age of female physicians = 46
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Reasons for Referral
Area of Concern # Of physiciansCognitive 11
Psychiatric 4Behavioral 18Neurologic 5
Medical 19Competence 14Substance Abuse 4
Boundaries 2
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Results
Final Grade N % Avg AgeClearly Fit 14 30.4% 56.4Fit with accommodations 17 37% 55.5Unfit 14 30.4% 56.0Incomplete 1 2.2% 59.0
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Dr. Gamma
• 80 year-old vascular and trauma surgeon enrolled in PACE as a result of a MBC
disciplinary action.
• Index case: postoperative death of a patient.
• PACE Phase I Assessment and a subsequent full battery of neuropsychological testing
• mild, but abnormal neurocognitive deficits of memory, learning, visuospatial perception, and dominant hand fine motor coordination.
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Dr. Gamma
• This case was very difficult for everyone.
• Dr. Gamma had an illustrious career, saved lives, and helped many people.
• Lessons from the airline industry: regular, universal, meaningful, valid health and competency assessment.
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Dr. Delta
• 57 yo Critical Care specialist diagnosed with Parkinson’s disease.
• Procedures: Intubation, central lines, chest tubes
• ICU hours: shifts at different times, multiple days in a row
• Hospital needed reassurance
• Has been to PACE 4 times (yearly)
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Dr. Delta• Interview with FFD Director
• Evaluation with movement disorder specialist
• Procedural evaluation of skills with comparison to “norms”
• Had done well, except for last visit
• Shift limitations
• Making retirement plans
• Yearly evaluations
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Dr. Epsilon• 52 year old vascular surgeon
• Original partner of a group
• DUI
• Group would not accept him back
• Secured second job – enabled
• DUI
• Disruptive behavior
o Communications
o Inappropriate material
o Patient complications
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Dr. Epsilon• Interview FFD Director
• Complete neuropsychological testing
• Behavioral assessment
• Substance use assessment
• 3600 evaluation
• Found unfit
o Brain changes, poor insight
o Abstinence
o Retesting after period of time with competency assessment
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Dr. Theta
• 56 year-old primary care internist referred by a hospital
• History of quiescent SLE
• Suffered myocardial infarction in 2006 and a right MCA stroke in 2008
• Appeared to have deficits in memory following
stroke, exacerbated by extreme difficulties adapting to a new EHR
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Dr. Theta
• MRI of brain July 2008 showed diffuse cortical atrophy
• A neuropsychological exam March 2009: moderate deficits in attention, learning and
memory, executive functioning, and visuospatial processing
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Dr. Theta
• What do you do?
• He is a nice man and a longtime colleague
• Harvard-trained and ABIM-certified
• No patient complaints or clinical errors noted, but colleagues say “he’s lost a step”
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Dr. Theta at UCSD PACE
• Very nice man; kind, professional
• Became lost several times
• Demonstrated left-sided neglect
• Verbal IQ=128 and Performance IQ=85 (Full Scale IQ=108)
• His exam of the mock patient was disorganized, but he was very kind and professional and the patient gave him the highest scores possible
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Dr. Theta at UCSD PACE
• Oral clinical exam score: 40% with passing being 70%
• Scores on all 4 NBME standardized exams, including the Internal Medicine Clinical Subject
Exam, were 1st percentile (the lowest percentile)
• Results of his MMPI-2 as well as conversations
with PACE faculty and staff suggest he has no insight into his cognitive deficits and perhaps is incapable of this
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Dr. Theta Summary
• Tragic case. Etiology is unclear because SLE can do some of these things, but most likely we are
seeing the sequellae of his right MCA stroke
• Marked gap between his verbal and performance
IQ scores is seen in only 0.1% of the population; almost certainly due to his stroke; this also explains how he escaped detection for so long-
because we judge each other largely on verbal interactions
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Dr. Theta Summary
• The problem is compounded by his lack of insight
• Outcome unknown, but Dr. Theta has disability insurance and a supportive hospital leadership, so
the plan is to help him retire gracefully
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Questions?
PACE Redacted Reports
Fitness for Duty Reports
Fitness for Duty Report
Example #1
January 22, 2015
D.B., M.D.Associate Medical DirectorProfessional Development and ServiceHawaii Permanente Medical Group Executive Office 2828 Pa'a Street Honolulu, HI 96819
RE: Fitness for Duty Report for Dr. X
Dear Dr. B:
Dr. X is a 59-year-old critical care specialist who was referred to the UCSD PACE Program for arepeat Fitness for Duty (FFD) evaluation by Hawaii Permanente Medical Group, specifically for follow-up of his Parkinson’s disease. This was our fourth FFD evaluation of Dr. X; however, unlike the first three FFD evaluations, this FFD evaluation followed a sentinel event, which resulted in Dr. X being placed on administrative leave. He was initially evaluated by the UCSD PACE Program in July 2011 and had subsequent re-evaluations in October 2012 and December 2013. Dr. X participated in this PACE Fitness for Duty evaluation November 13-14 and 20, 2014.This report details the four components of Dr. X’s evaluation: 1) Fitness for duty interview conducted by David E.J. Bazzo M.D., Fitness for Duty Program Director, UC San Diego PACE Program; 2) Fitness for duty – neuropsychological evaluation conducted by William Perry, Ph.D., Professor, In Residence, Associate Director of the Neuropsychiatry and Behavioral Medicine Service at the UCSD Medical Center; 3) Neurologic evaluation conducted by Stephanie Lessig, M.D., Associate Professor of Neurosciences, UC San Diego; and 4)Emergency medicine simulation conducted by Daniel Davis, M.D., Professor of Clinical Emergency Medicine, UC San Diego. A summary and recommendations section is provided at the conclusion of this report.
Inventory of Background Materials: Background information was received by way of written communication and telephone conversation. Below is a list detailing the written materials:
1. Synopsis from Dr. DB outlining the recent incident leading to Dr. X’s referral
Fitness for Duty Evaluation Results:
Fitness for Duty Interview: David Bazzo, M.D., Fitness for Duty Director, interviewed Dr. X to gather additional background information and discuss the incident that led to his FFD referral. The following is an excerpt from Dr. Bazzo’s report:
Dr. X was placed on administrative leave on October 15, 2014. Information provided by DB, M.D. Associate Medical Director, described placing Dr. X on
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leave after an incident in the intensive care unit (ICU) on October 13, 2014. Dr. Xwas unable to independently don his gloves for a sterile procedure to place a vascular access catheter. Dr. X received assistance putting on his sterile gloves from a nurse and was able to complete the procedure without complication.
During our interview, Dr. X reports that he and his wife separated in January 2014 and are currently in divorce proceedings. They had the first mediation session two weeks ago. He states that they had grown apart and the marriage no longer made sense. He describes some stress associated with this process but feels it is the right thing for him to do. His children are upset with him but he hopes to reconcile with them as time passes. He is currently “seeing someone”, an old acquaintance, who lives in Santa Barbara, California and he has been spending time with her while on leave. He estimates spending 40% of his time in Santa Barbara and 60% of his time in Hawaii.
Dr. X states that he still continues to surf and practice yoga, but that he feels as though the functional disease process of his Parkinson’s is progressing. He describes more tremors in his right upper extremity that are continuous as well as more motor weakness. He described the incident where he had difficulty putting on his gloves. The incident occurred near the end of a shift. He states he tried for approximately five minutes to don the gloves and then had the nurse give him help. He felt it was a “coordination and proprioceptive” issue. He denied any procedural complication with the aforementioned vascular access catheter placement. He also denies other procedural complications but also states that he continued to utilize support services for many procedures including the PICC line placement service, and deferring procedures when it was safe to do so.
After the incident, he initially thought he could get by and continue practicing; however, with more time to reflect on the incident, he has some relief that his “illness has set immediacy” to his choice to discontinue performance of procedures and therefore, an ICU practice.
He saw Dr. Tagliotta, his movement disorders physician at Cedars Sinai in Los Angeles, in April 2014 who made adjustments to his Sinemet to ¾ of a 25/100 mg pill four times per day. He was previously on Azilect but had dyskinesia with it and discontinued it between six and twelve months ago.
Dr. X feels that long term disability is the route he will likely have to pursue until he reaches retirement age. He has accepted his current predicament and states that his neurologist in Hawaii, Dr. Stuart Pang, will likely complete the evaluation and paperwork necessary for this step. He understands that his current disability limits the work he can do. He has a very strong commitment to patient safety and would never want to bring harm to a patient. This has been a very difficult decision for Dr. X. He states that he’s had only “two sick days in 22 years”.
For now, he plans to live in both Hawaii and Santa Barbara, splitting his time between the two. He will continue to surf, practice yoga, hike and concentrate on remaining as healthy as possible. He will continue his divorce proceedingsand will work on his relationship with his children.
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In my observation today, Dr. X appeared a bit frailer and was moving more slowly. I observed an intermittent slight tremor in his right upper extremity and a mild tremulousness to his voice.
Neuropsychological Evaluation: William Perry, Ph.D., performed a neuropsychological evaluation on Dr. X. The following excerpt is taken directly from his report:
Mental Status ExamDr. X arrived in a timely manner to his appointment dressed neatly in casual attire with adequate grooming and hygiene. He was generally slow and rigid in his movements and mild, intermittent resting tremor was observed in his dominant hand. He was soft spoken, yet speech output was fluent, grammatical, and did not contain paraphasic errors. His thought content was logical and coherent, with no indication of a thought disorder. His mood was euthymic with blunted affect. Although he brightened up at times, showing a greater range of affect, he generally showed little to no facial expression. Overall, he was appropriately engaged and cooperative with testing. He did not demonstrate difficulties understanding test instructions, was able to maintain his focus on testing, and appeared to have made a good effort throughout the testing.
Test Results and InterpretationEffort TestingDr. X performed adequately on effort measures (i.e., CVLT-II Forced Choice = 16/16). He appeared to put forth adequate effort throughout neuropsychological testing and the following profile is deemed to be a valid reflection of his cognitive abilities at the present time.
General Intellectual FunctioningDr. X’s performance on the WTAR estimated his premorbid level of general intellectual functioning to be within the above-average range. His performance on the WASI suggest that his current intellectual abilities fall within the above-average range (T = 66), which is consistent with his estimated premorbid level of general intellectual functioning. His verbal (T = 67) and nonverbal (T = 61) performances fell within the above-average range.
Attention/ConcentrationDr. X’s performance in this domain was not impaired. On a task requiring rote repetition and reversal of numbers (i.e., WAIS-III Digit Span), he performed within the average range when compared to his age group and a younger population (T = 46). Comparably, his performance on a measure of mental manipulation of alpha-numeric information (i.e., WAIS-III Letter-Number Sequencing) was within the average range when compared to his age group (T = 54) and a younger population (T = 51).
Processing SpeedDr. X’s performance in this domain was not impaired. His WAIS-III Processing Speed Index score was within the average range (T = 49) when compared to his age group and within the low-average range (T = 41) when compared to a younger age group. His performance on a task requiring visual perception and speed (i.e., WAIS-III Symbol Search) was within the average range when
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compared to his age group (T = 51) and a younger population (T = 47). On another test that requires rapid visual scanning and information processing speed (i.e., WAIS-III Digit-Symbol Coding), he performed within the average range (T = 45) when compared to his age group and within the mildly-impaired range (T = 38) when compared to a younger age group.
Motor/PsychomotorDr. X’s Grip Strength score for his dominant hand was within the average range (T = 46) when compared to his age group and within the low-average range (T = 44) when compared to a younger population. His Grip Strength score for his nondominant hand was within the average range when compared to his age group (T = 48) and a younger population (T = 46). His fine motor dexterity score (GPT) for his dominant hand was within the moderately-impaired range when compared to his age group (T = 28) and a younger age group (T = 25). Fine motor dexterity score for his nondominant hand was within the moderately-impaired range (T = 25) when compared to his age group and within the moderately-to-severely impaired range (T = 23) when compared to a younger population. On the FTT, his dominant hand performance was within the mildly-to-moderately impaired range when compared to his age group (T = 31) and a younger population (T = 30). His nondominant hand FTT performance was within the low-average range when compared to his age group (T = 43) and a younger age group (T = 42). On the TMT, his performance on the basic sequencing trial (TMT-A) was within the moderately-impaired range when compared to both his age group (T = 27) and a younger population (T = 25).
LanguageDr. X’s performance in this domain was without deficits. He evidenced no obvious difficulty understanding conversational speech or task instructions, suggesting grossly intact receptive language functioning. His speech output was fluent, grammatical, and did not contain paraphasic errors. His performance on a measure of expressive knowledge of vocabulary words (i.e., WASI Vocabulary) was within the above-average range when compared to his age group and a younger population (T = 66). Comparably, his verbal abstract reasoning performance (i.e., WASI Similarities) was within the above-average range relative to his age group (T = 63) and a younger population (T = 61).
Visuospatial FunctioningDr. X’s performance in this domain was not impaired. His performance on a task of spatial problem-solving skills (i.e., WASI Matrix Reasoning) was within the above-average range when compared to his age group (T = 68) and a younger age group (T = 65). On a task of manually constructing designs using colored blocks in a timely fashion (i.e., WASI Block Design), he performed within the average range relative to his age group (T = 52) and a younger population (T = 50).
Learning & MemoryDr. X’s performance in this domain was without deficits. On the CVLT-II, his total recall of words across the five learning trials was within the above-average range when compared to his age group and a younger population (T = 55). His Short Delayed Free Recall performance was within above-average range when
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compared to his age group and a younger age group (T = 60). Comparably, his Long Delayed Free Recall performance was within the above-average range relative to his age group and a younger population (T = 65). Short Delayed Cued Recall performance was within the above-average range when compared to his age group and a younger population (T = 60). Long Delayed Cued Recall performance was also within the above-average range when compared to his age group and a younger population (T = 70). His recognition hits score was within the above-average range when compared to his age group and a younger age group (T = 55). Overall recognition discriminability score was within the above-average range when compared to his age group and a younger population (T = 60).
Regarding learning and memory of visual materials, his BVMT-R immediate recall score was within the average range when compared to his age group (T = 51) and a younger age group (T = 48). His BVMT-R delayed recall score was within the average range (T = 47) compared to his age group and within the low-average range (T = 44) compared to a younger population.
Executive FunctioningDr. X’s performance in this domain was not impaired. On the Category Test, which requires multiple fundamental cognitive skills and higher-level executive functions, Dr. X’s performance was within the above-average range (T = 55) when compared to his age group and within the average range (T = 54) when compared to a younger age group. On a test requiring speed of information processing and cognitive switching (i.e., TMT-B), his performance fell within the low-average range (T = 41) when compared to his age group and within the mildly-impaired range (T = 39) when compared to a younger population. Dr. Xdid not commit any sequencing or shifting errors on the TMT-B; however, he demonstrated reduced psychomotor speed, which impacted his performance and reduced his overall score on this task.
Emotional FunctioningOn self-report questionnaires of mood symptoms, Dr. X endorsed minimal symptoms of depression (BDI-II = 7) and mild symptoms of anxiety (BAI = 13).
Summary and ImpressionsThe results of the current evaluation indicate that Dr. X’s general level of intellectual functioning is within the above-average range and consistent with estimated level of pre-morbid general intellectual functioning. Within specific neurocognitive domains, Dr. X demonstrated intact attention, speed of information processing, language, visuospatial/organizational skills, learning/memory, and executive functioning. His performances across these domains were largely within the average to above-average range of functioning. However, moderate deficits were observed on measures of fine motor dexterity and psychomotor speed.
Notwithstanding Dr. X’s cognitive strengths, the chief practical concerns at this time as it relates to his practice of medicine are his compromised psychomotor speed and manual dexterity/fine motor skills. The duties of a critical care physician not only include competency in a broad range of conditions common
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among critically ill patients, but also with the technological procedures and devices used in the intensive care setting. While it can be argued that the noted deficits are not of a sufficient degree to warrant a further restriction of his practice, it should be noted that Dr. X’s difficulties in the area of fine motor dexterity and speed may lead him to struggle with carrying out important procedural skills (e.g., placement of arterial and central venous lines, insertions of temporary pacemaker, endotracheal intubation, etc.) with confidence and competence. Additionally of concern are his self-reported fatigue and the likely progression of his condition over time.
Given the observed areas of deficits and its potential functional implications, it is recommended that Dr. X, at the very least, manage his caseloads appropriately to minimize cognitive and physician strain which can become taxing and result in an increased risk of performance issues. Dr. X may also benefit from a Focused Professional Practice Evaluation (FPPE); this can provide additional opportunity for continued evaluation of his ability to maintain acceptable practice guidelines. It is recommended that these safeguards be considered if the desire of the Medical Executive Committee is to preserve his ongoing work at the hospital. It is also recommended that Dr. X continue to work with his current therapist for added support and strengthening of coping as it relates to his medical illness, divorce proceedings, and estranged relationship with his children. Finally, Dr. X should be made aware of his relative deficits and its potential implications for medical practice so that he can make modifications in his daily practice to ensure optimal performance and ultimately patient safety.
Neurologic Evaluation: Stephanie Lessig, M.D., conducted a neurologic evaluation on Dr. X.The following excerpt is taken directly from Dr. Lessig’s report:
History of Present Illness:Dr. X presents today for reevaluation of his Parkinson’s disease. He was last seen by me on December 4, 2013.
Since his last visit, he had an event while working in the ICU during which he experienced difficulty putting on gloves. He was able to perform the procedure (placing a central line) he was doing without difficulty, but as a result, reported himself and was placed on administrative leave. He has not been working for the past 1 1/2 months, and is questioning whether he should return to work. At the time he does not feel he was "off" medication. Prior to this he was doing 10 days of 12 hours shifts per month. He was noting increasing difficulties with both fatigue and coordination. He has noted his tremor is worse in the right>left hand, as well as discoordination, though overall does not feel this is limiting. He otherwise continues to surf regularly, though he is taking smaller waves and is slower in movements. He has had 1-2 falls when going upstairs, and reports increasing instability with gait.
Regarding his PD symptoms, he continues to take Sinemet 25/100, taking 3/4 tabs in the am (between 0500 and 0700) followed by 1 tab every 4 hours, up to 4 times per day. Rasagiline was discontinued due to increasing dyskinesias, which have improved. On this regimen, he notes wearing off at about 6 hours, characterized by back pain and fatigue. He remains with mild head
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bobbing/dyskinesias after his morning Sinemet dosing, which occurs 0.5 hoursafter this dose. He has no nausea or hallucinations from medication. His speech has gotten lowered, particularly with fatigue and anxiety. Swallowing he has noted occasional coughing. His sleep is interrupted prompting a sleep study, which revealed mild sleep apnea, and CPAP was recommended. He has also noted increasing anxiety, particularly more with small things such as making appointments. His memory seems fine. He otherwise continues to have nocturia with occasional urge incontinence, and constipation, controlled with kale smoothies and prune juice.
Questionnaires administered:MDS-UPDRS (Movement Disorders Society-Unified Parkinson’s Disease Rating Scale, Parts I-V)
On Part I (non-motor aspects of Experience of Daily Living), he endorsed periods of anxiety greater than normal, more than one day at a time as well as being less assertive than usual; mentation was normal and there was no depression, hallucinations or compulsions for a score of 3 out of possible 24 (increased by 1 point from last visit). By self-report, he has had moderate problems with sleep, mild daytime sleepiness, slight pain at times, urinary urgency which can interfere with activities, slight constipation, dizziness on standing, and moderate fatigue for a total score of 13 out of 28 (increased by 5 points from last visit).On Part II, (Motor Aspects of Experiences of Daily Living), by self-report, he endorsed mild speech difficulties with need to repeat occasionally, slight increase in saliva, slight slowing to chew, eat, dress, and hygiene. He has moderate handwriting difficulties, mild tremor, and slight slowing doing activity, getting out of a bed or chair, and walking. There were no difficulties with turning in bed or freezing for a score of 15 out of a possible 52 (increased by 7 points from last visit).Part III (Motor exam, is described below)On Part IV (complications of therapy), he has mild dyskinesias, perhaps 1 hour per day, which are not troublesome. There are also leg and hand cramps upon awakening, prior to medication. He does not believe he has true "on"s and "off"s. Part V (Hoehn and Yahr Staging, is described below)
Epworth Sleepiness Scale Score was 6, within normal range (no excessive sleepiness noted).
Past Medical History is remarkable for benign prostatic hyperplasia, as well as GERD, for which he takes ranitidine and Cialis. Besides Sinemet 25/100 3/4 tabs TID-QID, he continues Coenzyme Q10, vitamin-B, glucosamine, magnesium, tumeric and occasional NSAIDS. Allergies include horse serum tetanus.
Family History is remarkable for an aunt and uncle of his father with Parkinson’s disease.
Social history: He is an MD in intensive care. Of note, he has been undergoing a divorce since January 2014.
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ROS is otherwise unremarkable.
General ExamPatient is well developed, & in no acute distress. HEENT: Normocephalic & atraumatic. Visual fields intact bilaterally. PERRLA. EOMI. Oropharynx clear. Hearing intact. Neck supple. Trachea midline. No lymphadenopathy. CV: Regular rate & rhythm. No murmurs, rubs, gallops, JVD or carotid bruits. Lungs: Clear to auscultation anteriorly bilaterally. Abdomen: Positive bowel sounds, nontender, nondistended. Extremities: No clubbing, cyanosis, or edema. Pulses: Equal throughout.
Neurologic ExamMental Status Examination:He scores 30/30 on the Mini-Mental Status Examination and 27/30 on the Montreal Cognitive Assessment (normal, missing 2/5 recall objects, but getting these with minimal prompts, and slight difficulties on trails).
General Neurologic Examination:CN: Cranial Nerves II-XII intact throughout: Cranial nerve II: Normal visual fields. PERRLA. Cranial nerve III, IV, and VI: Extra-ocular movements intact. Cranial nerve V: Normal facial sensation. Cranial nerve VII: Normal facial symmetry. Cranial nerve VIII: Normal hearing bilaterally. Cranial nerve IX and X: Palate elevates symmetrically. Cranial nerve XI: Normal shoulder shrugsbilaterally. Cranial nerve XII: Tongue midline without deviation.
Motor: Normal bulk in all 4 extremities. 5/5 strength in all muscle groups x 4 extremities. RUE: 5/5 Deltoid, 5/5 Triceps, 5/5 Biceps, 5/5 BrachioRadialis, 5/5 Intrinsics. LUE: 5/5 Deltoid, 5/5 Triceps, 5/5 Biceps, 5/5 BrachioRadialis, 5/5 Intrinsics. RLE: 5/5 Iliopsoas, 5/5 Knee Flexors, 5/5 Knee Extensors, 5/5 Ankle Flexors, 5/5 Ankle Extensors. LLE: 5/5 Iliopsoas, 5/5 Knee Flexors, 5/5 Knee Extensors, 5/5 Ankle Flexors, 5/5 Ankle Extensors. Sensory: Intact Touch, Position, & Temperature in all 4 extremities. DTRs: Deep Tendon Reflexes symmetric in all 4 extremities: (R) Bi/ Tri/ BR/ Pat/ Ach = 2 1 1 2 1 (L) Bi/ Tri/ BR/ Pat/ Ach = 2 1 1 2 1. Toes down going bilaterally.
Coordination and Gait: see UPDRS III below.
UPDRS III (MOTOR EXAM): (0=normal to 4=cannot do) (Last Sinemet dosing 4 hours ago)
Speech: Mild decreased (2)Facial Expression: 2 (mild)Involuntary Movements: Chin tremor, intermittent (1) along with right
upper extremity tremor, mild (2)Motor Function: axial rigidity: 2Right: RIGIDITY: UE: 1.0; LE: 0.0;
DEXTERITY: Grip: 1.0; Finger Tap: 2.0; Heel Tap: 3.0; toe tap 3.0;
COORDINATION: RAM: 1.0; FNF: 2.0 Left: RIGIDITY: UE: 1.0; LE: 1.0;
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DEXTERITY: Grip: 0.0; Finger Tap: 3.0; Heel Tap: 3.0; toe tap 2.0 COORDINATION: RAM: 0.0; FNF: 1.0
Arising: 0.0 Posture: 2.0 GAIT: normal 0.0 with normal arm swing. Retro Pull: 0.0 General Body Bradykinesia: 3 (moderate)
Total UPDRS III: 35 out of possible 132 (mild-borderline moderate, with mild worsening from last visit)
Assessment/Recommendations59 year-old male with asymmetric rigidity, bradykinesia, which is mild, and most suggestive of idiopathic Parkinson’s disease. The bilateral nature of his symptoms places him at a Hoehn and Yahr Stage II, suggestive of mild disease. While not a substitute for formal neuropsychological testing, all cognitive testing performed today is normal, and I do not suspect there are any difficulties with mentation. There is, overall, increase in slowing (bradykinesia), endorsed by self-report and on examination. There is some impact on his activities of daily living and current work duties, suggestive of a Schwab and England (functional) scale of 90% (out of 100%). On review of his history and expected work duties, he has just started to notice an impact in his coordination, which has potential to interfere with some aspects of his work. In addition there is anxiety which is likely starting to contribute. It is recommended he undergo a skills evaluation to objectively measure the impact of his bradykinesia on the specific skills required in the intensive care unit. Regarding treatment of his Parkinson’s disease, he is doing quite well with a regular exercise program, and would recommend he continue this along with his current medications. Sinemet could be increased slightly to aid with bradykinesia symptoms, and may improve anxiety as may use of an agent such as a dopamine agonist. Also discussed with him the need to consider anxiolytic medication should this not be effective.
Emergency Medicine Simulation: Daniel Davis, M.D., evaluated Dr. X’s performance on an emergency medicine simulation. The following excerpt is taken directly from Dr. Davis’ report and summarizes Dr. X’s performance:
This letter serves to document my repeat fitness evaluation of Dr. X on November 13, 2014. This letter references Dr. X’s original evaluations in 2011, 2012, and 2013. As with his original evaluations, my approach to this assessment was to have Dr. Xperform various resuscitation procedures on high-fidelity human patient simulators. These procedures included the following: endotracheal intubation, bag-valve-mask ventilation, surgical cricothyrotomy, internal jugular central venous catheter placement, and tube thoracostomy placement. For endotracheal intubation, the simulator was manipulated to produce progressively more difficult airways. In addition, several simulated cases were generated to allow assessment of psychomotor skills performance in the context of a challenging case scenario and allow some insight into cognitive function with critical patients. Assessments were based upon successful performance of each procedure and recording of elapsed time prior to task completion as well
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as overall approach to patient management. I have included prior years’ times for reference.
I have substantial experience using high-fidelity human patient simulators to assess critical care personnel. The curriculum was developed for flight nurses and paramedics, who routinely perform each of the procedures on which Dr. X was being assessed. These air medical provider assessments are used as the basis for hiring decisions and to trigger remediation protocols, both of which require a standardized approach to testing and interpretation. I have assessed over 600 crewmembers since the program was initiated more than 8 years ago. Since that time, I have developed similar curricula for emergency medicine residents and faculty, anesthesia house staff, and critical care fellows. It is this latter group that I have felt is most relevant in comparing Dr. X, since their institutional skills sets are essentially identical. In addition, referencing his prior performance has remained useful to evaluate for potential deterioration. While some degree of learning and familiarity with the simulators may be present, most research on simulation training suggests skills decay after approximately four months. Thus, I do not feel that his prior sessions with our simulators would contaminate our ability to assess his psychomotor and cognitive performance. Finally, while I recognize the artificiality of using simulators to assess clinical skills, I am confident that this is a valid approach to evaluating critical care providers, as the same individuals who struggle during simulation have difficulties in clinical practice.
EvaluationThis year more than in previous years, Dr. X's physical limitations were observable during casual interactions, with bradykinesia and a moderate tremor visible to a greater degree than in prior years. The bradykinesia became more apparent with initiation of the evaluation, which requires dexterity, fine motor skills, and some strength. As noted previously, Dr. X has developed compensatory strategies for the critical procedures that allow him to perform each effectively. This includes stabilization of his arms/hands against his body, the bed, and the patient as well as the leveraging of the laryngoscope blade against the upper teeth. Although this would be considered suboptimal technique for elective surgery and likely reflects some degree of motor dysfunction when significant force is required for laryngoscopy, this is not unreasonable in the setting of a difficult or emergency airway. Dr. X stated that the majority of his procedures are performed while waiting for arrival of a dedicated team or after failure by either a Nurse Anesthetist or Anesthesiologist.
Dr. X was allowed to practice endotracheal intubation several times before the simulator was manipulated to increase the difficulty level. Following a series of straightforward intubations, the following difficulty factors were added sequentially: inflation of pharyngeal balloon (P), trismus (Tr), a decrease in cervical spine mobility (C), tongue inflation (To), and laryngospasm (L). Time results are summarized below. Both time-to-insertion of the endotracheal tube as well as delivery of the first breath were recorded. The first time represents proficiency with laryngoscopy and is influenced not only by psychomotor function but experience and familiarity with the anatomy. The additional timerequired to deliver the first breath has not only clinical relevance but also reflects a series of fine motor activities that are relatively independent of experience
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level. Specific times for successful placement of the endotracheal tube and for delivery of the first breath are as follows:
2011 2012 2013 2014Baseline 21 sec/42 sec 33 sec/51 sec 14 sec/29 sec 25 sec/34 secP 30 sec/50 sec 17 sec/31 sec 17 sec/30 sec FailedTr 20 sec/44 sec 14 sec/28 sec 19 sec/34 sec 16 sec/31 secC 20 sec/38 sec 21 sec/34 sec 17 sec/28 sec 20 sec/36 secTo 21 sec/44 sec 19 sec/35 sec 17 sec/28 sec 20 sec/37 secTr+P 20 sec/37 sec 18 sec/33 sec 17 sec/33 sec FailedTr+To 16 sec/35 sec 16 sec/31 sec 28 sec/46 sec 28 sec/44 secTr+To+C 65 sec/85 sec 32 sec/45 sec 22 sec/34 sec 19 sec/34 secP+L 44 sec/85 sec 26 sec/45 sec 13 sec/27 sec 30 sec/45 sec
Two intubations were performed in the context of simulated cases. The first patient was presented as septic and requiring fluid and pressor resuscitation as well as intubation for airway protection and ventilatory support. No airway difficulty factors were applied. Dr. X intubated successfully in 22 seconds (versus 10, 8, and 8 seconds in 2011, 2012, and 2013), with the first breath applied in 37 seconds (versus 25, 21, and 19 seconds in 2011, 2012, and 2013). The second patient had COPD and was intubated for respiratory distress and hypoxemia. Both trismus and inflation of a pharyngeal balloon were applied. Dr. Xsuccessfully intubated in 81 seconds (versus 28, 26, and 18 seconds in 2011, 2012, and 2013) and delivered the first breath in 106 seconds (versus 55, 39, and 34 seconds in 2011, 2012, and 2013). There were no missed intubations throughout the patient scenario-based sessions.
Dr. X was also asked to perform bag-valve-mask ventilation using a standard AmbuBag and mask. In the past, he was able to achieve tidal volumes of 500 mL using the “out-of-the-box” mask. However, this year he correctly noted a substantial amount of air leak, with tidal volumes measured by the simulator of only 150-200 mL. When given a different mask that contains a high grade, supple rubber for better seal, Dr. X was able to achieve tidal volumes of 450 mL, which are consistent with what would be required clinically.
Dr. X also performed a surgical cricothyrotomy, completing the task in 81 seconds (versus 62, 52, and 59 seconds in 2011, 2012, and 2013). He had some difficulty manipulating the endotracheal tube into the opening and down the trachea, as some finger strength is required to bend the plastic tube. Dr. Xperformed tube thoracostomy without technical difficulties in 81 seconds (versus 90, 82, and 83 seconds in 2011, 2012, and 2013). He performed central venous catheter placement with some challenge in placing the guide wire into the catheter; the total time required 213 seconds (versus 204, 184, and 187 seconds in 2011, 2012, and 2013). These procedures generally involve more steps than for endotracheal intubation, which explains the longer time periods.
InterpretationThere has clearly been disease progression from last year to this year, which Dr. Xfreely acknowledges. This was visible with casual interaction as well as throughout the evaluations. Although his strength was diminished and his
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bradykinesia and tremor were more pronounced, Dr. X was still able to perform the majority of intubations as well as the central line placement, tube thoracostomy, and cricothyrotomy with times comparable to those in each of the previous years. This reflects his experience as a critical care physician, which brings enough familiarity with the procedures that he is able to adapt and compensate “on the fly” by leveraging and stabilizing the equipment and his hands/arms as noted above.
The limitations related to his disease progression were visible in two areas: simulated patient cases and whenever a greater degree of strength was required to complete the task. The simulated patients require that focus be shifted away from the technical aspects of the procedure and toward the clinical presentation and physiology of the patient. This appears to have distracted Dr. X enough that he could no longer employ the compensatory strategies with the same degree of effectiveness, leading to completion times that were 2-3 times longer than in previous years and when compared to similar airway configurations in the absence of simulated clinical information. In addition, addition of the pharyngeal balloon (P), which narrows the glottis and requires that additional force be applied to achieve intubation, resulted in much longer times and failure of the procedure on two occasions. Similarly, bag-valve-mask ventilation requires some hand strength in order to achieve a good mask seal and adequate tidal volumes. With use of a standard mask, Dr. X was unable to perform this task adequately. However, switching to a better quality mask allowed him to overcome his strength limitations.
In summary, my evaluation was consistent with the clinical information received beforehand and relayed by Dr. X. The disease progression was evident with casual interactions and during the evaluations. Dr. X has employed compensatory strategies for each of the procedures that allow him to perform at a level consistent with previous years and with other critical care practitioners. However, when procedures were performed in the context of simulated cases or when some measure of strength was required, completion times were substantially greater or procedure failure was observed. It is likely that the vast majority of procedures would not require the level of strength necessary during portions of the evaluation. It is also likely that Dr. X’s experience level would compensate for the distraction of physiological data in most clinical scenarios. However, it is also possible that his physical limitations would result in procedure failure under the right clinical circumstances.
I had several frank discussions with Dr. X about his expectations related to this evaluation. I believe that he truly wants to assure himself (as well as others) that he is – or is not – physically competent to practice critical care without the risk of injuring his patient. His desire to avoid patient harm is sincere. I believe that these results should be discussed with him directly and a decision about continuing clinical practice achieved with his input. I gave him an overview of my findings, which did not seem to surprise him in any way.
Final Summary and Recommendations:
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All of PACE’s findings and recommendations are based on the information available to us atthe time of presentation.
In summary, Dr. X is a 59 year old critical care specialist referred to PACE for a Fitness for Duty Evaluation by Hawaii Kaiser Permanente Medical Group for follow-up of his Parkinson’s disease after a recent incident resulted in him being placed on administrative leave. He was initially evaluated by the UCSD PACE Program in July 2011 and re-evaluated October 2012 and December 2013. As part of his FFD evaluation, Dr. X underwent an interview with Dr. Bazzo and the following three evaluations:
1. Fitness for duty – neuropsychological evaluation2. Neurology evaluation3. Emergency medicine simulation
The results of Dr. X’s FFD evaluation are as follows:
According to Dr. Bazzo, Dr. X appeared frailer and was moving more slowly than in previous evaluations. Additionally, he observed an intermittent slight tremor in his right upper extremity and a mild tremulousness to his voice. Dr. X’s neuropsychological testing revealed intact attention, speed of information processing, language, visuospatial/organizational skills, learning/memory, and executive functioning; however, moderate deficits were observed on measures of fine motor dexterity and psychomotor speed. Dr. Perry expressed concern over Dr. X’s difficulties in the areas of fine motor dexterity and speed and their implications to hispractice which may lead him to struggle with important procedural skills with confidence and competence. According to Dr. Perry, of additional concern is Dr. X’s self-reported fatigue and the progression of his condition over time. Based on Dr. Lessig’s neurological evaluation, Dr. X’s bilateral symptoms are suggestive of mild Parkinson’s disease with an increase in slowing and some impact on his activities of daily living and current work duties. During the emergency medicine simulation, Dr. Davis noted physical limitations and disease progression, marked bybradykinesia and a moderate tremor. While Dr. X displayed compensatory strategies that allowed him to perform at a level consistent with previous years and with other critical care practitioners, when procedures were performed in the context of simulated cases or when some strength was required, completion times were substantially greater or procedure failure was observed. Dr. Davis commented that although it is likely that Dr. X’s experience level would compensate for the distraction of physiological data, it is possible that his physical limitations could result in procedure failure under the right clinical circumstances.
Following Dr. X’s re-evaluation, the PACE Program has serious concerns about his ability to practice medicine safely. Dr. X’s overall performance on the UCSD PACE Fitness for Duty evaluation indicated that he is UNFIT FOR DUTY with respect to the customary clinical performance of critical care medicine, including procedures. However, if Dr. X were to assume a position that did not require manual procedural responsibilities, such as that of a teacher or mentor, he would be perfectly fit for duty.
The PACE Program has defined three possible outcomes of the Fitness for Duty Evaluation:
FIT FOR DUTYResults either indicate that no presence of illness exists that interferes with the physician’s ability to safely perform the duties of his or her job OR that presence of illness exists but currently does
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not interfere with the physician’s ability to safely perform the duties of his or her job. Re-evaluation may be recommended depending on the prognosis of present illness(es).
FIT WITH ACCOMODATION(S)Results indicate that presence of illness exists that interferes with the physician’s ability to safely perform some, but not all of his or her duties. The specific limitations for each functional area of concern will be described. Recommendations will be provided for possible methods of accommodation. Re-evaluation may be recommended depending on the prognosis of present illness(es).
UNFIT FOR DUTYResults indicate that presence of illness exists that interferes with the physician’s ability to safely perform most or all of the duties of his or her job. The physician presents a significant risk to patients, self, and others. It is unlikely that any reasonable accommodations could be made that would allow the physician to practice safely. Re-evaluation may be recommended depending on the prognosis of present illness(es).
Please contact our office at 619-543-6770 if you have any questions.
Sincerely,
William A. Norcross, M.D David Bazzo, M.D., FAAFPClinical Professor of Family Medicine Clinical Professor of Medicine Director, UCSD PACE Program Director, Fitness for Duty Program
UCSD PACE Program
Patricia Reid, M.P.H.Case ManagerAdministrative Director, Fitness for Duty ProgramUCSD PACE Program
Fitness for Duty Report
Example #2
October 21, 2014
Richard C. Engel, M.D.Chief of Staff Palomar Medical Center555 E Valley Pkwy Escondido, CA 92025
RE: Fitness for Duty Evaluation of Joseph M, M.D., License No. G021242
Dear Dr. Engel,
Dr. X is a 70 year old hand surgeon that was referred to the UCSD PACE Fitness for Duty (FFD) Program by Palomar Medical Center following concerns of his ability to safely perform surgical procedures after an eye infection led to monocular blindness.Specifically, his colleagues have noted possible depth of field issues during surgical procedures. Dr. X participated in the PACE Fitness for Duty evaluation September 22-23and October 6, 2014. This report details the four components of Dr. X’s evaluation: 1)Fitness for duty interview conducted by David, E.J. Bazzo, M.D., Fitness for Duty Program Director, UC San Diego PACE Program; 2) aging physician screen which includes: history and physical exam, hearing screen, cognitive health screen, and mental health screen;3) Ophthalmologic evaluation conducted by Jeffrey Lee, M.D., UC San Diego; and 4)Hand surgery simulation conducted by Reid Abrams, M.D., Chief, Division of Hand and Microvascular Surgery, UC San Diego. A summary and recommendations section is provided at the conclusion of this report.
Inventory of Background Materials: Background information was received by way of written communication and telephone conversation. Below is a list detailing the written materials:
1. Program application and intake questionnaires2. Curriculum vitae of Dr. X3. Root Cause Analysis from Dr. X4. Documents from Palomar Medical Center outlining concerns and reason for
referral5. Medical Records of Dr. X
Fitness for Duty Evaluation Results:
Fitness for Duty Interview: David Bazzo, M.D., Fitness for Duty Director, interviewed Dr. Xto gather additional background information and discuss the incidents that led to his FFD referral. The following is an excerpt from Dr. Bazzo’s report:
Dr. X grew up in Michigan where he attended high school. He attended Princeton University and then attended Northwestern Medical School. He
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graduated in 1970 and did his surgical internship at San Francisco General Hospital finishing in 1971. From 1971to 1975 he worked in the emergency department at Hillcrest Hospital in Petaluma, California. He then moved to Maine to assume the directorship of Augusta General Hospital Emergency Department. He remained there until 1977 when he then entered an orthopedic residency program at Tufts Medical Center in Boston. He completed his residency in 1980 and then went on to do a rotating hand surgery fellowship through 1981 in Phoenix and Tucson, Arizona and the Mayo Clinic in Rochester, Minnesota, spending 6 months at each location. After completing his training, Dr. X worked for five years in Coos Bay, Oregon as a hand and orthopedic surgeon. During that time, hesuccessfully passed his boards.
Dr. X moved to Escondido to purchase his friend’s practice on July 1, 1987. He had a solo hand surgery practice and operated at Palomar Hospitalonly. After seven years of solo practice, he joined an orthopedic group where he practiced for nine years. In 1996, he was made the head of orthopedics at Palomar Hospital, and in 1998 became Chief of Staff Elect, and then Chief of Staff in 2000. However, he was removed from the Chief of Staff position in 2001 when he underwent an intervention for substance abuse and entered the Diversion Program of the State of California. Dr. Xwas addicted to opiates, particularly Vicodin. He reports that he began to “self-medicate” his depression in the 1990s. He reported he had significantfinancial problems related to a divorce from a bad marriage. He reported that in 1990, his then wife, who never had finished college, decided to return to finish her degree and “disappeared” from 1990-1 (1.5 years). During that time, he had two children and acted as a single parent. He states that at that time, his wife managed the family’s finances, was depressed, and left him with significant financial problems in addition to the children.
Upon her return, they filed for divorce and the process was completed in January 1993. He stated that he had a difficult time, was responsible for everything and struggled. He started to use Vicodin then and notes that it “stimulated” him and made him “more productive” so that he “could get more done”. In 1994, he joined the group practice, thinking it would be better, but notes that the managing partner was “not a good person” and left Dr. X struggling financially with decreased income. It was after he became Chief of Staff and his ex-wife garnished his Chief of Staff stipend, that he was humiliated, decompensated, and the medical staff intervened regarding his opiate addiction. This occurred near the time of 9/11. He was scheduled to fly to Springbrook inpatient rehabilitation facility in Portland, Oregon when his flight was cancelled and he was driven there. He remained at the facility through December 2001. Upon his return, he was only allowed to practice 20 hours per week while engaged with the Diversion Program. This lasted for a few months and ultimately, he was allowed to increase his practice time. He remained in the Diversion Program until 2008.
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Dr. X suffered more hardship during this period when on July 22, 2002, his daughter committed suicide. Additionally, he had to declare bankruptcy in September 2003. He notes that at that time, a colleague, Paul Milling,MD, a general orthopedic surgeon, took him in and they have been partners since.
Unfortunately, Dr. X stated that he had poor judgment in 2006 and breeched sexual boundaries with an employee in the office and was sued for $100,000. Additionally, he had an issue with a seductive patient.The police investigated the incident and he received a letter of reprimand from the Medical Board of California. In 2007, he attended the UCSD PACE Professional Boundaries and Medical Record Keeping Programs. After completing these requirements and a prolonged time in the Diversion program, he felt rehabilitated.
However, in February 2008, Dr. X acutely lost the vision in his left eye due to acute retinal necrosis caused by herpes simplex. He underwent treatment with Dr. William Freeman, a retina specialist at UCSD Ophthalmology but never regained vision in that eye despite three attempts at surgery. Later that year, he resumed performing surgery and was proctored. In approximately 2009, someone at the hospital reported a concern about Dr. X’s surgeries. He stated that the Palomar Hospital Executive Committee evaluated the situation and were satisfied by a response from his treating ophthalmologist, that he continued operating. He notes that he made adjustments to compensate for his loss of stereovision. He used monocular clues to judge depth. He took familiar cues from anatomic landmarks, used lighting and magnification in addition to moving his head around to judge depth. He also used his hands to feel depth and exercised caution.
In May 2014, a complaint was levied by an anesthesiologist regarding Dr. X’s ability to safely perform surgery. Dr. X stated that he was unsure of why the complaint was made but does note that while performing a surgery, the surgical drill passed through a patient and into the surgical table during a case. Dr. X however stated that “driving a pin though a field is usually done by feel. First, one passes through the proximal cortex with resistance, then one encounters resistance on the distal cortex. It’s not visualization. If you don’t get resistance, you can go past the cortex.” Dr. Xwas informed by the hospital chief of staff and department head to cease performing surgery.
Dr. X reports one peer review case in the last few years. This took place in 2011-2 and did not involve surgical technique. The case involved a 25 year old female who developed gram negative sepsis. She was resuscitated, intubated and was on cardiac pressor medication. She developed ischemic hands and feet. She lost both legs and had bad hand ischemia. He evaluated her circulation and opted for conservative management to observe her. He decided to wait two weeks and then
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bring her to the operating room. However, the ischemia progressed and the patient necessitated amputation at the wrist on one side and at the palm on the other. He states that he took photos of the operation and showed them to her distraught family. He was later paged by an ICU nurse to speak to the patient and on the following day, was “fired from the patient’s care”. He notes the peer review found no fault. He notes that the drill incident, to his knowledge, did not go through a peer review.
With regard to Dr. X’s surgical privileges, he prefers to be conservative and “keep it simple.” He states he “does the simplest thing that will work.” He does no microsurgery, but utilized surgical magnifying loupes for his cases. He performs:
Carpal tunnel releasesTrigger finger releasesTendonitis releasesDupuytren contracture releasesOpen reduction, internal fixation for trauma casesRepair of lacerated tendons or nerves (uses biodegradable nerve tubes)Open tendon transfersPlastic surgery scar revision or flapsSmall joint replacement in the hand/wrist
His self-assessment is that he “doesn’t bite off more that he can chew.” He believes that by doing procedures that are simple and straightforward that he can continue his surgical practice. He prefers procedures that he’s performed many times and doesn’t do “one of a kind” procedures. He stated that he struggled with his vision at first, but that it is better now. He is deeply involved with his sobriety and had attended at least two Alcoholic Anonymous meetings per week, but is attending more now. He had made many friendships through AA and notes that he is a “spiritual seeker”. He works out regularly and is an avid reader. He does some travel. He now has his “second generation family” and has been happily married since 2008. From this marriage, he gained two sons and adaughter who are all living at home. He is still struggling with his finances as he hasn’t performed surgery in three months. He does continue to see patients in an outpatient setting three days per week and does office procedures. He states that he has a relationship that is a “bit distant” with his son from his first marriage, but he would like to improve it. Dr. X stated that he is anxious to proceed with our fitness for duty evaluation to confirm that he is fit to continue surgery.
During our approximately two hours together, I found Dr. X to be open, forthright and honest with my questioning. He displayed insight into his situation and wants to provide safe care to his patients. He values the doctor patient relationship and feels that he has more to offer his patients. His left eye was noted to be somewhat opaque appearing.
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Aging Physician Screen: Dr. X participated in an aging physician screen which included the following components:
1. History and physical examination2. Hearing screen3. Cognitive function screen
a. MicroCog™b. Montreal Cognitive Assessment (MoCA©)
4. Mental health screena. Patient Health Questionnaire (PHQ-9) scaleb. Generalized Anxiety Disorder (GAD-7) scale
History and Physical ExaminationSheila Pickwell, Ph.D., C.F.N.P., conducted the history and physical exam andhearing screen. Dr. X reports currently taking medication for atrial fibrillation, high cholesterol, and high blood pressure. He reports thirteen years of sobriety from alcohol and illicit drug use and regularly attends Alcoholics Anonymous. During the physical exam, Dr. Pickwell noted cerumen in his ear canal which may have contributed to his abnormal performance on the hearing exam.
Cognitive Screening TestsMicroCog™, a computer-based assessment of cognitive skills, is a screening test used to help determine which PACE participants should be referred for a full neuropsychological evaluation. The test is a screening instrument only; it is not a diagnostic tool. It does require some proficiency with computers; however, a proctor is available to answer questions about test instructions.
Relative to a person of similar age and educational background, Dr. X performed in the above average range on the following summary indices: general cognitive functioning, general cognitive proficiency, information processing accuracy, attention/mental control, reasoning/calculation, memory, and reaction time. Heperformed in the average range on the following summary indices: information processing speed and spatial processing. His results were reviewed by William Perry, Ph.D., Professor, In Residence, Associate Director of the Neuropsychiatry and Behavioral Medicine Service at the UCSD Medical Center on October 3, 2014. According to Dr. Perry, Dr. X’s performance does not indicate a recommendation for further neuropsychological evaluation at this time.
Dr. Pickwell administered the Montreal Cognitive Assessment (MoCA©) to Dr. X. He scored 29/30 which is in the normal range.
Mental Health ScreenDr. X completed the PHQ-9 Depression screen and the GAD-7 Anxiety screen. Dr. X’s scores on both the PHQ-9 and the GAD-7 were low and not indicative of significant depression or anxiety.
Ophthalmologic Evaluation: Jeffrey Lee, M.D., conducted an ophthalmologic evaluation on Dr. X. The following excerpt is taken directly from Dr. Lee’s report:
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Dr. X’s past medical history is notable for hyperlipidemia. His past ocular history is significant for previous Acute Retinal Necrosis infection of the lefteye that resulted in the inability of his left eye to perceive light. His family ocular history is non-contributory.
Here is a brief summary of the ophthalmologic exam:His visual acuity was 20/25 in the right eye and no light perception vision in the left eye. He noted that the previous infection has left his eye with no vision. With a plus 3.00 Diopter lens, patient’s near vision was J1 in his right eye. His pupillary exam was 4mm to 3mm in response to light right eye and fixed and inferiorly displaced in the left eye. A reverse afferent pupillary defect was present in the left eye. A Humphrey Visual Field 24-2 was done and the right eye was found to have essentially a full field. The left eye was not tested because no vision is present. Patient showed no color deficit based on Ishihara color plate testing (14/14 od). Stereoscopic testing revealed no stereopsis (this was expected given patient’s monocular status).
Slit lamp examination was revealing for mild dermatochalasis in both eyes that was consistent with aging changes. Similarly, early cataract changes of the right eye were found to be consistent with patient’s age and not visually significant. Otherwise the right eye was without any other notable findings. The left eye was noted to have an irregularly shaped and displaced pupil. The left eye was found to have significant band keratopathy and thus a poor view to see the rest of the eye. Of note, the patient was noted to be aphakic in the left eye.
The fundoscopic exam was within normal limits in the right eye. Cup to disc ratio was approximately 0.30 in the right eye with mild peripapillary atrophy. Optical Coherence Tomography of the right eye revealed no focal defects of the retinal nerve fiber layer. The left eye was found to have a detached retina with significant proliferative vitreoretinopathy. Otherwise, the view was too poor to differentiate other details.
Based on the exam and the clinical findings, patient had essentially a normal vision exam of the right eye. His left eye, as previously noted is without visual function and this is consistent with his exam findings of the left eye. With one healthy eye, patient is not expected to have any stereoacuity as noted on his eye exam. However, lack of stereoacuity does not preclude the function of depth perception as one can potentially use many other cues to determine depth. He will be followed by his ophthalmologist for continued management of his current eye status.
Hand Surgery Simulation: Reid Abrams, M.D., conducted a hand surgery simulation on Dr. X at the UCSD Center for the Future of Surgery (CFS). The following excerpt is taken directly from Dr. Abrams’ report:
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As part of Dr. X’s evaluation, I was asked to perform a surgical simulation exercise and evaluate as objectively as possible, Dr. X’s surgical ability and safety. Understanding there could be a conflict of interest due to my working in the same general community, I requested representatives from the PACE program to confirm with Dr. X that he was comfortable with me doing his evaluation, and it was communicated back to me that he was. Dr. X said to me he is reluctant to retire due to his love of taking care of patients and doing surgery as well as the need to continue for financial reasons.
Dr. X’s demeanor was humble, professional and friendly. He was not defensive and I did not perceive our interaction as adversarial.
Description of the simulation:After changing into surgical scrubs, Dr. X and I went to the OR, which was equipped with a fresh cadaver left hand and forearm. The OR at CFS is very similar to a real one, with standard operating table and ample light. We were provided with a real surgical hand set procured from the VA Hospital with sharp and serviceable instruments and retractors. We were provided with appropriate sutures for the procedures that we were going to simulate. We both donned our own operating magnification loupes.
We simulated 2 very common procedures that should be routine for all hand surgeons: Carpal tunnel release and zone-2 flexor tendon repair. Though Dr. X generally operates alone with a scrub nurse as his assistant, I served as his assistant. As this was not a cognitive test, I did not assess Dr. X’s surgical indications and thought processes. I limited my evaluation to the surgery and his ability to do the above mentioned procedures safely and effectively.
Carpal Tunnel Release (CTR): Dr. X drew out his incision in line with the radial border of the ring finger extending about 2 cm proximal from Kaplan’s line. This incision is typical for the commonly performed mini-open version of CTR. He made his incision down to and through the palmar fascia. He encountered the ulnar side of the thenar muscles and continued cutting down through them until he encountered the distal edge of the transverse carpal ligament (TCL), which he transected from distal to proximal until he indicated to me that he had completed the release. I then instructed him to open and extend his incision proximally and distally to be able to evaluate his surgery. It was apparent he had not completed the release leaving the proximal 25% of the ligament unreleased. On examination of the operated structures through the larger exposure, it was clear he performed the release more radially in the carpal tunnel than ideal, directly over the median nerve. Performing the release on the ulnar side of the canal is preferred to avoid nerve injury and scar adhesions re-entrapping the nerve. He should have recognized that he was off course when he encountered thenar musculature, which
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serves as a landmark for being too radial. He also came dangerously close to injuring the motor branch of the median nerve. During suture closure, I observed that he often had difficulty picking up the suture end with an instrument, making multiple grasps for it before succeeding, as one would expect with depth perception problems. Similarly, he would often make several passes with the needle to position the suture in the skin edge appropriately.
Zone-2 Flexor Tendon Repair: I created a flexor tendon injury by making a transverse scalpel laceration in the volar central portion of the middle finger just distal to the proximal interphalangeal joint (PIP). I made the injury close to the midline endeavoring to avoid the neurovascular bundles as part of the injury. Dr. X then appropriately drew out mid-lateral incisions incorporating the injury laceration. I observed that, when he was making his incisions and raising the skin flaps, he sometimes made multiple passes with the knife not in the same line making undesirable adjacent skin incisions. He had difficulty dissecting meticulously with knife and scissors compromising flap thickness as he lifted the flaps off the flexor sheath. This is concerning for flap viability and causes unnecessary scar formation. During Dr. X’s dissection, I believe he inadvertently lacerated the ulnar digital neurovascular bundle. When I pointed this out to him, he queried whether I might have caused the neurovascular bundle transection with my simulated injury (rather than a misadventure on his part), and, to be fair, I was not absolutely certain. I then asked him to dissect out the radial digital neurovascular bundle and in so doing; I witnessed him accidentally cut it in half. He did not realize this until I pointed it out to him, and this time he acknowledged the error.
We then proceeded to the tendon repair. He used a cruciate core suture repair with 2-0 Ethibond with fair accuracy, but requiring overly excessive tendon handling (hand surgeons universally try to minimize flexor tendon handling during repair in zone-2 to minimize scar formation and adhesions) again appearing to be challenged by depth perception when trying to pass sutures. He completed the repair not recognizing that he did not pull the repair together adequately, leaving a gap of approximately 3 mm (Tendon gapping results in adhesions, loss of tensile properties and tendon rupture). He acknowledged this when I pointed it out to him. He then proceeded with the epitendinous simple running suture repair with 6-0 Prolene. Due to the small but standard suture size and the diminutive size of the structures being repaired it was, at this point, extraordinarily apparent he was struggling with visual cues and depth perception, often making multiple passes at the tendon with inaccurate throws, abandoning this part of the repair completing only the anterior side of the tendon rather than finishing the accepted circumferential technique.
When we were finished we had a discussion about my observations and worries about his deficiencies. He admitted he has difficulty with depth
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perception in other areas of his life, such as going down stairs, consequently always relying on a banister. During part of the discussion, I told him that I believe for his benefit and that of his patients he should no longer be doing hand surgery due to the danger and he appeared to understand. Since before our simulation, he thought he could operate safely, this news was understandably distressing and seemed somewhat a surprise. He was not defensive, but understandably saddened and disappointed to hear my objective opinion. I mentioned there might be a non-surgical employment opportunity somewhere that could utilize his clinical judgment and knowledge. He thanked me for my candid opinion and my time.
Summary and Recommendations:
All of PACE’s findings and recommendations are based on information available to us at the time of evaluation.
Dr. X’s overall performance on the UCSD PACE Fitness for Duty evaluation indicates that he is currently UNFIT FOR DUTY as a hand surgeon. During the history and physical exam, Dr. X was noted to have build-up of cerumen in his ear canal which may have affected his hearing screen. He scored in the average to above average range on the MicroCog™ cognitive screening test. Additionally, he performed in the normal range on the Montreal Cognitive Assessment. Dr. X’s visual acuity was determined to be 20/25 in the right eye and without light perception vision in his left eye. He performed unsatisfactorily on the hand surgery simulation. Specifically, on the carpal tunnel release case, he left the proximal 25% of the ligament unreleased and during the suture closure, he often had difficulty picking up the suture end with an instrument. On the zone-2flexor tendon repair case, he accidently cut the radial digital neurovascular bundle in half while trying to dissect it out. Additionally, he did not pull the repair together adequately, leaving a gap of approximately 3mm. Dr. X again appeared challenged when trying to pass sutures, often making multiple passes at the tendon with inaccurate throws.
Following Dr. X’s Fitness for Duty evaluation, the PACE Program has serious concerns about his ability to perform hand surgery procedures. While his hand surgery simulation revealed significant deficiencies with depth perception and visual cues, his cognitive capacities were determined to be intact on both the MicroCog™ and MoCA© cognitive screening tests. As such, although we recommend he discontinue performing any surgical procedures, his performance on the rest of our fitness for duty evaluation does not preclude him from pursuing a non-surgical employment opportunity. It should be noted, however, that we did not evaluate Dr. X’s non-surgical abilities and as a result cannot comment on his competence to practice in that area. Our recommendations are outlined below:
1. Discontinue performance of any surgical procedures2. Obtain ear lavage and have hearing retested
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The PACE Program has defined three possible outcomes of the Fitness for Duty Evaluation:
FIT FOR DUTYResults either indicate that no presence of illness exists that interferes with the physician’s ability to safely perform the duties of his or her job OR that presence of illness exists but currently does not interfere with the physician’s ability to safely perform the duties of his or her job. Re-evaluation may be recommended depending on the prognosis of present illness(es).
FIT WITH ACCOMODATION(S)Results indicate that presence of illness exists that interferes with the physician’s ability to safely perform some, but not all of his or her duties. The specific limitations for each functional area of concern will be described. Recommendations will be provided for possible methods of accommodation. Re-evaluation may be recommended depending on the prognosis of present illness(es).
UNFIT FOR DUTYResults indicate that presence of illness exists that interferes with the physician’s ability to safely perform most or all of the duties of his or her job. The physician presents a significant risk to patients, self, and others. It is unlikely that any reasonable accommodations could be made that would allow the physician to practice safely. Re-evaluation may be recommended depending on the prognosis of present illness(es).
Please contact our office at (619) 543-6770 if you have any questions.
Sincerely Yours,
William A. Norcross, M.D David Bazzo, M.D., FAAFP Clinical Professor of Family Medicine Clinical Professor of Family MedicineDirector, UCSD PACE Program Director, Fitness for Duty Program
Patricia Reid, M.P.H.Case ManagerUCSD PACE Program
Fitness for Duty Report
Example #3
