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Investigation of early warning signs of problematic behaviours by physicians

Amani Oakley of the law firm of Oakley & Oakley has generously provided C-QUIPS with a $50,000 donation to support patient safety research. This donation came from a medical malpractice settlement involving injuries and unnecessary operations on a large number of women by an individual gynecologist. This donation will be used to support work led by Dr. Chaim Bell.

The field of patient safety has overwhelmingly focused on “system problems” as the causes of errors and injuries to patients. This focus marked an abandonment of the traditional attitude that all bad outcomes reflected failings of individual providers. The traditional “blame and shame” approach was counterproductive, because it meant competent clinicians shied away from analyzing bad outcomes for their patients , and it ignored the large body of literature (not just from healthcare but from other high risk industries) that “latent system problems” set up competent individual operators within the system to make predictable types of errors. These predictable, system-related errors (unconnected medical records systems, fragmented, hyper-specialized delivery of care, poor communication between providers of care, poorly designed alarms, sound-alike/look-alike drug labeling and packaging, and numerous others) lead to far more problems for patients than do the actions (or inactions) of incompetent individuals.

Yet, we know some individual clinicians generate recurrent complaints from patients and repeatedly exhibit questionable competence or unprofessional behaviours. A recent research article in BMJ Qual & Safety reported that, among over 18,000 complaints from patients, 3% of doctors accounted for 49% of complaints. One of the several companion commentaries discussed the need to address the problem of “bad apples” as a new kind of system problem. Too often, investigation of cases involving egregious patterns of behaviour reveal early signals of poor quality or inappropriate care. The medical profession has generally shied away from acting on these signals. As the commentators wrote “Just as early warning systems detect deteriorating patients and alert medical emergency teams to intervene, the time may have come to recognize the need for early warning systems to identify physicians in need of intervention. In some cases, remediation may improve behavior. In others, recalcitrant behavior or continued legitimate complaints from patients will warrant restricted licenses or even removal from practice.”

Dr. Chaim Bell, a core member of C-QUIPs has conducted past research describing the characteristics of physicians across Canada who have been disciplined (including suspensions from practice and removal of licensure). The donation will support further work led by Dr. Bell to investigate earlier warning signs of problematic behaviours by physicians. While system problems remain the dominant target for quality improvement efforts, continuing to ignore the problem of “bad apples” understandably erodes public trust.

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