The Case of the Peripatetic Physician: A Strategy to Avoid Accountability

Stephen H. Miller, MD, MPH

Disclosures

November 30, 2009

The Case

Peripatetic: itinerant, moving around, ambulatory
Webster's Online Dictionary

Dr. N is a 55-year-old male physician. He graduated from a state university in the Southwestern United States in 1978, and obtained a medical degree in 1984 from a school in Mexico. Between 1984 and 1986, he participated in and successfully graduated from a rotating internship at a large metropolitan hospital affiliated with the medical school that he attended. He then participated in postgraduate year two (PGY2) training at a social health service hospital in another Mexican city. In mid-1988 he returned to the United States and secured a position in a family medicine residency at a local community hospital in Oklahoma. After 1 year, he reported that he was not happy with the training program, although he offered no specifics about his unhappiness. He moved on to another family medicine residency in Texas, where he remained for only 6 months. He reported that "an increasing interest in obstetrics and conflicts with the faculty" impelled him to join a family medicine training program in New Mexico that was responsible for a large population of obstetric patients. He completed 2 years of training in that program and was recommended as a candidate for certification to the American Board of Family Medicine (ABFM). He denied having any academic or behavioral problems during medical school or residency training and was certified by the ABFM in 1995 and recertified in 2002.

Following his residency in New Mexico, Dr. N began a solo family medicine practice in a small town in Wyoming, but left that community after 2 years, due, he said, "to financial difficulties, the hardships imposed by solo practice, and because patients did not appreciate his efforts on their behalf." He moved to a 3-physician family practice clinic in a small rural town in Utah, but left within 9 months because of "a partnership misunderstanding about his obstetric patient care." He then moved to a semirural community in Nevada and joined a group of 12 family medicine physicians, where he still practices.

The community in which he works owns a 30-bed hospital where he and members of his family medicine practice are granted staff privileges. He sees an average of 25-30 patients a week in his office and an additional 10-12 patients in the hospital or emergency department of the hospital. He is on call 3 nights per month and 1 weekend every 2 months. Overall he reports working 60 hours per week, sleeps 7 hours per night, and takes an annual vacation for 7-10 days with his family.

An external evaluation of the quality of medical care offered by the staff at the hospital was conducted. During the course of this evaluation, Dr. N's care involving 5 high-risk obstetric patients was called into question. His behavior with the nursing and ancillary healthcare staff was thought to be arrogant and, in some instances, abusive. In addition, it was noted that he frequently failed to maintain adequate patient records in a timely fashion. As a result, the external evaluators and the hospital medical staff requested Dr. N to obtain an independent assessment of his clinical competence. He elected to attend a special program that assessed competence and performance.

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