Kate Johnson

November 01, 2012

MONTREAL, Canada — Physicians who are monitored by a physician health program (PHP) reduce their risk of a paid malpractice claim to 20% below that of nonmonitored physicians, suggesting "one advantage of PHP participation is increased safety and not just better health," according to Michael Gendel, MD, a Denver psychiatrist and medical director emeritus of the Colorado PHP.

The findings, from a preliminary investigation by the Colorado PHP (CPHP), "strongly suggest the need for early PHP involvement" — not necessarily restricted to physicians with substance abuse or mental health disorders, said Dr. Gendel, who presented the study here at the 2012 AMA/CMA/BMA International Conference on Physician Health (ICPH).

"We must try to create conditions that encourage self-referral and voluntary referral to our PHPs," said Dr. Gendel, noting that 40% of the CPHP participants come voluntarily and another 20% are encouraged (but not mandated), sometimes for less overt problems, such as "behavioral issues."

"I'm convinced that developing a relationship with all the people we monitor over time is a source of support and sometimes confrontation, but has a salutary effect," he said. "Even among the group simply with behavioral problems, they actually do change when they have a certain amount of accountability and they're seen on a regular basis and asked about behavioral issues and stresses that precipitate those problems."

Among CPHP's behavioral referrals, "about a third have an underlying psychiatric illness that can be treated, another third have significant psychosocial problems that we believe influence their behavior, and a third don't have any those things," said Doris Gunderson, MD, medical director of the CPHP.

The study included active and former participants in the Colorado PHP program with a mix of both voluntary and mandated involvement, said Elizabeth Brooks, MD, the organization's research assistant.

Each physician's risk relativity rating was compared with that of a non-PHP physician reference group that was matched for medical specialty and years of malpractice insurance — with all participants and control physicians being insured by the same provider (COPIC), which is Colorado's largest medical malpractice insurer, she explained.

"Risk relativity ratings are used by insurers to understand whether 2 groups are different in terms of their risk, which is defined as the number of claims and the cost of those claims (both direct and indirect) paid by the malpractice insurer," Dr. Brooks said.

The study found that, although starting from a higher risk category, PHP participants ended up decreasing their risk to 20% below that of the non-PHP group after monitoring.

"So in monetary terms, from the insurer's perspective, for every dollar spent by the malpractice insurer, the PHP physicians required about 20% less than their peers," she said.

Of particular interest is that the study did not find an association between malpractice risk and substance use disorders or mandated care," said Dr. Brooks. "Meaning that physicians who presented to the PHP who had a substance use disorder were no more likely to have a medical malpractice claim than those who presented without substance abuse, and the same for those who were mandated for evaluation compared to volunteers."

Male physicians had an increased risk for malpractice claims, as did older physicians, she said. The specialties most likely to face claims were family medicine, anesthesiology, general surgery, and obstetrics/gynecology.

"Actually, I was surprised by these findings," said Dr. Gendel. "Though it's what we should expect in the PHP world, I was really surprised at how robust the numbers were."

The 20% drop in risk among monitored physicians could be due to a number of things, he speculated.

"It could be that participants learned skills during their treatment and recovery — skills to communicate better with colleagues, staff, and patients. It may be that experience with the PHP led participants to make use of other professional supports — that is, maybe to seek consultation earlier in their work. Or maybe they were more motivated to practice conservatively and adhere to standards of practice, given what they learned in the PHP program."

The findings suggest the need to educate others about the benefits of PHP participation, said Dr. Gendel. "That education should be provided for physicians and for students and trainees, employers, insurers, hospitals, and licensing boards. This could improve the public safety and create avenues for early and confidential intervention."

But barriers to PHP participation remain a challenge, said Anna Reid, MD, president of the Canadian Medical Association.

"People are afraid of being monitored, we all are, that's just human nature," she said in an interview with Medscape Medical News. "We do need to educate people that the resources are out there, and we need to use them early."

She said even informal brief contact with a PHP can be tremendously helpful — something she learned herself after making a call.

"I needed some help that was confidential and I could not get from my peers around me at work. It was just a 1-hour phone call that gave me the support I needed at that time. Probably earlier in my career I would have had a harder time phoning because I thought I should be strong, but not now that I am later in my career."

Luis Sanchez, MD, director of Physician Health Services for the Massachusetts Medical Society, agreed that a cohort of the physicians referred to his program also have no substance or mental health problems but fall into a more vague category of behavioral issues.

"They have difficulty in getting along with others, personal and workplace conflict, they're distressed, and they're disruptive. If there seems to be no major illness and diagnosis, we often refer for professional coaching and our workplace conflict course," he told Medscape Medical News. "Most benefit from it — they learn to be better doctors and better citizens."

Dr. Sanchez said insurance companies cite communication problems as one of the major reasons that physicians get sued, "when the physician doesn't get along with the claimant — the patient or family.... It's my sense that when those physicians come to us, just being told to come to a physician health program has a helpful effect."

He said the addition of curriculum courses addressing such issues might be helpful, and "awareness of its importance is the first step."

The speakers and the commentator have disclosed no relevant financial relationships.

2012 AMA/CMA/BMA International Conference on Physician Health (ICPH). Presented October 26, 2012.

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