by Elizabeth Hofheinz, M.P.H., M.Ed., September 3, 2019
If an attending behaves unprofessionally, you go to the chair. If the chair or CEO misbehaves, where do you go? There is a real void in oversight of medical leadership, says Paul Tornetta, M.D., chairman of orthopaedics and director of orthopaedic trauma at Boston Medical Center.
“There are many instances in private practice and academic centers where department or hospital leaders wield quite a lot of power over their subordinates. While there are methods in place to manage issues raised about someone in the department, if the problem is with the chair themselves or in some cases a section chief, then we are largely at a loss for how to proceed. Physicians and other employees need the ability to report misconduct, particularly if it affects patients care in a way that is confidential and safe for them”
“Most facilities have a confidential tip line that goes to a compliance or safety officer and is then investigated by the appropriate department depending on the concern(s) raised. Many hospitals, like Boston Medical Center, where I work have done an excellent job with the reporting of safety issues, near misses, etc. For example, if a staff member reports that they went to see a patient and the SCD’s used to protect the patient from a blood clot was not on their leg, then a report will be filed and a team will review and act on it from a quality improvement standpoint. However, these reporting strategies are of little help when the issue is that someone in a perceived position of power is not taking appropriate care of patients, or if a high level hospital administrator is not acting in the best interest of patients”
So what if someone with behavioral issues has made his or her way into a real position of power in the administration of your hospital? Dr. Tornetta: “There are cases of intimidation and frank dishonesty and while total transparency is not always needed, a pattern of dishonesty can easily deteriorate confidence in leadership and morale of doctors and employees in an institution. To be clear, I am not talking about my own facility, but I have had more than a few colleagues and friends in facilities where one individual has led a department to a point of complete dysfunction or revolt. It is possible that many of these situations are salvageable with appropriate intervention”
“Ideally we would be able to obtain broad based information about leaders’ performance. I would recommend a truly anonymous survey about how colleagues and staff feel about working with you. I did a 360-degree evaluation for myself; Anonymous surveys were sent to multiple levels of employees ranging from the CEO to the clinic staff. One of my colleagues in general surgery just did the same thing. These evaluations can give one insight into behaviors and perceptions to which they are blind. But don’t ask if you don’t want to improve.”
“I see those who don’t want to improve as draconian and self-interested. They are essentially conflicted because their own interests may be in opposition to those of the employees. Yes, it is possible for horrible behaviors to come to light in those in leadership positions…you just have to look at recent reports in the media.”
And what of clinical competence? Who is going to hold physicians to the standards they agreed to when they took the Hippocratic Oath? “In the event that I were losing my ability to operate, or my clinical judgment, I know there are faculty in my department who would tell me if they thought I was ‘off’ in any way. I have a senior partner who immediately ask ‘What’s going on?’ But most surgeons don’t have someone who is going to challenge their clinical abilities.”
“At our hospital we are planning to begin a routine external review of our clinically active chairs. Why external? If I as a chair begin to have reductions that are a little worse than they used to be, or am operating on things that do not require it, input from an ENT surgeon or a Urologist is not going to be helpful. Likewise, if a sports medicine physician was doing my review, he or she would be unlikely to notice a nuanced shift in my practice—or to know whether I am practicing within standard guidelines (and vice versa). An external review is the only way to provide a realistic peer evaluation of an acting chair. At too many places a subordinate in the department will sign off annually on their professional ability.”
“The bottom line,” says Dr. Tornetta, “is that whenever anyone is thinking about reporting concerns about a person in the highest echelons, they are taking a huge personal risk—even though all institutions have a ‘no reprisal’ policy.”
The solution? “I am not sure what the ultimate answer is and I have been reaching out to many experts in institutional compliance to look for answers. I think that I, along with a few other people will put together a symposia for consideration by the AOA for their annual meeting to discuss these issues,” says Dr. Tornetta, “and we’ll go from there.”
