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Watson GL, Selfridge NJ, Wright BE. The opioid-impaired provider: A call for national guidance to maximize rehabilitation while protecting patient safety. Health Sci Rep 2020; 3:e193. [PMID: 33043151 PMCID: PMC7537421 DOI: 10.1002/hsr2.193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/03/2020] [Accepted: 08/26/2020] [Indexed: 11/10/2022] Open
Affiliation(s)
- Gretchen LeFever Watson
- PresidentSafety & Leadership SolutionsNorfolkVirginia
- Departments of Clinical and Medical FoundationsRoss University School of MedicineBridgetownBarbados
| | - Nancy J. Selfridge
- Departments of Clinical and Medical FoundationsRoss University School of MedicineBridgetownBarbados
| | - Bruce E. Wright
- Departments of Clinical and Medical FoundationsRoss University School of MedicineBridgetownBarbados
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DuBois JM, Walsh HA, Chibnall JT, Anderson EE, Eggers MR, Fowose M, Ziobrowski H. Sexual Violation of Patients by Physicians: A Mixed-Methods, Exploratory Analysis of 101 Cases. SEXUAL ABUSE : A JOURNAL OF RESEARCH AND TREATMENT 2019; 31:503-523. [PMID: 28627296 PMCID: PMC6031470 DOI: 10.1177/1079063217712217] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
A mixed-method, exploratory design was used to examine 101 cases of sexual violations in medicine. The study involved content analysis of cases to characterize the physicians, patient-victims, the practice setting, kinds of sexual violations, and consequences to the perpetrator. In each case, a criminal law framework was used to examine how motives, means, and opportunity combined to generate sexual misconduct. Finally, cross-case analysis was performed to identify clusters of causal factors that explain specific kinds of sexual misconduct. Most cases involved a combination of five factors: male physicians (100%), older than the age of 39 (92%), who were not board certified (70%), practicing in nonacademic settings (94%) where they always examined patients alone (85%). Only three factors (suspected antisocial personality, physician board certification, and vulnerable patients) differed significantly across the different kinds of sexual abuse: personality disorders were suspected most frequently in cases of rape, physicians were more frequently board certified in cases of consensual sex with patients, and patients were more commonly vulnerable in cases of child molestation. Drawing on study findings and past research, we offer a series of recommendations to medical schools, medical boards, chaperones, patients, and the national practitioners database.
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Affiliation(s)
- James M. DuBois
- Washington University School of
Medicine, St. Louis, MO, USA
| | - Heidi A. Walsh
- Washington University School of
Medicine, St. Louis, MO, USA
| | | | - Emily E. Anderson
- Loyola University Chicago, Stritch
School of Medicine, Chicago, IL, USA
| | | | - Mobolaji Fowose
- Washington University School of
Medicine, St. Louis, MO, USA
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DuBois JM, Anderson EE, Chibnall JT, Diakov L, Doukas DJ, Holmboe ES, Koenig HM, Krause JH, McMillan G, Mendelsohn M, Mozersky J, Norcross WA, Whelan AJ. Preventing Egregious Ethical Violations in Medical Practice: Evidence-Informed Recommendations from a Multidisciplinary Working Group. ACTA ACUST UNITED AC 2019; 104:23-31. [PMID: 30984914 DOI: 10.30770/2572-1852-104.4.23] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This article reports the consensus recommendations of a working group that was convened at the end of a 4-year research project funded by the National Institutes of Health that examined 280 cases of egregious ethical violations in medical practice. The group reviewed data from the parent project, as well as other research on sexual abuse of patients, criminal prescribing of controlled substances, and unnecessary invasive procedures that were prosecuted as fraud. The working group embraced the goals of making such violations significantly less frequent and, when they do occur, identifying them sooner and taking necessary steps to ensure they are not repeated. Following review of data and previously published recommendations, the working group developed 10 recommendations that provide a starting point to meet these goals. Recommendations address leadership, oversight, tracking, disciplinary actions, education of patients, partnerships with law enforcement, further research and related matters. The working group recognized the need for further refinement of the recommendations to ensure feasibility and appropriate balance between protection of patients and fairness to physicians. While full implementation of appropriate measures will require time and study, we believe it is urgent to take visible actions to acknowledge and address the problem at hand.
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Haramia C. Disabusing Physicians of the Assumption of Competing Interests. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:46-47. [PMID: 31307364 DOI: 10.1080/15265161.2018.1544319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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DuBois JM, Anderson EE, Chibnall JT, Mozersky J, Walsh HA. Serious Ethical Violations in Medicine: A Statistical and Ethical Analysis of 280 Cases in the United States From 2008-2016. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:16-34. [PMID: 30676904 PMCID: PMC6460481 DOI: 10.1080/15265161.2018.1544305] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Serious ethical violations in medicine, such as sexual abuse, criminal prescribing of opioids, and unnecessary surgeries, directly harm patients and undermine trust in the profession of medicine. We review the literature on violations in medicine and present an analysis of 280 cases. Nearly all cases involved repeated instances (97%) of intentional wrongdoing (99%), by males (95%) in nonacademic medical settings (95%), with oversight problems (89%) and a selfish motive such as financial gain or sex (90%). More than half of cases involved a wrongdoer with a suspected personality disorder or substance use disorder (51%). Despite clear patterns, no factors provide readily observable red flags, making prevention difficult. Early identification and intervention in cases requires significant policy shifts that prioritize the safety of patients over physician interests in privacy, fair processes, and proportionate disciplinary actions. We explore a series of 10 questions regarding policy, oversight, discipline, and education options. Satisfactory answers to these questions will require input from diverse stakeholders to help society negotiate effective and ethically balanced solutions.
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Affiliation(s)
- James M. DuBois
- Division of General Medical Sciences, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8005, St Louis MO 63110, USA,
| | - Emily E. Anderson
- Neiswanger Institute for Bioethics & Health Policy, Loyola University Chicago Stritch School of Medicine, 2160 S. First Avenue, Maywood, IL 60153,
| | - John T. Chibnall
- Department of Neurology & Psychiatry, Saint Louis University School of Medicine, 1438 S. Grand Blvd., St. Louis, MO 63104,
| | - Jessica Mozersky
- Division of General Medical Sciences, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8005, St Louis MO 63110, USA,
| | - Heidi A. Walsh
- Division of General Medical Sciences, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8005, St Louis MO 63110, USA,
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Lawson ND, Boyd JW. How broad are state physician health program descriptions of physician impairment? Subst Abuse Treat Prev Policy 2018; 13:30. [PMID: 30139369 PMCID: PMC6107949 DOI: 10.1186/s13011-018-0168-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 08/14/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Physician health program websites in 23 states provide many descriptions of possible physician impairment. This study sought to determine whether these descriptions are so broad that almost everyone might potentially be suspected of being impaired given these descriptions. METHODS The authors randomly selected 25 descriptions of impairment and then presented them anonymously online to members of the general population in full-time employment through Amazon's Mechanical Turk (N = 199). Half of the respondents randomly received a narrowly worded version, and half received a broadly worded version of the survey questions. RESULTS In the narrowly worded version of the survey, 70.9% of respondents endorsed at least one description of impairment, and 59.2% endorsed more than one. In the broadly phrased version, 96.9% endorsed at least one description, and 95.8% endorsed more than one. These respondents endorsed a median of 10 out of 25 (40%) descriptions. CONCLUSIONS These findings call into question whether these descriptions really identify persons with poor performance or who pose a high risk of substantial, imminent harm to self or others in the workplace. They also demonstrate the extent to which these descriptions could potentially be misapplied and brand almost anyone as impaired.
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Affiliation(s)
- Nicholas D. Lawson
- Georgetown University Law Center, 600 New Jersey Ave NW, Washington, DC, 20001 USA
| | - J. Wesley Boyd
- Department of Psychiatry, Cambridge Health Alliance/Harvard Medical School, 26 Central St, Somerville, MA 02143 USA
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DuBois JM, Chibnall JT, Anderson EE, Walsh HA, Eggers M, Baldwin K, Dineen KK. Exploring unnecessary invasive procedures in the United States: a retrospective mixed-methods analysis of cases from 2008-2016. Patient Saf Surg 2017; 11:30. [PMID: 29270224 PMCID: PMC5735893 DOI: 10.1186/s13037-017-0144-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 11/23/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Unnecessary invasive procedures risk harming patients physically, emotionally, and financially. Very little is known about the factors that provide the motive, means, and opportunity (MMO) for unnecessary procedures. METHODS This project used a mixed-methods design that involved five key steps: (1) systematically searching the literature to identify cases of unnecessary procedures reported from 2008 to 2016; (2) identifying all medical board, court, and news records on relevant cases; (3) coding all relevant records using a structured codebook of case characteristics; (4) analyzing each case using a MMO framework to develop a causal theory of the case; and (5) identifying typologies of cases through a two-step cluster analysis using variables hypothesized to be causally related to unnecessary procedures. RESULTS Seventy-nine cases met inclusion criteria. The mean number of documents or sources examined for each case was 36.4. Unnecessary procedures were performed for at least five years in most cases (53.2%); 56.3% of the cases involved 30 or more patients, and 37.5% involved 100 or more patients. In nearly all cases the physician was male (96.2%) and working in private practice (92.4%); 57.0% of the physicians had an accomplice, 48.1% were 50 years of age or older, and 40.5% trained outside the U.S. The most common motives were financial gain (92.4%) and suspected antisocial personality (48.1%), followed by poor problem-solving or clinical skills (11.4%) and ambition (3.8%). The most common environmental factors that provided opportunity for unnecessary procedures included a lack of oversight (40.5%) or oversight failures (39.2%), a corrupt moral climate (26.6%), vulnerable patients (20.3%), and financial conflicts of interest (13.9%). CONCLUSIONS Unnecessary procedures usually appear motivated by financial gain and occur in settings that have oversight problems. Preventive efforts should focus on early detection by peers and institutions, and decisive action by medical boards and federal prosecutors.
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Affiliation(s)
- James M. DuBois
- Division of General Medical Sciences, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8005, St Louis, MO 63110 USA
| | - John T. Chibnall
- Department of Neurology & Psychiatry, Saint Louis University School of Medicine, 1438 S. Grand Blvd, St. Louis, MO 63104 USA
| | - Emily E. Anderson
- Neiswanger Institute for Bioethics & Health Policy, Loyola University Chicago Stritch School of Medicine, 2160 S. First Avenue, Maywood, IL 60153 USA
| | - Heidi A. Walsh
- Division of General Medical Sciences, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8005, St Louis, MO 63110 USA
| | - Michelle Eggers
- Division of General Medical Sciences, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8005, St Louis, MO 63110 USA
| | - Kari Baldwin
- Division of General Medical Sciences, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8005, St Louis, MO 63110 USA
| | - Kelly K. Dineen
- Creighton University, School of Law, 2500 California Plaza, Omaha, NE 68178 USA
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Dineen KK, DuBois JM. BETWEEN A ROCK AND A HARD PLACE: CAN PHYSICIANS PRESCRIBE OPIOIDS TO TREAT PAIN ADEQUATELY WHILE AVOIDING LEGAL SANCTION? AMERICAN JOURNAL OF LAW & MEDICINE 2016; 42:7-52. [PMID: 27263262 PMCID: PMC5494184 DOI: 10.1177/0098858816644712] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Prescription opioids are an important tool for physicians in treating pain but also carry significant risks of harm when prescribed inappropriately or misused by patients or others. Recent increases in opioid-related morbidity and mortality has reignited scrutiny of prescribing practices by law enforcement, regulatory agencies, and state medical boards. At the same time, the predominant 4D model of misprescribers is outdated and insufficient; it groups physician misprescribers as dated, duped, disabled, or dishonest. The weaknesses and inaccuracies of the 4D model are explored, along with the serious consequences of its application. This Article calls for development of an evidence base in this area and suggests an alternate model of misprescribers, the 3C model, which more accurately characterizes misprescribers as careless, corrupt, or compromised by impairment.
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