Physician autonomy vs clinic policies

[mojetter]

Hello everyone,

I have an issue with one of the employed docs at the clinic who has done things that are somewhat different from the "clinic policy" and I had a heated discussion with the clinical director regarding this docs tendency to do things his/her way.

Lets say for example an issue such a providing refills. Can a clinic create a policy limiting providing refills (ie no refills) that the physician has to follow?

I'm the medical director and argue there are only so many limits a licensed board certified physician has to adhere to....the doc reports that he/she is using case-by-case scenarios and their own clinical judgement. The clinical director (not an MD) argues the policies are created for structure and should be adhered to.

So basically my question is does physician autonomy supersede clinic policy regarding clinical decision making for all/most clinic policies?

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[MacDonaldTriad]

That all depends on the clinic’s teeth and the clinician’s expendability. Not following clinic policy is insubordinate and grounds for termination. The only question is, does the clinic want to terminate the clinician because of this or not.

 

[Psychobabbling]

A little hard to follow. Usually a physician's decision making ethically can supercede a clinic's policy. For example - a clinic tells Doc A that if a patient no shows 2 times, they must be discharged. 3 year long patient no shows twice in a row, and is told he must discharge. For Doc A, he may consider this abandonment. He can ignore the policy and continue to see the patient...see the patient until they find follow up elsewhere....either would be ethical for the relationship with the patient. (This is a blown out example of course)

The best I can say with the info provided is "It Depends"

 

[nitemagi]

Interesting Q. I'd say your license gives you the right to practice how you want, though if the clinic sets rules against that, it could be grounds for firing. A gray area is if you can medically justify your decisions as good quality of care, and that the policies are dangerous or fall below the standard of care.

 

[PikminOC]

Hello everyone,

I have an issue with one of the employed docs at the clinic who has done things that are somewhat different from the "clinic policy" and I had a heated discussion with the clinical director regarding this docs tendency to do things his/her way.

Lets say for example an issue such a providing refills. Can a clinic create a policy limiting providing refills (ie no refills) that the physician has to follow?

I'm the medical director and argue there are only so many limits a licensed board certified physician has to adhere to....the doc reports that he/she is using case-by-case scenarios and their own clinical judgement. The clinical director (not an MD) argues the policies are created for structure and should be adhered to.

So basically my question is does physician autonomy supersede clinic policy regarding clinical decision making for all/most clinic policies?

So is the clinic trying to increase their billing by not allowing refills?

And what do you mean by "so many limits a licensed board certified physician" as if non board cert physicians are cowboys?

 

[vistaril]

Hello everyone,

I have an issue with one of the employed docs at the clinic who has done things that are somewhat different from the "clinic policy" and I had a heated discussion with the clinical director regarding this docs tendency to do things his/her way.

Lets say for example an issue such a providing refills. Can a clinic create a policy limiting providing refills (ie no refills) that the physician has to follow?

I'm the medical director and argue there are only so many limits a licensed board certified physician has to adhere to....the doc reports that he/she is using case-by-case scenarios and their own clinical judgement. The clinical director (not an MD) argues the policies are created for structure and should be adhered to.

So basically my question is does physician autonomy supersede clinic policy regarding clinical decision making for all/most clinic policies?

this is simple: no, the clinician(regardless of what their title is) doesn't have to do it. And yes, they can be fired.

 

[vistaril]

So is the clinic trying to increase their billing by not allowing refills?

And what do you mean by "so many limits a licensed board certified physician" as if non board cert physicians are cowboys?

I wouldn't say cowboys, but let's be real- if someone is practicing for more than a few years out of residency and doesn't even bother to get board certified, it does go towards their professionalism or speaks to their attitude. (and I say that as someone who thinks all those board people are useless crooks anyways for most part)

 

[mojetter]

...oh sorry i meant nothing by the "board-certified" thing, just ranting a bit.

So for clarity the conversation was basically clinical director vs medical director (me) arguing about if a doctor has to practice according to "clinic policy" and if they refuse to that the clinic's options are basically to fire that doctor.

The clinical director was trying to convince me to basically have an intervention and/or write-up that doctor despite the fact he/she had done nothing grossly wrong from a treatment perspective, it just didn't follow the protocol the clinical director had a policy for. The doctor is aware they are not following policy and continues to practice that way.

IMO, after residency doctors dont reprimand each other the way a tech, secretary, or other non-physician can be reprimanded.

 

[mojetter]

That all depends on the clinic’s teeth and the clinician’s expendability. Not following clinic policy is insubordinate and grounds for termination. The only question is, does the clinic want to terminate the clinician because of this or not.

....I agree, no the clinic wants to keep the clinician and shape the behavior to match the policy by having the medical director intervene... #nobueno

 

[smalltownpsych]

Why can't they meet and talk and come up with a reasonable plan or agreement? Who set the clinic policy and why can't it be modified? Power struggles are so unproductive.

 

[MLT2MT2DO]

Why can't they meet and talk and come up with a reasonable plan or agreement? Who set the clinic policy and why can't it be modified? Power struggles are so unproductive.

Agreed, this sounds petty.

 

[MacDonaldTriad]

Why can't they meet and talk and come up with a reasonable plan or agreement? Who set the clinic policy and why can't it be modified? Power struggles are so unproductive.

Are you sure you work for a VA????

 

[smalltownpsych]

Are you sure you work for a VA????

hehe I don't work for a VA. I have been a clinical director and I had to mediate disputes between employees and I have done couples counseling and also worked with defiant teens. It's all about the same thing. Lots of hurt feelings and pouting and tantrums and anxiety driven control dynamics.

 

[MacDonaldTriad]

I had to mediate disputes between employees and I also worked with defiant teens. Lots of hurt feelings and pouting and tantrums and anxiety driven control dynamics.

Now that sounds like a VA.

 

[mojetter]

...at the end of the day it is petty, but being pulled into a petty dispute is even worse.

BTW the clinical director (again not an physician, but a LCSW) advocates for and influences policies that dictate the way the physicians practice and later refers to the policy when the physician chooses to do things his/her way. So I get the hear "so and so isnt following policy" to which I state "so long as patients arent harmed I cant make the physician follow it."

It IS a power struggle! ...one where im trying to excuse myself.

 

[MacDonaldTriad]

the term “Pissing Contest” has been used as a slang idiomatic phrase describing contests that are "futile or purposeless", especially if waged in a "conspicuously aggressive manner".[2] As a metaphor it is used figuratively to characterize ego-driven battling in a pejorative or facetious manner that is often considered vulgar


Pissing contests are not unique to humans. Trevor Corson's The Secret Life of Lobsters describes a pissing match between lobsters:[12]

The American lobster urinates not from some posterior region of its body, but directly out the front of its face. Two bladders inside the head hold copious amounts of urine, which the lobster squirts through a pair of muscular nozzles beneath its antennae. These powerful streams mix with the gill outflow and are carried some five feet ahead of the lobster in its plume ... What the researchers discovered during the ensuing fights was that dueling lobsters accompanied their most punishing blows during combat by intense squirts of piss at the opponent's face. What was more, in scenes akin to a showdown at the OK Corral, the winner of the physical combat almost always turned out to be the lobster that had urinated first. And well after the fight was over, the winner kept pissing. By contrast, the loser shuts off his urine valves immediately.

 

[smalltownpsych]

...at the end of the day it is petty, but being pulled into a petty dispute is even worse.

BTW the clinical director (again not an physician, but a LCSW) advocates for and influences policies that dictate the way the physicians practice and later refers to the policy when the physician chooses to do things his/her way. So I get the hear "so and so isnt following policy" to which I state "so long as patients arent harmed I cant make the physician follow it."

It IS a power struggle! ...one where im trying to excuse myself.

Sounds like there are too many policies. Some people love to make a new policy every time there is any type of problem. He could have a great future in politics.

 

[vistaril]

...at the end of the day it is petty, but being pulled into a petty dispute is even worse.

BTW the clinical director (again not an physician, but a LCSW) advocates for and influences policies that dictate the way the physicians practice and later refers to the policy when the physician chooses to do things his/her way. So I get the hear "so and so isnt following policy" to which I state "so long as patients arent harmed I cant make the physician follow it."

It IS a power struggle! ...one where im trying to excuse myself.

you are looking at this completely wrong: ALL that matters at the end of the day is whether the person with an ownership interest or firing power cares enough about the rule/policy to get rid of the person for breaking it. It doesnt matter if that person is a physician or not, and it doesnt matter if the person breaking it is a physician or not.

It doesnt matter that its in health care, Wal Mart, an oil change, etc....and it doesnt matter whether its good for patient care or bad for patient care. If you are an employee you can't break the rules just because 'it doesnt harm patient care'. That is irrelevant. Or I guess you can break the rules....as long as the owner/ultimate supervisor doesn't care.

Part of being an employee(vs an owner) is that you can't make your own rules. You have to do things according to policies others set, even if you may not agree with them.

 

[vistaril]

...at the end of the day it is petty, but being pulled into a petty dispute is even worse.

BTW the clinical director (again not an physician, but a LCSW) advocates for and influences policies that dictate the way the physicians practice and later refers to the policy when the physician chooses to do things his/her way. So I get the hear "so and so isnt following policy" to which I state "so long as patients arent harmed I cant make the physician follow it.".

huh? Of course you can make them follow it. Whether you choose not to is another matter, and then whether the owner/ultimate supervisor chooses not to sh**can you for failing to do that part of your job is up to them as well.

this concept you have of employee psychiatrists having special leeway to ignore rules and policy vs other businesses is bizarre and not based in reality.

 

[milesed]

Could you specify what the clinic policy is?

If the doc is an employee, then he could be written up, fired, or whatever you deem appropriate. Like others have said, it may not need to get to that point. On the other hand, you will want to hold him accountable to some degree out of fairness to others and to prevent future problems with him following policies.

 

[mojetter]

Could you specify what the clinic policy is?

If the doc is an employee, then he could be written up, fired, or whatever you deem appropriate. Like others have said, it may not need to get to that point. On the other hand, you will want to hold him accountable to some degree out of fairness to others and to prevent future problems with him following policies.

Lets say for instance the policy is to directly admit (voluntary) a patient to the inpatient unit and the provider felt it was better to EP the patient and have them medically cleared in the ED first simply because they have a history of something such as well-controlled HTN.

 

[Armadillos]

Seems like different folks are talking about "forcing" the doc to do something differently.

Lets say there is hypothetically a hard and fast clinic policy that docs don't prescribe benzos ever. But then say a doc has a really good reason to prescribe some, maybe short term taper for withdrawal or something, doesn't matter exact scenario.

Legally I wouldn't think the clinic could actually prevent the doc from writing the script, but later on I imagine he could be disciplined/fired for doing so.

 

[smalltownpsych]

Lets say for instance the policy is to directly admit (voluntary) a patient to the inpatient unit and the provider felt it was better to EP the patient and have them medically cleared in the ED first simply because they have a history of something such as well-controlled HTN.

That is our typical procedure to have them through the ED first, although I have bypassed that because the ED doesn't want to have to deal with it. The good thing about our hospital is that we don't have very many policies to follow so that provides us flexibility, but the negative thing is that we have no policies so it makes it a bit unpredictable and this could increase risk. For example, when I decide to hospitalize a patient, how does that happen logistically and who is in charge of that process and what do we do when patient resists? Seriously, we handle each case individually and it can get a bit scary.

 

[ferning]

Ur question worried me till I saw u were a psychologist.

If I was bypassing the ED, I would have family bring them straight to the unit or if they resisted police/EMS. Have either party petition an involuntary status depending on ur state.

I'd also ask security to be on hand when the patient arrives if u think theyll elope

The ED visit also allows insurance precert if its needed as well. Less incentive for them to approve if theyre already on the unit

 

[smalltownpsych]

Ur question worried me till I saw u were a psychologist.

If I was bypassing the ED, I would have family bring them straight to the unit or if they resisted police/EMS. Have either party petition an involuntary status depending on ur state.

I'd also ask security to be on hand when the patient arrives if u think theyll elope

The ED visit also allows insurance precert if its needed as well. Less incentive for them to approve if theyre already on the unit

I don't see how my being a psychologist relates to critiquing hospital procedures. Unless you were somehow implying that I have less experience in a hospital setting than psychiatrists would. Anyway, Those were rhetorical questions to illustrate the unpredictability when there aren't policies in place. When it comes to security, for example, we don't have them. There are times when I have stayed on the unit because I didn't feel safe leaving a couple of female staff alone with an agitated male patient. That is also an example of a case where it would make a difference if I was a psychiatrist because I would probably just sedate the patient and go home.

 

[Doctor Bagel]

So did the physician not follow a policy because it went again their clinical judgment? Assuming their judgment was reasonable, I think that's very different from not following administrative policies just because you don't like them or whatever. Of course jobs seem to have so many policies that are always changing, so we're all not following all the policies correctly. And as mentioned above, firing a psychiatrist for not following an unimportant policy means you need to find a new psychiatrist, which isn't easy. If you're known for firing psychiatrists for silly things, that makes hiring even harder.

But yeah, if you're an employee, you're an employee, and it's not insane to expect you to follow basic protocols from your employer. If the protocol puts a patient at risk, that's a different thing.

 

[mojetter]

So did the physician not follow a policy because it went again their clinical judgment? Assuming their judgment was reasonable, I think that's very different from not following administrative policies just because you don't like them or whatever. Of course jobs seem to have so many policies that are always changing, so we're all not following all the policies correctly. And as mentioned above, firing a psychiatrist for not following an unimportant policy means you need to find a new psychiatrist, which isn't easy. If you're known for firing psychiatrists for silly things, that makes hiring even harder.

But yeah, if you're an employee, you're an employee, and it's not insane to expect you to follow basic protocols from your employer. If the protocol puts a patient at risk, that's a different thing.

I think you make a great point, the doc says its a clinical call but the clinical director is feeling is because the doc doesnt like them. I dont feel to be in a position to question the docs clinical judgement out of respect. Again its not an egregious clinical/patient safety issue.

 

[vistaril]

If the provider is insisting pts with 'well controlled htn' present to the ed first to be cleared because of that(as opposed to what poorly controlled htn?), they should probably be fired for that anyways and not just because they break the rules/policies.....

 

[Wilf]

this concept you have of employee psychiatrists having special leeway to ignore rules and policy vs other businesses is bizarre and not based in reality.

Please don't underestimate the importance of physician autonomy. And keep in mind that in other fields physicians less often have to adhere to rules created by midlevels (I'm including SWs and PhDs as midlevels). Psychiatry will have an even harder time attracting good physicians if they know they will be treated as lower than other physicians.

 

[milesed]

We always had patients cleared by ER before admitting. It was short and superficial, but prevented some issues after admitted. I think his clinical judgement makes sense in this example, but am wondering if there were other more serious infractions.

 

[Wilf]

I think it is always important to keep this chart in mind, both for professional satisfaction and best care for patients.

 

[erg923]

I think it is always important to keep this chart in mind, both for professional satisfaction and best care for patients.

Why?

 

[smalltownpsych]

I think it is always important to keep this chart in mind, both for professional satisfaction and best care for patients.

I really hope this was meant as a joke. If not the combination of ignorance and arrogance would be astounding and scary. i could be talking about either the avatar or the chart.

 

[Wilf]

I really hope this was meant as a joke. If not the combination of ignorance and arrogance would be astounding and scary. i could be talking about either the avatar or the chart.

I make it my policy not to respond to troll posts but the irony in your post was too strong not to comment on!

And why do psychologists post in the psychiatry threads? Do psychiatrists post in the psychology threads?

 

[erg923]

And why do psychologists post in the psychiatry threads? Do psychiatrists post in the psychology threads?

Is there a problem?

Would you care to answer my question from above? If not thats fine-just say so. But you don't need to be dick about it.

 

[erg923]

i could be talking about either the avatar or the chart.

I have heard of that guy. I didn't realize he was running. Wonder what that "IQ chart" says something about members of congress?

 

[SunburstTan]

To address the original questions:

You need to accumulate a patter of willful disregard of policies, DESPITE remediation efforts, to be able to fire a physician, depending on his contract; otherwise you are risk of a civil suit.

I would also re-assess your clinic policies: you can certainly have a policy that states "no refills," but is it really in the best interest of your patients?? It sounds a little too prescriptive and authoritarian, and should not apply to most psychiatric patients. If the policy can be disregarded without causing any harm or increase in risk for most patients, it should probably be changed to something like "no refills for patients who meet criteria A or B+C"

If it's personality clash, maybe a "sit down" with a neutral party will help. But there is still something about this policy that the psychiatrist picked it, and not some other issues to "act out." Again, the organizing principle should be, how can we best serve our patients.

You can also try to engage the physician by asking them to help to re-draft the policy.

 

[Therapist4Chnge]

Please don't underestimate the importance of physician autonomy. And keep in mind that in other fields physicians less often have to adhere to rules created by midlevels (I'm including SWs and PhDs as midlevels). Psychiatry will have an even harder time attracting good physicians if they know they will be treated as lower than other physicians.

Psychologists aren't midlevels.

 

[Therapist4Chnge]

And why do psychologists post in the psychiatry threads? Do psychiatrists post in the psychology threads?

Much like in the real world, psychologists and psychiatrists don't segregate from each other on SDN. Maybe if/when you graduate residency and spend a few years working independently you'll have a better appreciation for the importance of collegial collaboration. I stress the importance of collaboration with the residents in my dept bc they don't last long if they can't get along with everyone else.

 

[SunburstTan]

guys, keep it classy

 

[erg923]

To address the original questions:

You need to accumulate a patter of willful disregard of policies, DESPITE remediation efforts, to be able to fire a physician, depending on his contract; otherwise you are risk of a civil suit.

I would also re-assess your clinic policies: you can certainly have a policy that states "no refills," but is it really in the best interest of your patients?? It sounds a little too prescriptive and authoritarian, and should not apply to most psychiatric patients. If the policy can be disregarded without causing any harm or increase in risk for most patients, it should probably be changed to something like "no refills for patients who meet criteria A or B+C"

If it's personality clash, maybe a "sit down" with a neutral party will help. But there is still something about this policy that the psychiatrist picked it, and not some other issues to "act out." Again, the organizing principle should be, how can we best serve our patients.

You can also try to engage the physician by asking them to help to re-draft the policy.

"Sit downs" is how we do it where I come from. This avoid gratuitous "wackings," or as Jimmy Coonan said; "offs, ya..."

 

[smalltownpsych]

I make it my policy not to respond to troll posts but the irony in your post was too strong not to comment on!

And why do psychologists post in the psychiatry threads? Do psychiatrists post in the psychology threads?

First question, why not? I have received some valuable feedback at times that I wouldn't have received otherwise since I don't have the opportunity to work with psychiatrists since we don't have any in our town. I also think that our perspective as psychologists can be useful in the other direction, as well. As you pointed out, there are times when psychologists are in charge administratively so I would think this particular topic would be one that engages both professions.

To answer the second question, yes, several of the regulars from this site will comment on relevant threads in the psychology forum.

Final point, I fail to see the irony, although cognitive assessment and the interpretations and research in this area are obviously an arena that psychologists have the most expertise and it is an area that has historically been fraught with misunderstanding and misuse of the various measures. I do see the irony in that. I can't believe you didn't appreciate my joke about the politician (I forget his name). He reminds me of Mr. Haney, the traveling salesman from Green Acres. Maybe ability to appreciate humor isn't measured by the Henmon-Nelson IQ test.

 

[Doctor Bagel]

I think it is always important to keep this chart in mind, both for professional satisfaction and best care for patients.

Do you really think the smartest people you've met have been in medicine? We're not dummies, but that doesn't fit with my experience. You certainly can't say our training better prepares us for critical thinking than lots of Ph.Ds, lawyers and other STEM folk.

 

[Therapist4Chnge]

Do you really think the smartest people you've met have been in medicine? We're not dummies, but that doesn't fit with my experience. You certainly can't say our training better prepares us for critical thinking than lots of Ph.Ds, lawyers and other STEM folk.

As someone who has eval'd hundreds of white collar professionals (IQ et al.), physicians generally score in the avg range to high avg range (100-120ish), in line w. Social Science Ph.Ds, and consistently behind engineers and basic science professionals (120+).

 

[Wilf]

As someone who has eval'd hundreds of white collar professionals (IQ et al.), physicians generally score in the avg range to high avg range (100-120ish), in line w. Social Science Ph.Ds, and consistently behind engineers and basic science professionals (120+).

Notwithstanding your n of "hundreds", the average IQ of physicians is actually around 125. This makes sense considering the average IQ of a college graduate is 115. It also makes sense considering the Gaussian distribution of IQ scores with a mean of the population around 105.

 

[MacDonaldTriad]

Yep, 125.
J.D. Matarazzo, S.G. Goldstein The intellectual caliber of medical students Journal of Medical Education, 47 (2) (1972), pp. 102

It is old, but hopefully we haven't gotten worse. I'm no psychologist, but unless I have been really out of it for a long time, I thought the mean IQ of a population was 100 by definition.

 

[smalltownpsych]

Yep, 125.
J.D. Matarazzo, S.G. Goldstein The intellectual caliber of medical students Journal of Medical Education, 47 (2) (1972), pp. 102

It is old, but hopefully we haven't gotten worse. I'm no psychologist, but unless I have been really out of it for a long time, I thought the mean IQ of a population was 100 by definition.

Yep, it's calibrated to have the mean at a standard score of 100. I was also surprised at T4C stating that he has seen a number of physicians who score a 100 on an IQ test. IQ tests are predictors of academic achievement and academic achievement is a prerequisite for med school. Perhaps his sample is skewed since it is a clinical sample.

 

[MacDonaldTriad]

Here is a paper about the IQ of MDs in trouble vs regular MDs.
http://www.sciencedirect.com/science/article/pii/S0887617704000769
It is easy to be a gnome of knowledge now we have the internet.

 

[MLT2MT2DO]

Yep, it's calibrated to have the mean at a standard score of 100. I was also surprised at T4C stating that he has seen a number of physicians who score a 100 on an IQ test. IQ tests are predictors of academic achievement and academic achievement is a prerequisite for med school. Perhaps his sample is skewed since it is a clinical sample.

Or perhaps he practices in Arkansas?

 

[smalltownpsych]

Or perhaps he practices in Arkansas?

Ouch!

One reason I like to frequent this board is that the physicians don't pull any punches.