Part Three: A "Disruptive" Decision, The Faux Chairman Of Neonatology At Randolph Hospital That I Could Have/Should Have Sued For Slander

I have struggled with this post for quite some time. I hope when you read it that you simply cannot believe what you are reading.

I've lived it for eleven years and I still don't believe it.

First and foremost, I want you to put yourself in the shoes of the parents of this infant - people who believed the advertisng and put their trust in Randolph Hospital.

Then I want you to try and put yourself in my shoes . . . as a young professional who trained for a lot of years to be the very best doctor she could be . . . a home-girl who set aside a bad childhood experience, bought into the "new & improved" Randolph's "mission", and busted her tail to make it so.

If you can do these things, I think you will understand why I still seethe with white-hot rage that this ever happened . . . and that none of the checks or balances that one would expect a hosptial-charged-with-the-public-good to use were employed . . . and that those behind this professional rape of a good physician in public service have not been held accountable by ANY of the regulatory and/or law enforcement agencies whose job it is to protect both patients and doctors.

At first . . . after languishing in a jurisdictional never-never land where oversight is non-existant and laws are not enforced and the local "watchdog" press couldn't care less . . . I was resolved to release everything to the ether - my Peer Reveiw complaint against Dr. Mick Irwin (of Asheboro Family Phyisicians), the complaint I filed with the North Carolina Medical Board, the medical records of the baby, you name it.

If everyone else involved in this medico-legal fiasco could break all the rules . . . and fracture all the laws . . . and still sit so fat (look it up), happy and pretty, why couldn't I?

However, after considerable contemplation, I have decided to play by the rules. Medical records are going to be referred to but not published. Idenitities of everyone but the doctors involved will not be published.

Keep in mind that the incident I am going to describe happened just two days after I got then-Randolph Medical Associates (RMA) Director, Mike Bridges' nasty "warning letter".

To refresh everyone's memory, after Bridges was done hurling the distortions, flat-out lies, slurs & insults, this is the KEY directive in that letter:

You are required, until further notice, to reveiw with me any letters you write regarding the dismissal of patients from our practice, or your concerns about the behavior or actions of others. I do not expect you to discuss this action with anyone other than myself. It is, however, appropriate for you to address my decision with Steve Eblin if you disagree. Failure to comply with this requirement, or one other instance of the above noted behaviors will result in the termination of your employment with Randolph Medical Associates.

We've already covered "the dismissal" of a certain very important patient (a letter Bridges did, in fact, review). And I've previously alluded to (without publishing the reasons for ) my personal & professional differences with Dr. Kathleen Riley . . . my former "partner" at RMA . . . whose fingerprints I felt were all over this "warning". Bridges' message was crystal clear:

SHUT UP. "DROP IT". OR ELSE.

(As an aside, it has always amazed me at how much of what was offered as feedback to Clinton USDHHS Secretary Donna Shalala was NOT alleged to be false when Randolph Hospital unsuccessfully sued me for "libel" over selected excerpts.)

I immediately decided that I would not be communicating further with anyone in RMA or Randolph Hospital management without (1) a retraction, or (2) a lawyer present.

Why a lawyer, you ask? Well, in reducing what he did to writing, Mike Bridges had declared his inablility to be objective, and had lost ALL credibility as a third-party mediator between the Pediatricians.

Mike Bridges' memo is what I was sleeping on when I was rudely awakened by the LDRP (Labor/Delivery/Recovery/Postpartem) charge nurse at Randolph Hospital in the wee hours of a January 1998 morning.

As I've strolled down this particularly dark part of memory lane . . . as I've looked back upon the consult note I did on this case - and the medical records - and the subsequent incident reports (involving Dr. Irwin's behavior afterwards) - and even the "Shalala" complaint . . . I get the same sick, nauseous feeling in the pit of my stomach every time.

For a long time, I had nightmares.

To this day, I do not know what Dr. Irwin was thinking or why he did what he did. I still cannot wrap my head around it.

Nor can I fathom why RMA & Randolph Hospital executives ever DREAMED I would take what they did next lying down.

Before we really get started with the story, I'm going to jump ahead six months . . . in order to explain how I came to be here . . . telling this story in the blogosphere. You see, I filed a complaint . . . on what I've come to call "the Irwin incident" . . . with the North Carolina Medical Board after I was fired. For my own self-preservation, it had to wait six months . . . after my "notice" at RMA was up (again, we'll get to that later in the post) . . . when I could no longer be fired for cause for writing "inflammatory" letters or "disparaging" Randolph or talking back to the omnipotent (NOT) practice management "team" of Morrison, Eblin and Bridges.

The complaint was supported by the baby's parents. We were hoping the big bad North Carolina Medical Board would do something.

I was, in fact, SCREAMING for help. I had done my duty . . . I had put a patient above everything I had worked to build and held dear. But, as was its habit and nature at the time, the Medical Board ignored my plight . . . and merely slapped Dr. Irwin on the hand behind the scenes (taking another six more months to do even that).

The Board could not help me with "my problems".

And let's be crystal clear on what that translates to: The North Carolina Medical Board was absolutely a-okay with the concept of one of its licensees being professionally torn to shreds because she did the right thing. A hospital, even a "non-profit" (i.e. charged with the public good) hospital retaliating against a doctor for doing her duty (all the while hiding behind privilege and confidentiality and privacy) was no big deal.

Moreover, the doctor who put a baby's life in danger . . . AND then trashed the Pediatrician who rescued him had to be protected. What he had done was "embarassing". And that, my friends, was ALL about the collegial wink & nod . . . "the White Wall".

I digress. Mick Irwin subsequently released the complaint I filed with the Medical Board to Bob Morrison and Steven Eblin during litigation, and they, in turn, released it to discovery. Morrison and Eblin (and apparently their trial lawyers), were clueless. Peer review and Medical Board documents were just something else to plunder and use to their own ends.

Dr. Irwin did not have my permission to release the complaint. He did not have the parents' permission to do that. And he never answered correpsondence from my lawyer inquiring as to his thinking.

I do not care what he - or anyone else - thinks now.

After filing yet another complaint with the Medical Board regarding Irwin's breach of confidentiality (that's me . . . I always go through channels), the NCMB's Chief Legal Eagle, Thomas Mansfield, said Dr. Irwin could do whatever he wanted with the complaint.

Ergo, so can I. And here we are. Heavy sigh.

Let me also establish that back in 1998, the relationship between RMA Pediatrics and Asheboro Family Physicians was strained. You see, it had been brought to our attention that when parents decided to take their children to RMA to see a Pediatrician (which involved a records transfer), Drs. Robert Dough/Fred Graham, & Lawrence Perry sent the family a letter discharging the child from their practice. Many parents took the letter (as it was written) to mean the entire family had been discharged.

Asheboro Family Physicians rarely, if ever, consulted RMA Pediatrics - even when the nurses thought they should. At the time, the practice was owned by LeBauer Healthcare, which was in turn, owned by Cone Hospital.

Cone Hospital being the hospital that Mike Bridges had recently "encouraged" the "ladies" at RMA Pediatrics to refer neonatal cases to . . . in the interest of furthering Randolph Hospital's "cooperative" ties to Cone.

Asheboro Family Phyisicians & Randolph Hospital had, in fact, recently published an ad in the Courier Tribune that touted the recently-recruited Dr. Irwin's abilites in neonatal resuscitation, (quoting Dr. Irwin): I especially like working with babies, younger children and young families . . . I'm a neonatal resuscitation regional trainer, so I'm comfortable working with sick babies."

Irwin also lauded Randolph's thoroughness in checking physician credentials.

Here's the thing about that: NALS (Neonatal Advanced Life Support), re-named NRP (Neonatal Resuscitation Program) is a several-hour course that many doctors and nurses take and then maintain in order to learn and/or refresh basic skills in neonatal resuscitation. I myself try to take the basic course every 2-3 years (as I do with ACLS and PALS) . . . just to see if there have been any changes. But it is a course that does not "certify" competence or experience in anything. People (doctors or nurses) who complete the course and score a certain score can become instructors after completing a training course.

Now, in Asheboro, being an NRP instructor apparently makes you more qualified to take care of sick infants than Board-certified Pediatricians who only lived and breathed critical care (NICU/PICU/ER) during their residencies.

But hey, the Pediatricians were only "arrogant and cliquish" girls . . . a "dime a dozen".

And obviously, in publishing this tripe, the Courier Tribune did not know or appreciate the difference between apples and oranges.

I've never been interested in becoming certified as an NRP instructor . . . I have plenty of letters behind my name already, and I teach staff as situations arise (I think that's how you learn best) . . . in fact, I'm very good at it. But I had enough on my plate.

However, at the time this ad ran in the Courier, Dr. Anderson, was an NRP instructor. She was not amused by Dr. Irwin's grandstanding.

But I took what I knew amounted to false advertising as par-for-the-course with Morrison and Eblin's public relations machine . . . pump up the qualifications of the male physician who was, in fact, a wannabe Neonatologist . . . and ignore "the girls" who had the training & experience in Neonatal & Pediatric critical care, and who were actually carrying all the water (uphill).

It was very "mill-town" Asheboro . . . where women are often treated as second-class citizens.

The following is the text of the complaint I filed against Mick Irwin with the N.C. Medical Board on August 3, 2008 (the names of the child/parents have been changed to Doe). The complaint will be in blue. Additional commentary (based on the actual medical record, which I cannot publish), will be inserted in red. Please keep in mind, that I was trying to briefly summarize a very complicated situation for the Medical Board, and "keep it short", ala the instructions I've often gotten here in the blogosphere from "helpful"/progressive types like Ed Cone of the Cones:

My name is Dr. Mary Johnson. I am a Board-certified Pediatrician formerly associated with RMA-Pediatrics, a controlled affiliate of Randolph Hospital in Asheboro, North Carolina. I am Fellow in the American Academy of Pediatrics and a section member of its committees on Child Abuse, Emergency Medicine and Children with Disabilities. I am also Chairman of the Perinatal Committee at Randolph Hospital.

I've since dropped being a section member. It's just more money on dues - and for a number of years after this happened, I just did not have the money.

It was in this capacity that I encountered Dr. Michael Irwin during his management of a newborn infant, Baby Girl Doe - on January XX, 1998. Dr. Irwin is a Family Practitioner.

I wish to file a complaint regarding Dr. Irwin's behavior. The baby's parents, John and Jane Doe, have indicated to me that they will support my complaint by releasing her medical records and cooperating fully with deposition and/or tesitmony if the need arises.

I have considered and discarded filing a defamation suit against Dr. Irwin.

To support my complaint, I have enclosed copies of Baby Doe's medical records - including Dr. Irwin's H&P and my consult note, as well as copies of the comments I submitted to the Peer Review Committee of Randolph Hospital. The nurses' notes and incident reports, which I believe are essential to your review of the care, are not in my possesssion. I have also enclosed ads that Dr. Irwin's practice (Asheboro Family Physicians) has run in the Courier Tribune (both before and after the incident in January) which I believe are misleading. Additionally, I have enclosed correspondence sent to LeBauer Healthcare in Greensboro (which owns AFP) detailing my objections to these ads. That letter was one of at least two sent to LeBauer by physicians in the community who objected to the ads for one reason or another. The ads were subsequently pulled.

This issues at hand are (1) medical competence - specifically in neonatal critical care, (2) inappropriate professional behavior - specifically the deliberate slander of one physician by another to a patients' parents, and (3) truth in advertising.

In the early morning hours of January XX, I was notified by the LDRP charge nurse that Dr. Irwin required assistance in the management of a critically-ill newborn. Dr. Irwin what not requested my assistance, but the charge nurse (whose clinical judgement I implicitly trust) felt that his management of the infant was inadequate. She was terrified that the child might die before help could arrive from Baptist. I asked the nurse to make Dr. Irwin aware of the fact that I had been notified and that I had offered assistance. Dr. Irwin declined. Several phone calls later (in a period of only a few minutes), I made the decision that I could NOT "not go in". I did not speak to Dr. Irwin directly because, based on past experience, I did not think he would be favorably inclined towards my offer to help, and I wished to minimize his opportunity to "turn me down". I also felt morally and ethically compelled to actually see the child for myself - in order to assess her condition and evaluate the appropriateness of the nurses' plea for help.

I've reveiwed my consult note and Dr. Irwin's H&P (in which he idenitfied the female infant as a boy), as well as comments I submitted to hospital Peer Review. Incredibly, Dr. Irwin's H&P states that there were no complications of the baby's admission prior to transport.

Baby Doe's entire course at Randolph Hospital was a complication!

The gist of the story is that, after a STAT C-Section for a suspected placental abruption, this newborn was misdiagnosed and woefully inadequately managed for the better part of 2 1/2 hours before the nurses had had enough and called me.

In the very first exchange with the charge nurse over the phone, I asked her to tell Dr. Irwin that I was aware of the situation, and to give him the opportunity to consult me. She informed me that he'd already said he did not want my help. But the charge nurse was desperate, "Dr. Johnson, he does not know what he is doing! This baby is going to die if you don't get here! Can't you come in and tell him you were in the ER or something - and just decided to drop by?"

In the wee hours of the morning, not having any reason to be up other than her phone call, I had no patients in the ED. I told the charge nurse to speak to Dr. Irwin again and call me back within 5 minutes. I got up, took a 2-3 minute shower, threw on some clothes, and called the nursery. Dr. Irwin was adament. He did not need my help.

But the nurses (who were good nurses) were just as adament that he did. And my decision was made.

When I arrived, before entering the nursery, I took stock of the situation. The nurses relayed the birth history and told me that the baby's Apgars had been "fudged" upwards (to 4 and 7). They also told me that Dr. Irwin had to be prodded to call Baptist . . . whose neonatal team was en route. He did not think the baby was that sick.

But at the nursery door, and even from across the room, the trained eye could tell that the baby was obviously critically-ill and on the verge of respiratory failure. Purely and simply, she was tired of working so hard to breathe. I quickly reveiwed what had been done. Despite heavy meconium at delivery (likely secondary to stress associated with the placental abruption), and her increased work-of-breathing/oxygen requirement, the baby was not currently intubated, her stomach had not been suctioned, and her peripheral IV was only running at @ 1/2 maintenance (i.e. inadequate fluid resuscitaion & volume support for presumed shock). The antibiotic doses she have been given were inadequate for presumed sepsis (she had a white count of 39,000 with a significant left shift/bandemia).

The infant was simply lying under an oxyhood, and Dr. Irwin was preparing to needle her chest to treat a "pneumomediastinum".

But one look at the child's chest X-Ray hanging on the lightbox in the nursery (revealing diffuse patchy infiltrates consistent with meconium aspiration/pneumonia) disproved Irwin's theory (there was no pneumomediastinum and no pneumothorax), and I stopped him from needling the child's chest.

I was afraid the baby would crash/code if she was pushed much more. Then we would really have a mess - because if she coded, there was a good chance we would not get her back. In truth, I was scared to death the baby would die before the transport team arrived.

On exam, the child was breathing very shallowly at @ 100-110 times/minute (way too fast) on 100% oxygen. Her Pulse Ox was only 94%. She was flaring but not "grunting" (I believe because she was too tired). Her lungs sounded "wet" and awful. She was pale & ashen, and was actually fairly blue from about the waist down. Her capillary refill was 4-5 seconds (a blood pressure had not been taken). Her tone was poor, but she did respond to noxious stimuli.

But here's the thing - and it's a big thing. As I quickly examined her, this exhausted baby opened her eyes and looked at me . . . right into my eyes. And in that second, I KNEW that she was STILL THERE (i.e. she was neuorlogically intact), and that I was going to fight for her . . . and that Dr. Mick Irwin, faux Neonatologist, could kiss my ass. So could the clueless control-freaks, Mike Bridges and Steven Eblin.

The baby was very air hungry, and with even the minimal stimulation of an exam became very agitated. After she briefly locked eyes with me, her tiny little eyes began darting all over the room . . . like a trapped animal.

SHE NEEDED SOMEBODY TO DO SOMETHING!!!

Compounding the awful/dire clinical situation, her Father was in the room, pacing and worried and watching every move I made. Of course, his presence prohibited me from throttling Irwin and demanding that he explain just exactly what he had been doing for two hours.

Very politely and firmly, I told Dr. Irwin that the baby required immediate intubation, and I told the nurses (already scurrying around the room/warmer gathering the things I would need) to prepare for me to do that.

But Dr. Irwin objected and insisted that I call the Neonatologist On-Call at NCBH (Steve Block) . . . who had "approved" everything he had done (I thought it strange Irwin had called Baptist instead of Cone). Gritting my teeth, I immediately got on the NCBH PALS line (which at the time I on speed-dial), and told Dr. Block (someone under whom I had trained) what was going on.

Steve was operating on the diagnosis of pneumomediastinum/pneumothorax . . . not meconium aspiration . . . from information Irwin had given him in the ONE phone call he placed.

Dr. Block told me that the baby was in front of me . . . not him . . . and to proceed immediately with whatever I deemed necessary because he trusted my judgement. He didn't know who Irwin was. He would call the transport team, and tell them to punch it.

It took several attempts to get the baby intubated (mostly secondary to thick secretions & meconium oozing up from below her cords and from her stomach). The NCBH transport team arrived during these attempts and ultimately assisted me with a successful intubation. The baby's stomach was then suctioned of 20 cc of particulate meconium. She had been laying on that warmer for over two hours without an unprotected airway and inadequate ventilation literally choking on her own stool. And Irwin was going to stick a needle in her chest for a nonexistant pneumothorax!

But hey, he was "comfortable" seeing sick babies.

The NCBH transport team, being an astute bunch, quickly sized up the gravity of the baby's condition . . . as well as the political heat of the situation . . . and elected to "scoop and run" . . . without staying to put in central umbilical lines (something we might normally have done) or make the usual chit-chat. The baby, suffering from persistant pulmonary hypertension of the newborn, "crashed" shortly after arrival at NCBH and had to be manually-ventilated (bagged) for two hours before being stable enough to put back on a ventilator. She was subsequently placed on a Nitrous Oxide trial and managed to avoid ECMO (very loose translation: baby by-pass).

She "graduated" from the NICU to suffer no permanent sequelae of her ordeal, and to have a normal life. Her doctor was not so lucky.

As I watched that baby roll out the nursery door with the team - not knowing if she would live or die - I decided right then and there that Mike Bridges was a damned moron . . . I was NOT going to live/practice under Kathleen Riley's thumb . . . and that this kind of BULLSHIT (it's time to use English again) would not stand on my watch.

I did not bill for my services.

I filed a complaint against Irwin with Peer Review that morning.

I did not "clear" it with Mike Bridges - or Steve Eblin. It was not their business.

Of course, the nurses told me that Kathleen Riley was snooping around the next morning asking everyone but her "partner" what had "really" happened the night before. I knew who she was asking for.

For his part, Irwin and I had a brief encounter in the hall on Med/Surg/Peds very shortly after the incident. He told me that we needed to talk. I responded that yes, we did. But we were not going to do it in the hall and we were not going to do it that day. We've not spoken since.

Let's return to the Medical Board complaint:

When I arrived, it was very obvious that Dr. Irwin was operating on a misdiagnosis (pneumothorax instead of pulmonary hypertension secondary to meconium aspiration), and that they baby had been GROSSLY under/mismanaged. Baby Doe was VERY critically ill and literally minutes away from "crashing". I had not been that frightened about a child's outcome (before transport) in a long time.

I elected to intervene without Dr. Irwin's request. As I indicated before, what records and note I have ahre enclosed. Apart from a few cryptic comments about Baby Doe's deteriorating condition he made to me after the transport team's arrival and the baby's subsequent successful intubation (comments which he included in his H&P), Dr. Irwin's behavior towards me was restrained and polite. He left the nursery before we could speak to one another in private.

Late that evening, I returned to the hospital to give the baby's parents an update on her condition (I had just gotten off the phone with her neonatologist at Baptist). Dr. Irwin had apparently very recently spoken with the parents, and in that conversation had indicated that I was responsible for the baby's deterioration and critical condition. He has also given them the impression that his credentials, experience and skills in neonatal and pediatric critical care were "better" than mine. This, of course, was gross falsehood. The parents confronted me - her father was understandibly furious (Author's note: It was a restrained furious;). I did my best to explain the situation and my actions. I then notified Baby Doe's neonatologists about the incident. My notes about that encounter are enclosed.

And here is the text of that note:

Earlier this evening, I visited the parents of Baby Girl Doe to update them on her condition. I had recently spoken with Mamta Fuloria, Neonatology Fellow at NCBH who indicated that Baby Doe was critical but "brittley stable" on the conventional ventilator and aggressive support. Things could be worse.

Her Mother seemed pleased to see me, but her Father seemed distand and angry.

I advised them that it was important for them to know why I was at the hospital this morning - I was not Baby Doe's physician of record nor was I consulted by him. I was asked to come in by the staff - specifically the nursing staff. I told the parents I had never done this before or been put in quite this situation. I told them I wished I had the opportunity to come in earlier and that I really did not want to have the conversation at all. But I had to explain why I was there when they did not me and Dr. Irwin did not ask me.

Baby Doe's Mother seemed to absorb this information, but her Father (still angry) said, "That's interesting. Dr. Irwin was just in here and he told us that everything was fine until you came in."

I told the parents that Baby Doe was critically-ill with pulmonary hypertension secondary to meconium aspiration syndrome when I arrived and that babies frequently "look fine" to inexperienced eyes before they crash. I reiterated that I was unable to do much more than assist the transport team because of the delay in my arrival, and that I could have done so much more for Baby Doe had Dr. Irwin called me in earlier.

I told the parents to talk about it, pray about it, discuss it with the neonatologists tomorrow, and feel free to call me with any questions they might have. I told them that "the blame game" did not interest me but Baby Doe's best interests did.

I have advised Dr. Fuloria that she may be placed in a difficult situation tomorrow. She reports that she will be glad to answer any questions the parents have, and that she will advise Dr. O'Shea of the situation.

I remember feeling physically ill after the encounter with the parents - quite literally shaking & nauseous. I came out of the Mother's room and went straight to the desk . . . to ask the staff just what-in-the-hell was going on with Dr. Irwin? Where did he get off? Was he fricking crazy? The nurses advised me that Dr. Irwin had told the parents that he was "Chief of Neonatology" at Randolph Hospital (according to him, the medical staff had gotten together and elected him).

The nurses were reasuring . . . telling me that they were already "on it". The parents had made inquiries with the nursing staff, and had been informed that Dr. Irwin's claims were false, and that when the nurses needed help, they called the doctors at RMA . . . and that usually meant Dr. Johnson, who was Chair of the Perinatal Committee.

The parents were also told that Randolph Hospital did not employ Neonatologists.

My "incident report" describes the baby's Father as "angry". Although he later insisted that he was not "angry" (this makes me smile because of the kind of man I know him to be), that was my perception at the time . . . he was nursing a simmering, white-hot (albeit polite) rage. And he had every right to be angry. Had it been my newborn daughter who was desperately ill and tethered to a ventitlator in a NICU an hour away, and two different doctors were telling me two different stories, I'd be angry too.

In that regard, all ended well. The next morning, I received a message from the baby's Mother . . . delivered through office staff . . . that thanked me for my help. Someone, somewhere had set the parents straight.

Here's another thing about comparative credentials: Dr. O'Shea, the baby's attending Neonatologist of record at Brenner's, was my residency advisor (my friends joked that he deserved "combat pay"). The following is an excerpt from the letter of recommendation he wrote on my behalf:

Mary was one of our most knowledgeable residents. She is quite capable in handling nearly all types of pediatic problems including emergencies. She is particularly excellent in critical care and has considerably more than average experience in this area . . . (she) is an extremely determined individual and works hard to accomplish those goals which she regards as important to the health of her patients. She seems to me to be very genuinly excited about her work in primary care and in my experience, she is extremely diligent whenever she feels she is making a difference.

Back to the Medical Board complaint . . .

Fortunately, as the parents asked questions, the nursing staff on LDRP, and later, the neonatology staff at NCBH/Brenner's were able to gently and discretely correct the misinformation Dr. Irwin had given Baby Doe's parents. The parents subsequently apologized to me.

I APOLOGIZED TO THEM. I AM PROFOUNDLY DISTURBED THAT THEY (AND I) WERE EVEN PLACED IN THIS SITUATION.

Dr. Irwin later filed a formal complaint with the Peer Review Committee regarding MY behavior - specifically intervening in Baby Doe's case without his request. I was exonerated (see enclosed). I have no idea was specific action was taken by the Committee with regards to Dr. Irwin's behavior.

Dr. Irwin's allegations were that (1) I treated the baby without his consent, (2) the nurses were wrong to call in a Pediatrician, and (3) my conversation with the family after his hatchet job was "inappropriate".

Please remember that this so-called peer "review" came AFTER I had already been fired. AND, I was never notified that my actions that night were under review. The Peer Review was over and done - without anyone interviewing me - without any kind of due process - before I was even notified!!!

The Peer Reveiw Committee very bravely and generously concluded that, "If nurses or physicians have reason to believe that a patient is critically-ill and not receiving adequate care, then they have a DUTY to intervene in the care of that patient."

OH REALLY GUYS (although I do not have an inclusive list, at the time the Medical Executive Committee would have included prominent Department-chair names like Juberg and Teague and West and Helsabeck)???

Did ANY of you bother to SHARE that opinion (anchored in a little thing called MEDICAL ETHICS) with the neanderthal executives at your hospital-owned, "safety-net" practice that fired me?

Knowing that I had been fired - and that the circumstances SMELLED - did ANY of your recommend a hearing or review?

I later heard, through the grapevine (nothing is "secret" at a small-town hospital), that as a result of my complaint on Dr. Irwin, Randolph Hospital charged him to do some more CME.

Ooooooo . . . ahhhhhhh.

A short while after that, Randolph Hospital allowed him to teach an NRP class!?!

And a few years later, he was later promoted to Chief of Staff.

Meanwhile, Mary Johnson thrown out on the street like garbage after busting her tail for three years to build a practice she could be proud of, was embroiled in litigation, making a meager living on the road, fighting tooth and nail for vindication and the chance to come back home.

Say it with me, "Care you can trust".

Back to the Medical Board complaint:

Very shortly afterwards, my contract with RMA-Pediatrics was abruptly terminated "without cause". For the Board's information, RMA-Pediatrics is a "controlled affiliate" of Randolph Hospital. Randolph Hospital and Cone Hospital in Greensboro have recently begun a "cooperative relationship" for referrals. If I am not mistaken, Cone either owns LeBaeur Healthcare or has made overtures towards "buy-out". LeBaeur owns Asheboro Family Physicians.

My privileges at Randolph Hospital were not affected by RMA's actions. I remain a member in good standing of the medical staff. I have unresolved contractual disputes with RMA (and by extension, Randolph Hospital). Notice that my contract had been terminated was served on February 2. I was given five days to complete charts and vacate the office. For the balance of the notice, I was not allowed to see patients. My salary was paid on the condition that I did not "disparage" RMA/Randolph Hospital and thereby "hamper" its mission in the community. I was essentially kept from practicing in Asheboro or competing wiht RMA for the balance of my notice. I refused to "settle" for a lump sum pay-out (the only offer RMA made was woefully inadequate fiscally and on terms that were personally and professionally unacceptable). The situation is quite complicated (my description here is simplified for brevity) and lawyers are involved. If the Board requires additional information, I or my attorney will be most happy to provide it.

My actions in Baby Doe'se case were obviously no "politically correct". It is my opinion that my intervention is Baby Doe's case was a contributing factor to my termination by RMA (management denies this). Of course, I probably will never be able to prove it.

My future plans in Asheboro are uncertain at the time of this writing. I am considering opening my own Pediatric practice in Asheboro with another Pediatrician who recently served RMA notice.

Asheboro Pediatrics never opened (although I remain incoporated for purposes of the work I now independently contract). There was simply no way to overcome what Morrison and Eblin had done.

This "incident" has caused me considerable personal (and professional) distress. I have literally agonized over what course of action to take - this complaint to the Board was delayed considerably because I did not feel comfortable incurrring the further "wrath" of RMA or of Randolph Hospital until my contract expired on August 2.

As I alluded to before, I strongly considered legal action for defamation against Dr. Irwin.

However, I do not wish to "drag" Baby Doe or her parents through a legal process that in the end (if it were successful) would only benefit me. Her parents have confided to me in the past that they "are not the type of people" who pursue malpractice claims (that in and of itself is admirable - I do not think I would be as charitable if I were in their shoes). And Baby Doe, after all, did recover and is thriving. In the end, that is all that really matters.

I submit the case to the Board for investigation because I do NOT want another baby, another set of parents, or another Pediatrician to go through ANYTHING like this again. I would like a neutral third party without any "interests" in Asheboro to evaluate the case. I will be most happy to provide more informaiton upon request.

For the Medical Board's information, Baby Doe's neonatologists at NCBH/Brenner's were Mamta Fuloria (a fellow) and Mike O'Shea. Also for your information, I trained at Brenner's. Dr. O'Shea was my residency advisor. He can provide feedback as to my credentials and abilities in neonatal and pediatric critical care.

Thank you, in advance, for your kind attention to this matter.

Mary Helen Johnson, M.D., FAAP

Later that week, Mike Bridges stopped me in the hall outside my office in the middle of the day . . . just as I was scheduled to see patients. He had not made an appointment. I already had three patients in rooms. They were not going to wait. Bridges wanted to talk. I told him, "NO!", and moved on to my first patient.

Bridges never made another attempt to talk to me. It apparently never occurred to him that in light of what had happened, it might be a good idea to formally retract the accusations he made in his letter . . . or rescind the threats he made.

And he styled his actions to the hospital lawyers and the BOD as, "Mary has a lawyer, Mary won't talk to me." Insert his lip quivering.

Jeez, I wonder why she won't talk to you? YOU PUT HER THROUGH HELL!!!

The following is Mike Bridges' "notice" of "voluntary terminination" delivered two weeks later on February 2, 1998. Please note that it was important to fire the oh-so-disruptive Dr. Mary Johnson and get her out of RMA's offices . . . but not important enough to do so until she had covered one more week of vacation for Dr. Kathleen Riley:

Dear Dr. Johnson,

Pursuant to paragraph 25 of the Employment Agreement between Randolph Medical Associates ("RMA") and you, dated January 12, 1995 ("Agreement"), we hereby give you notice of voluntary termination of such agreement by RMA. According to the provisions of paragraph 25, your employment relationship with RMA will end one hundred eighty (180) days from the date of this letter, August 2, 1998. We expect you to complete all pending chart documentation for patients, as well as to cooperate fully in a smooth transition of patients primarily seen by you to other physicians employed by RMA within the next five (5) days. Following that time and for the balance of the notice period, you may not see patients or come to RMA's offices except for reasons approved my me in advance. If you do come to RMA"s offices for reasons approved by me, you must be accompanied at all times by me while you are in the office. RMA hopes that you will make use of this time to find employment which best meets your needs.

Although your employment relationship with RMA will by ending in accordance with this letter, you should be aware that this action does not affect your continued medical staff membership and clinical privileges at Randolph Hospital.

If requested, RMA will provide a neutral reference for your future employment. If however, during the notice period referred above, RMA determines that you have disparaged or defamed RMA, Randolph Hospital, or any of the employees or business of RMA and Randolph Hospital in the community, RMA will consider you to be in breach of the Agreement, it will immediately sever the employment relationship, and it will terminate the Agreement for cause, thereby discontinuing any further obligation of RMA thereunder.

If you have any questions regarding the above, please call me,

Sincerely,

Mike Bridges
Executive Director

cc. Mr. Steve Eblin

So ladies and gents, between the "letter of warning" and the "notice of voluntary termination" that Mike Bridges sent to me (with Steve Eblin's approval), let's review the terms of my "notice".

(1) Under threat of termination "for cause", I cannot open my mouth about anything going on at the practice or the hospital . . . be it Mick Irwin's incompetence, Breton Juberg's open zipper, Kathy Riley's misrepresentations of my conduct & character . . . or any of the clinical issues warranting my attention in the nursery or on the floor.

(2) I don't have the right to defend myself. I am tossed out on the streets of my own hometown . . . in full view of my mortified parents . . . condemned without ANY kind of due process or hearing.

(3) I can only talk to Mike Bridges or Steve Eblin. I cannot talk to RMA or Randolph Hospial Board members. I cannot talk to colleagues. I cannot talk to patients.

(4) Instead of being allowed to work out the six month "notice" (as any physician signing one of these contracts might expect) and smoothly transition my practice, I am to leave the office in five days and hand everything over to Kathleen Riley (because let's be clear, that's where the patients were going to be assigned unless they objected). I am thereafter banned from coming to the office.

(5) I can "look" for employment, but no provision is made to allow me to take it. For the uninformed, North Carolina employment law is crystal clear that if, while under exclusive contract to RMA, I accept employment anywhere else . . . without specific permission from the RMA Board of Directors . . . with whom, by Mike Bridges' specific instructions, I CANNOT communicate . . . I can be fired "for cause" with complete loss of salary & benefits.

(6) Moreover, staring a practice in Asheboro (i.e. self-employment) would be competing with RMA . . . interferring with its business . . . in violation of my employment agreement and grounds for involuntary dismissal (i.e. "for cause" termination).

(7) Speaking of benefits, the "severance" offer that Bridges wants me to accept only offers a payoff of the salary RMA owed me the second Bridges threw me out of the office and banned from doing the job I was contracted to do. It does not address insurance, healthcare, sick leave, malpractice or any of the other benefits that are part of my employment arrangement.

Moreover, Mike's plan most certainly does not honor the agreement RMA had made with the National Health Service Corps in order to secure my loan-repayment-for-service deal.

VERY SPECIFICALLY, RMA is not supposed to interfere in ANY way with my continued practice in the area during or after I leave the practice. If RMA were playing by the rules, I would work out a six-month notice and smoothly transition my practice (as Brad Thomas and Sid Blake were later allowed to do).

And clearly, adequate quality assurance protocols and peer reveiw (required by the site agreement) are not in place.

But Mike, you see, is trying to get out on the cheap by ambushing me . . . and putting me in a box. He has even cancelled my malpractice insurance despite the fact that I am still technically employed (something that will become problematic a short while later).

Mike Bridge, Steven Eblin and Bob Morrison wanted silence above all else. Nothing else mattered.

(8) There's a reason Bridges makes the point that my hospital privileges are not affected by RMA's action. You see, a physician's hospital privileges are a protected property right, and Morrison/Eblin/Bridges could attack them without just cause. And, as we've established, they didn't have anything remotely resembling just cause.

But here's the thing about that: Bridges says I can still see patients at the hospital, but I can't really. Because my patients are RMA's patients (Bridges will not provide a list and is fordamnedsure not going to give me permission). Once again, I cannot interfere with RMA's "business", or I will be fired "for cause".

That, and I'm not insured. And medical malpractice insurance is REQUIRED in order to practice at the hospital (else I could be disciplined for practicing "bare").

(9) And, OBTW, if I play this stupid, sick, warped game, and take their "generous" deal (Eblin's words), I can have a "neutral" reference from Mike Bridges . . .

. . . . Mike Bridges, who is not a doctor . . . Mike Bridges who has not even moved to Asheboro . . . Mike Bridges who is incapable of entertaining an idea that isn't Kathleen Riley's . . . Mike Bridges, whose name is not anywhere on my RMA employment contract . . . Mike Bridges, the little tin god who doesn't think firing the Pediatric practice's founding member deserves a little thing called due process - or the attention & approval of the RMA Board of Directors (who all say they don't know what's going on) . . . Mike Bridges is the guy making this decision!

Randolph Medical Associates was created . . . as a wholly-owned "controlled affiliate" of "non-profit" Randolph Hospital to be the "safety-net" practice in Asheboro . . . to see the kids who were falling through the cracks . . . and to do the Pediatric "dirty work" & heavy-lifting at the hospital . . . to "clean things up". Board members no doubt had considerable input into the process - including the recruitment and hiring of physicians. I knew it was going to be difficult and I was assured that hospital administration would have my back.

By law, the Boards of Directors were/are charged with oversight. It's not just about a free retreat twice a year.

But instead of taking my back, Bob and Steve put knives in it . . . and after I was fired, the oh-so-"honorable" RMA & Randolph Hospital Board members . . . like Jim Kinlaw and Charles Stout and Bill Redding and Ted Matney and Jim Culberson and Joe Bossong . . . had the unmitgated gall to write to angry parents and tell them they had no repsonsibility for what had happened (admitting that they had no knowledge or input into the decision to fire me) . . . and that they really wanted me to stay in Asheboro . . . and that I was "free" to start my own practice.

I think we've established that these men were (1) being led around by the nose and (2) LYING THROUGH THEIR TEETH. And I can guarantee you that if this baby had been one of their children - or grandchildren - Mike Bridges/Steve Eblin/Bob Morrison would have not dared touched Mary Johnson. But in our fair mill town, the patient, her parents and the doctor who intervened to help her were "nobodies and nothings" compared to the Cone-owned Mick Irwin . . .

. . . or Cheryl Freeman who sat on the Board of Health. I wonder if the good dentist wants to lecture the "dime-a-dozen" Pediatrician on how she treats patients now? I wonder if Denise Gimenez (wife of a surgeon - with all "the right" connections) understands how fundamentally INAPPROPRIATE it was to butt into (and chat up Steven Eblin about) a medical matter in which she was not involved? I wonder if Craig Gaccione still believes that Anesthesiologists are more important than Pediatricians in the equation of taking care of his patients?

That's the way things work in Asheboro.

CALL ME A "WACK-JOB" ALL YOU LIKE, BUT THE MANAGEMENT OF RANDOLPH HOSPITAL IS JUST SICK AND WARPED IN TERMS OF THE WAY IT DOES "BUSINESS"!

AND IF YOU'RE A PEDIATRICIAN, PLEASE JUST STAY AWAY FROM THIS PLACE!

I also think this is a good place to stop. I've more than made the case for wrongful termination. I was threatened . . . based on trumped-up accusations. I ignored those threats to do my duty. Hospital executives retaliated because they could not be "embarrassed". No one on the Board or Executive Medical Staff could be bothered to step outside of their comfort zones to stop what was going on.

And I long ago made the case for perjury, contempt and fraud . . . crimes which have yet to be punished.

I am going to let this post stand for a while and take a break.

Then I am going to start publishing the letters of parents who objected to my termination . . . letters that Board members ignored and the Courier Tribune refused to publish.

I'm very tired. But tonight it's a good tired. It's good to finally get this off my chest. It's been like a lead weight.

Ahem, Mr. Justice, Whatever Happened To Firing Squads?

I don't care what the N.C. Supremes say (4-3), doctors have no place in the equation of death. I have news for Sarah Ovaska (the N&O's mouthpiece on this one): If the state really wants to kill somebody, maybe they should resort to the older/messier ways (that don't "need" IV's). It might keep them honest. (Here's the 5/2 N&O update.)

Looks like the N.C. Medical Practice Act is still in dire need of some legislative tweaking . . . not just about this, but about whistle-blower protection as well (see the preceding post). And the N.C. Medical Board, always way-late to the party . . . or not there at all (what-the-hay, let's put them all up) when it comes to enforcing ethical principles, certainly has its work cut out for it.

5/2 Update: This post originally went up on 5/1. But I have moved it back to 4/28 because I really want "Part Three" in my series from the legal files to sit prominently on the "home page" and percolate.

I had intended to take a long break prior to resuming posting again (with letters from parents that the Randolph Hospital Board of Directors ignored and the Courier Tribune would not publish). But the N.C. Supreme Court trumped that plan.

It is clear from the Supreme Court's decision that Medical Ethics means NOTHING in this state.

Of course, I already knew that.

"That We Also May Be Like All The Nations"

My BlogFather has an interesting post up today . . . especially in lieu of a conversation I had with my brother over the weekend, "This nation has lost its blessing", he said.

There's more than a little truth in that, I'm afraid.

Attitude Adjustment

As Kevin found out, these days, the mere mention of the NHSC (National Health Service Corps) makes my blood boil . . . especially when the Obamanation offers it up as a part of a "solution" to doctor shortages . . . particularly shortages in primary care.

Kevin's mistake was using it in a sentence. In my book, that's a plug.

"Good Pediatricians are a dime a dozen."

That's the attitude that you have to fix.

I know a way.

So You're A "Non-Profit" And You Want You Some Of That Stimulus Money?

According to Bev Perdue's Commerce Secretary, Keith Crisco, North Carolina "non-profits" are going to have to embrace “efficiency, transparency and accountability” if they want to get any of Obama's stimulus money.

Oh really, Keith? Cuz I'm really not seeing it.

I'm on Bev's propaganda . . . excuse me . . . e-mail list. But lately, Bev's e-mails have been identified by RoadRunner as spam (nothing I did), and I've missed several of them. But I did check out her Facebook page today.

And I left a message;)

This Little Piggy

Got the swine flu memos today. Watch and wait.

"Crazy Americans"

Hattip to Kevin: An interesting interview with investigative journalist Philip Dawdy on the "purely American" tendency to diagnose and treat small children for psychiatric "illness" where none actually exists.

Public Citizen On The N.C. Medical Board: I Wonder If I'm "Relevant" Yet?

Courtesy of Carolina Online, I present an editorial from the Wilmington Star News . . . relevent to these two posts. It's old news.

And I would not count "the Honorables" at the N.C. Medical Board & N.C. Medical Society out just yet.

They excel at watering things down . . . or ignoring them altogether.

There's an interesting excerpt from the Star News editorial . . . relevent to this post:

Public Citizen, which has criticized medical boards for failing to discipline bad doctors, announced this week that in 2008 the N.C. Medical Board was the 14th most aggressive in going after doctors who violated ethical standards or made serious medical errors. Considering its ranking of 41st just a few years ago, that's reason to be impressed.

Several high-profile cases shone an unflattering light on its failure to deal with physicians who make serious errors or violate rules of patient care. Since then the state medical board has made a number of positive changes. It has stepped up enforcement and has made more information about complaints available to prospective patients.

In a few days we're going to be talking about a much lower profile case . . . in fact, a case that the local newspapers so concerned with the "hyper-local" have determinedly buried . . . in order to protect the reputations of the hospitals involved.

There's a reason newspapers are dying, and they DESERVE to die.

No one . . . not the oh-so-ethical "Honorables" on the Randolph Hospital Medical Executive Committee or its Board of Directors . . . or on the N.C. Medical Board . . . or at NCDHHS/the Attorney General's office . . . or at USDHHS/the U.S. Attorney's Office . . . or the N.C. State Bar (these days I actually chuckle every time I think about how naive I was to expect that crowd of crooks to act honorably) . . . lifted a finger to STOP what was going on . . . or help the doctor who went above and beyond.

They've all hidden behind privilege and confidentiality . . . and notions of medical collegiality . . . and they've all dodged their pieces of jurisdiction in this mess . . . for far too long.

Once I get it all out of my system on this blog, if these agencies do not shortly MOVE to hold Randolph Hospital accountable for its despicable/reprehensible actions (a "positive change" I've yet to see happen despite eleven years of trying), I am going to chat me up some lawyers . . . and we'll see if we can make us another "high profile" case to showcase the determinded apathy and fundamental uselessness of the N.C. Medical Board as a defender of those in its ranks who need protection . . . as opposed to discipline.

Medscape Lays A Rotten Egg: Offering Continuing Medical Education On Weeding Out "The Disruptive Physician"

This is a nice set-up for "Part 3" (I haven't forgotten). As it pertains to physicians, what does "disruptive" mean?

I don't have much use for MedScape. I think it's a fairly poorly-disguised mouthpiece for corporate medicine.

I also don't like the way that it limits access only to healthcare professionals. As far as Medscape is concerned, the "ignorant" (about the way medicine really works) lay public can just stay ignorant.

Moreover, Medscape's registration process is akin to signing away the birthright of your first child . . . apart from your name/address/e-mail, they want your credentials . . . your Social Security Number . . . all kinds of things that I'm just not comfortable giving to someone for the dubious privilege of reading their propaganda.

It also seems to me that the only way blogging is going to make a REAL difference in the evolution of medicine is to get topics . . . and doctors' voices . . . "out there" . . . as opposed to hiding them behind yet another version of "The White Wall".

A few of my online doctor-pals newer to this blogging scene have been vexed and thwarted by Medscape's quirks and predilections.

One of those friends called me Monday . . . absolutely LIVID over a new CME course offered by Medscape . . . which basically gives step-by-step instructions as to how to rat out one's colleague for the nebulous, ill-defined sin of being "disruptive".

Over the last fifteen years or so, labeling physicians as "disruptive" . . . and targeting them for termination or (even worse/potentially more destructive) hospital peer review actions based on that "diagnosis" . . . has become the modus operandi for hospitals wanting to get rid of a doctor who might not tow the company line (I believe it's called being a "team player") . . . or blow the whistle on things that might not paint said hospital in a favorable light. In fact, it's become a fricking cottage industry . . . one that Medical Boards everywhere - and JCAHO - have now latched onto . . . fueling the practices of attorneys who defend & prosecute these doctors . . . and the psychiatrists & psychologists who evaluate them.

Again, my problem with the whole "disruptive physician" argument comes down to a very simple question that none of the aforementioned learned legal and medical professionals seem to have the insight to ask . . . i.e. what comes first . . . the chicken or the egg? What outside forces (not under the same microscope as the physician under scrutiny) are contributing to the physician's "disruptiveness"?

For instance, does anyone consider the hospital or practice administrator who could not administrate his/her way out of a wet paper bag? Or other "more-favored"/"suck-up" colleagues who seem to be coated in Teflon no matter what they do? Or bad facilities? Bad policy? Poor staffing? Overwork? And what about that nurse/lab technician who made a mistake wanting "revenge"? Or even the motivation of a patient/colleague who might complain?

This Medscape article offering CME offered NONE of that scientific process.

There is, in fact, a spirited on-going debate in a nearly two-year-old thread buried deep in one of Medscape's forums on the subject of the "disruptive physician". I lost interest long ago, But at last glance, it had well over 2000 comments (beat that Ed Cone-of-the-Cones). I'd link the thread (just for the public's information), but the lay person could not see it even if they wanted to (well, unless they impersonated a physician).

Anyway, despite the raging debate, Medscape (being the corporate mouthpiece that it is) now offers CME in how to identify and report the "disruptive" physician. My friend send me the link.

I'll just bet his face was contorted on the other end of the phone (according to this piece of fluff, he's be categorized as "disruptive", but we'll get to that).

As I am a bit of an expert on being targeted (by the nimul suits running Randolph Hospital) for alleged "disruptive" behaviors . . . despite over-whelming evidence to the contrary . . . my friend dialed me up.

"Mary, DO SOMETHING, with this!", he pleaded. I told him I'd take a look.

And Sweet-Merciful-Mary-Mother-Of-God (I'm not even Catholic), I don't think I've read such a fundamentally frightening, ominous, disturbing, in-your-face fascist, just-put-on-a-brown-shirt load of caca-del-toro in my life.

As my friend said (very succinctly for a change;), "There's no scientific process or due process!"

Again, I'd link the article, but the lay reader would not be able to read it. I don't feel like quoting a lot of the propaganda either. It is authored by Paul S Mueller, MD, MPH (of the Mayo Clinic) and Lois Snyder, JD (Director of the Center for Ethics & Professionalism at the American College of Physicians in Philadelphia). It begins with a disclaimer:

This case study is one in a series with commentaries by the American College of Physician's Ethics, Professionalism and Human Rights Committee and the Center for Ethics and Professionalism. The series uses hypothetical examples to elaborate on controversial or subtle aspects of issues not addressed in detail in the College's Ethics Manual, the Physician's Charter on professionalism, or other College position statements.

The "Introduction" sets up a hypothetical situation: "Dr. Smith" (a generalist) refers a patient (obese, hypertensive, Type-II diabetic with nephropathy) to "Dr. White" (a renowned, professor/cardiologist/rainmaker). The patient (a prominent executive) returns from said referral very unhappy with the visit - and complaining about "Dr. White's" bedside manner - for telling him that he was obese. The patient left the encounter prematurely without learning about the abnormal results of a treadmill test. Dr. Smith refers the patient to another cardiologist.

Other patients of Dr. Smith have complained about Dr. Smith's gruff bedside manner. But Dr. Smith has kept right on referring to Dr. White.

I dunno about you, but that seems to me to be a simple enough problem to solve without "reporting" anybody. Don't refer to Dr. White.

Turning the page, the article moves on to commentary. First it started by defining the "disruptive" physician:

Patients identify being confident, empathetic, humane, personal (ie, viewing the patient as a person, not a disease), forthright, respectful, and thorough as ideal physician behaviors. Valuing teamwork, handling stress, punctuality, and self-motivation to pursue professional and personal growth are also ideal physician behaviors.

The article then goes on to list physician behaviors that might be considered "disruptive" and might negatively affect patient care and/or learning & work environments. Inappropriate language, yelling, gossip, facial expressions and other mannerisms, and physical boundary violations were dutifully included.

Obviously, the people writing this work in an ivory tower . . . not a real hospital. And once again, their notion of the "disruptive physician" pays no heed to the notion that the physician might be reacting negatively to something negative in the workplace.

The reference to abusive facial expressions really torqued off my friend. Using a very personal example, let's say (in any hospital , anywhere) I'm roused from a deep sleep to attend an emergency in the middle of the night. As a result of the assault to my sleep cycle and auditory system, my face is burning and twitching from trigeminal neuralgia (a condition which prompted me to re-visit my neurosurgeon yesterday) . . . a purely physiologic reaction triggered when my beeper went off. If the wrong person with an agenda saw the grimace on my face, that could be considered "disruptive".

And they could report it. Anonymously.

The article then goes on to discuss the prevalence of "disruptive" behaviors . . . citing a survey of 1627 "physician executives" (key word, executives). 95.7% reported regularly encountering disruptive physician behavior, and 70.3% said disruptive behaviors nearly always involved the same physician(s). Common disruptive behaviors were disrespect (again, only physician executives were polled, and I can only imagine what constitutes "disrespect"), refusal to complete tasks and carry out duties, yelling, insults, and physical abuse (including throwing items). A majority (56.5%) reported that disruptive physician behaviors most often involve conflict with a nurse or other allied healthcare staff. Other respondents said disruptive behaviors most often involved other physicians (14.7%), administrators (14.5%), and patients (14.2%).

I wonder what would happen if physicians labeled "disruptive" were polled? Taking another page from my own experience at Randolph Hospital (and flipping through Randolph Hospital's discovery responses), what if you, as a Pediatrician/young professional charged to cover a majority of the Neonatal & Pediatric critical care at your small hospital kept getting parking tickets every time you got called in for a code? What if EMS workers (employed by the hospital VP's husband) see fit to dismiss your orders and call you "Honey"? What if you spend hours telling parents to have faith in the hospital & ER (whose horrible reputation you're trying to improve) . . . and finally get them there . . . only to get an inadequate/incomplete work-up? What if the unit dedicated to Pediatrics (that you were promised at recruitment) was summarily shut down? What if the lab will not run a test that it took you multiple sticks to draw (because they wouldn't/couldn't) based on some stupid "policy" that has NOTHING to do with what's going on with the patient right in front of you? What if you spend your days and nights fielding off every manner of complaint (about your Teflon-coated colleagues), or negotiating stupid/petty turf wars? What if you're tired of making excuses for botched procedures and missed diagnoses of others? Given your expanded duties at the hospital, what if you're sick of your office schedule not being your own? What if you're exasperated with a Chief of Obstetrics who cannot keep his "thang" zipped up? What if a micro-managing Director & President (who are fundamentally lost when it comes to Pediatric practice management) have decided that you (as the resident/token opinionated female) are "arrogant and cliquish" . . . and are only listening to a colleague who is supposed to represent you, but isn't telling you/your other partner much of anything until after the fact?

Okay. My face is starting to twitch. There's MUCH more. But I'll stop.

The article then goes on to cite surveys of nurses, pharmacists and medical students - reporting that 86-90% of them have suffered "verbal abuse".

My first response was, "Well, DUH". My seven years of medical training was nothing but a whirlwind of abuse - a whole lot of it sexist. You sucked it up and dealt with most of it.

The article also cited an Australian study (I guess it's not important enough to study in the U.S. before you offer CME) indicating that 36% of patient complaints to medical boards were the direct result of "disruptive" physician behaviors.

This statement was interesting: Notably, nearly 80% of the respondents said disruptive physician behavior is under-reported because of victim fear of reprisal or is only reported when a serious violation occurs.

Dr. Mary Johnson, Pediatrician in public service at Randolph Hospital, certainly understands fear and reprisal.

The Medscape article then goes on to discus the "consequences" of disruptive behavior:

Disruptive physicians undermine morale, diminish productivity and quality of patient care, and cause work environment distress leading to heightened employee turnover. One survey found that most nurses believe physician disruptive behavior causes stress, frustration, impaired concentration, reduced collaboration and communication, and potentially negative patient outcomes. Another survey found that nurses see a direct link between physician disruptive behavior and nurse satisfaction, retention, and the quality of the nurse-physician relationship.

Again, beliefs are not proof. Seeing a "direct link" does not establish one.

And hey, I have an idea! Why don't we ask the nurses at Randolph . . . the ones who were in the office and on the LDRP & Med-Surg-Peds units when I was there . . . about how "disruptive" Mary Johnson could be?

And here's another thought: Maybe the nurses working the LDRP unit that fateful night in January 1998 called Dr. Mary Johnson because she was "disruptive" enough to take on a doctor who clearly was in over his head . . . and whose failure to acknowledge that/ask for help put a newborn's life at risk.

They knew Dr. Johnson would have "the balls" to stop him.

More from the article:

Other consequences of disruptive physician behavior include disciplinary actions, dysfunctional physician colleague activities (eg, coverage, leadership, peer review, referral, etc), and compromised communication within and efficiency of healthcare teams.

Again (referencing my own situation), offering 24/7 Neonatal & Pediatric back-up coverage . . . for anyone who asked . . . was apparently "disruptive". Answering the nurses questions . . . telling them no question was "stupid" and to never to be afraid to call . . . was "disruptive". Investigating patient/nursing complaints and filing complaints to peer review (when warranted) was "disruptive". Insisting that people maintain the CME to do the things they were credentialed to do was "disruptive". Insisting the basic Pediatric protocols - in the office - on the floor - in the ED - be followed was "disruptive".

Mary Johnson wasn't playing on the right team.

Many physicians engage in teaching activities. Attending physicians should treat learners with respect, empathy, and compassion and should role model virtues. Abusive treatment, like that of Dr. White, and role model pessimism lead to learner dissatisfaction, burnout, depression and unprofessional behaviors. In fact, abuse of medical students is common and the main sources of the abuse are physicians. Furthermore, compared to non-abused students, abused students experience more difficulty learning, anxiety, depression, and alcohol use.

As it pertains to my relationship with the nurses at the time . . . and my efforts to teach them . . . and advocate for them . . . one statement, made by a nurse after I was fired, sticks with me after all of these years: "If they (RMA/Randolph Hospital) can do this to you, Dr. Johnson, what hope do the rest of us have?"

The Medscape article then abandons all pretense of scientific process and lets loose with the flowery visionary mumbo-jumbo that hospital administrators love:

The Physician Charter on Medical Professionalism is comprised of 3 fundamental principles -- the primacy of patient welfare, respect for patient autonomy, and social justice -- and 10 professional responsibilities. The disruptive physician probably violates many of these principles and responsibilities. Certainly patient welfare is affected and respect for patient autonomy, which requires discerning and acknowledging patient healthcare values and goals, is violated. Disruptive physicians are less likely to acknowledge these values and goals. They may also violate the principle of social justice by wasting scarce healthcare resources, diminishing productivity and heightening turnover of allied healthcare staff. Indeed, unnecessary staff turnover caused by disruptive physicians can cost institutions hundreds of thousands of dollars.

All current models on reporting the "disruptive" physician emphasize confidentiality and anonymity for the person doing the reporting. But that would seem to me to violate one of the most basic principles of social justice . . . that being due process. It also leaves the door wide open for abuse of the process by those who might have a less-than-noble agenda. My Mama used to say that if you could not sign your name to something you wrote, you had no business writing it.

It's about personal responsibility. If you file a complaint against one of your colleagues, you need to be able to stand behind it . . . you need to sign your name. And you need to be protected when you do it.

I wasn't.

Medicine, of all professions, should not be a safe haven for witch hunts.

And while physicians like Dr. White may be knowledgeable and skilled, they do not demonstrate "professional competence," which, according to the Association of American Medical Colleges includes being altruistic and dutiful and to the Accreditation Council for Graduate Medical Education includes possessing effective interpersonal and communication skills and professionalism.

We're going to address this in "Part Three", so for now I'm just going to let that stand.

Another physician responsibility in the Charter is honesty with patients. Physicians should ensure that patients are adequately informed of their diagnoses, the risks and benefits of and alternatives to treatments, and their prognoses. Being honest with patients, however, does not mean that physicians should bludgeon patients with information (eg, sad, bad or unexpected news). Such behavior is disruptive. Instead, physicians should convey information to patients with compassion and empathy and endeavor to meet patients' informational, emotional, and spiritual needs.

Again, referencing my own experience at Randolph, I wonder if this Mother would have liked to have known what was going on behind the scenes? Was anyone really honest with her?

Disruptive physicians like Dr. White violate the commitment to maintaining appropriate relations with patients. Patients are inherently vulnerable and dependent on physicians and other healthcare providers. Patients must be confident that their needs, not the physician's, will take priority (but hey, Mary Johnson is not a "team player"?).

Physicians who violate sexual and financial boundaries with patients are obviously disruptive (not that Randolph Hospital cared until the Medical Board made them care). In some ways, it is easier to deal with these behaviors through suspension or termination processes. But physicians who are abrupt and rude when interacting with patients are also disruptive.

I've said it before and I will say it again. This is medicine. The customer is not always right. And the physician-patient RELATIONSHIP is a two-way street. I don't care what the corporate PR gurus in the ivory tower say, the (increasingly entitled) customer who yells and stomps and throws things and calls names to get their way does not need to be coddled. The customer who steals from you doesn't get a second chance to do it. The customer who accuses you of "malpractice" because you say, "No", has destroyed the trust and ended the relationship (or at least that's what the expensive consultants hired by the gurus told me).

I certainly don't believe that all patients are "inherently vulnerable". That is condescending and paternalistic in the extreme. Patients these days are empowered as never before. It's not a bad thing. But it can be taken to extremes.

The article then rattles on about how the "disruptive" physician factors into quality of care and patient outcomes. Again, there is a lot of flowery language and generalizations (disruptive physicians cause this . . . disruptive physicians cause that), but no scientific evidence to back up statements passed off as fact.

And, again, NO ONE ELSE IN THE COMPLICATED EQUATION OF TODAY'S PATIENT-PHYSICIAN RELATIONSHIP is factored into this fluff!

Professionalism is associated with increased patient satisfaction and trust, adherence with treatments, greater likelihood a patient will 'stay with' and recommend a physician, fewer patient complaints, and less patient litigation.

Well, duh.

Finally, the results of the surveys discussed here reveal that disruptive physicians commonly violate the commitment to professional responsibilities. The ACP Ethics Manual states, "Physicians share their commitment to care for ill persons with a broad team of health professionals. The team's ability to care effectively for the patient depends on the ability of individual persons to treat each other with integrity, honesty, and respect . Particular attention is warranted with regard to certain types of relationships and power imbalances that could be abusive or lead to harassment, such as those between attending physician and resident, resident and medical student, or physician and nurse."

Again, a scenario is not even considered that does not have the physician in power and doling out the abuse . . . never mind that many physicians these days are NOT in a position of "power", and are, in fact, under the thumb of outside economic/corporate forces that would dictate their behavior . . .

. . . like the ones that would have kept Dr. Mary Johnson at home in her bed while a baby was dying.

Institutions also violate this commitment if they fail to identify and address disruptive physician behavior. Many institutions have adopted policies for acceptable physician behavior and established disciplinary procedures for physicians who breach these policies.

In addition, the Joint Commission on Accreditation of Healthcare Organizations requires that institutions have a mechanism for handling physician health and behavior problems apart from the medical staff disciplinary process and is considering a patient safety goal, "Discourage Disruptive Behavior" as a leadership standard to apply to all hospital staff.

Does that include hospital administrators who lie/cheat/steal/slander to get their way? As I've blogged before, I met with the mighty bigwigs at JCAHO twice during my legal battle with Randolph Hospital. Both time, I got mealy-mouthed "sympathy", but was told that JCAHO had NO MECHANISM in place to address the problem of the abusive/corrupt hospital/practice administrator.

As far as I can tell, eleven years later, JCAHO still doesn't have a policy in place.

It's much easier to blame everything on the doctor.

The Medscape article then goes on to discuss how to identify/report the "disruptive" physician.

Disruptive physicians are not usually difficult to identify since disruptive behaviors nearly always involve the same physician(s). A major reason for identifying and addressing disruptive physicians is to prevent adverse patient care and work environment outcomes. Indeed, the American Medical Association Code of Medical Ethics states that physicians and healthcare institutions have duties to identify and address "physicians deficient in character or competence." Institutions affiliated with medical schools and other teaching programs should identify negative physician role models and sharply deal with abusive behavior. Additional reasons for identifying disruptive physicians are to address underlying causes for the behavior (eg, mental illness, substance abuse, etc) and to change learned attitudes and behaviors. In fact, evidence suggests that formal and informal curricula can change -- for the better -- disruptive attitudes and behaviors.

THE FOLLOWING ARE THE IMPORTANT DISCLAIMERS MOST HOSPITAL ADMINSITRATORS (AND THEIR LAWYERS) MISS:

On the other hand, physicians should not disparage the professional competence, knowledge, qualifications, or services of another physician without substantial evidence (again, I'm going to discuss this in Part 3, so for now we'll let it pass).

And while physicians have a duty to promote standards of professionalism, they should also avoid labeling "whistleblowers" and physicians with unique personality traits as "disruptive."

I guess the guys at Randolph missed that class in the evil administrator's curriculum.

Disruptive physicians can be identified by a number of means including patient complaints and surveys, peer assessments, and anonymous 360-degree reviews (eg, by nurses, allied health employees, learners, etc). Primary care and referring physicians should encourage patients to report back to them experiences with physicians -- especially disruptive physicians -- to whom they are referred.

Institutions should develop and implement formal processes for reporting disruptive physician behaviors. Clear descriptions of the disruptive behaviors (eg, date, time, parties involved, quotes, outcomes, etc) should be documented and reported to appropriate institutional leaders. Institutional policies should ensure that reporting disruptive physicians will not result in retaliation.

Again, I know all about retaliation (for confronting/reporting truly "disruptive" physicians). And I cannot emphasize enough that anonymity has NO PLACE in this equation. FORMAL PROCESS MEANS DUE PROCESS! You are attacking someone's character/competance . . . their livelihood . . . and in some cases, you are even setting the groundwork for a potential "psychiatric diagnosis". In this country, you do not get to point a finger and then duck back behind a wall . . . with no consequences to you if you act with something less than noble intent.

You certainly should be protected if you act in good faith . . . but there must be a mechanism for you to be held accountable if you act in bad faith or with malice.

Randolph Hospital (at this point it's not just about the executives, but their rubber-stamp Board members) did NOTHING but act with deliberate, calculated malice when it retaliated against Dr. Mary Johnson for doing the job she was recruited and hired to do.

And that is why I would discourage any young physician/Pediatrician . . . any young professional . . . from buying into Steve Eblin's recruitment pitch. That's why I would tell them to STAY AWAY from Randolph Hospital (this counts as my Friday afternoon post).

Institutions should be clear that disruptive behavior is unacceptable and develop formal processes for handling disruptive physicians. Policies should be applied fairly (another class in evil administrator school that Eblin & Bridges missed). For example, a physician may manifest disruptive behavior that for him or her is rare. Such physicians are likely to respond to timely feedback from colleagues. If disruptive behaviors persist, then the disruptive physician should be reported to institutional physician leaders.

One model for giving corrective feedback effectively includes preparing the disruptive physician for the feedback session (eg, informing the physician ahead of time, setting a date and time, providing a private and respectful atmosphere, and negotiating an agenda). At the meeting, the physician should be asked for a self-assessment of their behaviors and interactions with patients, colleagues, and others. Observations of specific disruptive behaviors (and why the behaviors are disruptive) should then be shared with the physician. Strategies for improvement should be elicited from and suggested to the disruptive physician. If necessary, the disruptive physician should be offered help (eg, counseling, communication training, etc). A shared plan for improvement should be developed and implemented. Expected improvements in behaviors, monitoring, and consequences of not improving (eg, disciplinary actions) should be clearly articulated.

Please note that this is the trap Mike Bridges and Steven Eblin wanted to lay for me in January 1998 . . . with NO documentation in my personnel or peer review files to back up any of what they had reduced to writing. They were essentially acting on Kathy Riley's word & version of events - and one letter from an angry "VIP". Moreover, I was not drinking the Koolaid on their planned physician bonus scheme (which almost doubled Dr. Riley's salary after I was gone) . . . I was not rolling over for extended hours (without entertaining some very good reasons for implementing them) . . . I was not going to stand by while my nurses got crapped on . . . I was referring preferentially to Baptist instead of Cone . . . and I definitely wasn't looking the other way when it came to physician scew-ups.

Bridge's particular specialty was "hit and run" . . . attacking at unscheduled times . . . right before I was set to see patients . . . hurling the unsubstantiated, unspecified accusations & insults . . . demonstrating NO RESPECT for me or my patients/parents. He was "the boss". I was the peon.

His MO was to push the buttons . . . and then blame me for reacting.

Emotional responses (eg, anger, defensiveness, etc) to corrective feedback from disruptive physicians should be anticipated.

Especially when the accusations are fabricated/not true.

Nevertheless, genuine concern for the disruptive physician should be demonstrated as appropriate.

Oh, well that makes the witch hunt okay!

Physicians are first and foremost advocates for their patients. But they should also be advocates for their peers.

There comes a time when some peers do not deserve advocacy.

And/so, we shall shortly move on to Part 3.