A Physician's Covenant
Editor's Note: This column presents a problematic case, one that poses a medicalethical dilemma for patients, families and healthcare professionals. As it is based on a real situation, identifying features and facts have been altered in this scenario to preserve anonymity and to conform to professional medical regulations. In this case, the department chairman is given information that demands a decision.
Column Editor: Ferdinand D. Yates, Jr., MD, MA (Bioethics), Professor of Clinical Pediatrics, State University of New York at Buffalo, and Medical Director for Neighborhood Community Center.
What are the responsibilities of a department head in supervising the quality of work provided by the department members?
Dr. Jones was the vice president for medical affairs at a large northeastern hospital. His role made him responsible for general administrative oversight of 567 physicians, including recruitment and quality assurance.
Some new physicians had been recruited for several different departments, and the new pulmonary recruits were often board certified in Pulmonary, Critical Care and Sleep Medicine, and most were looking for positions that accommodate their interests. Dr. Simpkins was recently hired under this scenario, with his primary appointment being in Critical Care Medicine.
Two years after Dr. Simpkins was hired, Dr. Garrett - the Department Chair of Sleep Medicine - approached Dr. Jones and asked to meet with him regarding an urgent matter. When Dr. Garrett arrived at the meeting, she produced a three-inch-thick pile of documents outlining and providing evidence that Dr. Simpkins was consistently exhibiting what seemed like inappropriate work in his Sleep Medicine duties. Dr. Garrett noted that Dr. Simpkins frequently missed meetings, filed incomplete test requisitions - requiring additional work for his staff - and failed to respond to pages in a timely manner. She also stated that she had spoken to him about each of these failings on numerous occasions. He always answered affirmatively, promising to rectify these failings, but in actuality he had made no changes.
Dr. Garrett then showed fifteen examples of inconsistent histories, inadequate examinations, and, most disturbingly, fabricated entries in the medical records, which she noted were a sample of his work from only the past two months. Dr. Garrett claimed that Dr. Simpkins had listed physical weights, neck circumferences, and Epworth Sleepiness Scale scores that differed significantly from values documented by his own technical and nursing staff. Furthermore, she alleged that he not only failed to list important medical comorbidities, but also (based on nursing and concurrent medical notes) listed tobacco habits incorrectly. Dr. Garrett believed that Dr. Simpkins' work was putting patients at risk of receiving inappropriate evaluations, diagnoses, and treatments.
In addition, Dr. Garrett had reviewed Dr. Simpkins' work schedule and billing practice pattern. He had seemingly billed at levels that were unsupported by his documentation, and high-level consults had been billed for inappropriately short patient time slots. Dr. Garrett opined that not only was the medical work and documentation unprofessional and inaccurate, but it could be construed as being at variance with the requirements of Medicare and Medicaid, and that the hospital might be accused of insurance fraud.
Dr. Jones approached Dr. Stanley, Department Chair of Critical Care Medicine and the department head to whom Dr. Simpkins primarily reported. Dr. Stanley downplayed the gravity of the situation, stating that Dr. …