Commentary: The clinical implications of doctors' evaluating doctors.

The American Psychiatric Association Guidelines for Psychiatric Fitness-for-Duty Evaluations of Physicians is a welcome resource document for forensic examiners who perform independent medical examinations of potentially impaired physicians. Anecdotal and published reports indicate that requests for such evaluations are growing; hence, there is growing attention to the process of conducting these examinations and of highlighting important pitfalls and clinical concerns in evaluating fellow physicians. While there has always been a need for guidelines for fitness-for-duty evaluations of physicians, there have been emerging trends in who orders such evaluations of physicians and why. With the change from a fee-for-service system to a managed-care environment as well as the increasing complexity of the provision of health care, fewer physicians are their own bosses and increasingly must be able to participate cooperatively within a health care team. These changes can be in conflict with traditional expectations held by some physicians about the authority and autonomy of the profession. Physicians can be stressed by such changes, and that stress can sometimes translate into disruptive behavior. In addition to patients’ making complaints, paraprofessional employees (such as nurses and aides) may feel more empowered to make complaints about a physician’s behavior. Most hospitals have now created policies pertaining to disruptive behavior of physicians based on American Medical Association guidelines and Joint Commission on Accreditation of Health Care Organizations standards, which can prompt request for a fitness-for-duty evaluation of a physician. While hospitals and physician health committees of medical associations can request fitness-for-duty evaluations, complaints about the behavior of physicians and requests for such evaluations are now more frequently the province of state medical boards. Because state medical boards can revoke the license of the physician being examined, and because hospitals can revoke privileges, the results of the fitness-forduty evaluation can have powerful financial and therapeutic impacts on the physician who has come to the attention of his or her employer or state medical board. The forensic psychiatric assessment can also have major implications for the examinee when the findings have the potential for public access, as described in the resource document. These days, medical associations typically have roles that are more therapeutic than sanctioning. In the past, however, this was not always the case. For example, it was not uncommon for the American Psychiatric Association’s district branch, state association, or national ethics committees to have a role in evaluating the conduct of psychiatrists. These assessments were internal, and so the reporting of the findings was sometimes less formal. However, with its increased focus on advocacy for patients and other broader agendas over the past few years, the Association has less time and fewer resources to pursue internal investigations of physicians. Further, the outcome of investigations by specialty societies have not always had the good impact desired by the physician community. Adverse findings have sometimes resulted in little more than the termination of membership in the specialty association, while allowing the evaluee to continue practicing medicine. Although the American Psychiatric Association’s procedures for handling complaints of unethical behavior now includes an educational option for less Dr. Wall is Clinical Associate Professor, Department of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, RI. Address correspondence to: Barry W. Wall, MD, 184 Waterman Street, Providence, RI 02906. E-mail: [email protected]