Unexpected Moments of Peril

Unexpected Moments of Peril

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Best Practices Clinician Health Education

Panic breeds mistakes. So do boredom and routine. It’s often during mundane activities that clinicians do things they later regret.

Forewarned is Forearmed.

Moments of peril lurk in the mundane aspects of your work. Practitioners have had their lives turned upside down because they failed to pay attention to seemingly innocuous parts of their jobs — everything from overseeing staff to filling out renewal applications. Licensing boards take such issues seriously. You should too. If you know what to look for at each stage in your career, you may be able to spot your moment of peril early enough to avoid trouble.

Consider Where You Are in Your Career.

Few moments in a practitioner’s life are as stressful as medical school and residency. So it’s no surprise that this period is filled with peril. What surprises many young practitioners are the particular kinds of transgressions associated with training. Any of the following can end a career before it starts.

• Thinking like a student, not a clinician: Concerns about grades, graduation and residency placement make students especially vulnerable to fraud violations, including falsifying patient logs, plagiarism, cheating on tests, and exaggerating accomplishments on applications. 
• Acting like a pal, instead of a professional: Uncomfortable with authority and eager to help, students sometimes give patients money for prescriptions, offer them rides home, or tell them to call their personal cell phone number if they have a question. 
• Flirting like you did in college: Just about everyone flirts when they’re in college. But the same behavior in med school and residency will almost certainly lead to complaints. The moment you start training to be a professional, you must act like one, not just with patients but also with colleagues and staff. 
• Accepting gifts: Refusing gifts from a grateful patient can seem rude, but failing to do so can create a risky sense of obligation. According to the Texas Medical Association, “It is particularly dangerous in the case of a student, who may feel obligated to provide “special care” in the form of sexual favors or other inappropriate gestures because the student cannot realistically provide medical care.”
• Prescribing for family and friends: A resident may relish the feeling of importance they get when writing a prescription for a family member or friend, or they may find it difficult to refuse helping someone they are close to. Yet even when the activity isn’t explicitly prohibited, casual prescribing is always a violation if it is done, as is almost always the case, without taking a history first or updating medical records afterwards.
• Becoming romantically or sexually involved with a patient or colleague: Without proper training, naïve students and residents can find it hard to accept that there is no such thing as a consensual relationship with someone who is dependent on you. No matter how mutual the attraction may feel, the power differential—between caregiver and patient or between resident and student—makes anything other than a professional relationship inherently coercive.

Watch out for the midlife “valley of discontent.”  When you’re a young adult just starting out, you feel you can do anything. By the time you’ve cleared most of life’s hurdles, you’re satisfied with what you’ve done. It’s the middle, when you’re in your prime but nearing the top of the career ladder, that you’re most likely to feel dissatisfied. Research shows that for most of us, life follows a U-shaped curve, with highs at either end and a valley of discontent in midlife. 

Practitioners are as likely as anyone else to suffer doubts and frustrations as they enter this period, maybe more so. The everyday demands of modern health care are draining enough in good times. Frustrated by mounting responsibilities and diminishing opportunities, middle-aged practitioners often feel uninspired and trapped by medicine.  For them, the very idea of breaking the rules takes on a new luster and making bold, if rash decisions seems exhilarating. There are plenty of benefits to midlife reassessment, but it’s also a time to realize you are apt to do something you will later regret.  

Age brings wisdom, experience, and trouble. The most commonly expressed concern about older practitioners is how the aging process can affect their care of patients. But it’s not just mental acuity and physical stamina that raise senior clinicians’ violation potential. It’s also their ethical complacency. After decades of practice, many practitioners believe their spotless record is a testament to their innate goodness. Convinced that their own moral rectitude has stood the test of time, they relax their vigilance. Others, they think, may need to pay attention to the rules and regulations; they themselves are beyond that — or so they imagine.

It’s this sense of invulnerability that trips up experienced practitioners. They start taking a more relaxed approach with patients, joking good-naturedly, perhaps, or playfully flirting. They may also grow intolerant of anyone, including well-meaning staff and senior administrators, who offers constructive criticism or suggestions. 

Just when you thought it was safe…  Many practitioners resist retiring. The profession has been so central to their lives and so integral to their sense of self-worth that the thought of letting go is simply too threatening to contemplate. According to Glen Gabbard, MD, professor of psychiatry at Baylor College of Medicine and an expert in physician health and professionalism, “For most of us, the practice isn’t a job: It’s more of a calling. One of the things that’s unique about physicians is that who we are—our identity—is so wrapped up in being a physician.”

Even those who do let go and retire often keep a tight grip on their license and prescription pad—which is how they run afoul of their state licensing board. No longer in practice, these licensed retirees generally fail to keep up with the latest developments or CME requirements. Still, they cannot resist offering medical advice and prescribing for family and friends, almost always without taking adequate histories and updating patients’ charts. Boards are quick to discipline such lax professional behavior, and clinicians who have retired after a long and distinguished career can end up with a tarnished reputation, not to mention other penalties.

Don’t Forget the Everyday Stuff

You are the captain of the team. If you hire someone, whether a receptionist or clinical assistant, you are responsible for what they do on the job. If someone on your staff violates patient confidentiality, harasses someone, or makes a billing error, you are the one the board will discipline—and the discipline can be severe. In one case, a physician lost his license when he signed the paperwork submitted by a physician assistant in a satellite office without first reviewing it—a clear violation of the laws governing “collaborative practices.” In another, a dentist ended up in jail because he failed to adequately supervise the billing company he employed. 

The greatest threat to proper supervision is allowing professional relationships with staff to collapse into personal friendships. As always, the key is maintaining boundaries between your personal and professional lives.

Few aspects of medicine are more basic than record keeping, or more misunderstood. Inadequate record keeping is considered an ethical violation by state licensing boards. Among other things, be sure to:

• Keep complete records. According to healthcare attorney and PBI faculty member Jon Porter, licensing boards insist that a record “stand on its own.” That means when the next practitioner looks at a patient’s record, they have to be able to understand from start to finish what’s been done and why. Think of each entry not as a chapter in an epic novel, suggests Porter, but as a short story with its own beginning, middle, and end. 
• Document functionality. If a patient’s hypertension is being successfully treated by medication, it is not enough to simply renew the prescription and add a quick note. You must document the fact that that the patient’s blood pressure is within acceptable limits under the medication. Given today’s rampant opioid epidemic, it is especially important that you fully document the extent to which a patient’s functionality is improved by the prescription of a controlled substance. 
• Beware of the auto-populate feature in electronic medical records. A lot has been written about the pros and cons of electronic medical records. One of the pros is supposed to be the time saved when the software automatically populates certain information. But this auto-populate feature has to be carefully monitored. Clinicians run into problems when they fail to double check that all of the auto-populated fields contain correct data. 

All of the above tips and much more are covered in depth in PBI’s Medical Record Keeping Course, which is offered on the weekend and confers 17 CME credits. Click here to learn more and enroll today.

You worked hard to earn the board’s trust. It’s a lot easier to lose it. Your license does not belong to you. It’s yours in trust and you get to keep it only as long as the board trusts you. Don’t give them any reason to doubt their decision.

• Be vigilant about renewing your license:  How often do you have to apply for a renewal? Can you renew online? Have the rules changed since the last time you applied? How does the pandemic affect the process? Each state has its own requirements. It’s up to you to know what they are. That’s true for each state you are licensed in, which is why it’s important to…
• Keep up with your state(s) Medical Practice Act: These laws are continually changing to stay abreast of changes in medicine and healthcare. In fact, New Mexico recently added a new CME requirement to ensure all licensees are aware of changes to the law. Other states are waiving some CME requirements in response to pandemic-related challenges. And just about every state is reviewing and changing the rules governing telehealth. Be sure to check your state board’s website regularly for changes. You can find the URL for your board here.
• Answer all questions on applications honestly and completely: You may not think the DUI you got as a teenager is worth mentioning. You may consider a question about your mental health an invasion of your privacy. These are not your decisions to make. If the board finds out you have not answered a question truthfully, it may well reject your application.

It’s all too easy to dismiss these moments of peril. You may have sailed through earlier stages of your career without any of the problems mentioned above and assume it will continue to be smooth sailing from now on. You may scoff at practitioners who failed to adequately supervise staff or complete medical records, convinced you won’t ever make such rudimentary mistakes. For more than 20 years, PBI has helped thousands of practitioners who felt just this way. Every one of them wished they had been more vigilant early on.