AMA Journal of Ethics^®

Case

Dr. George Redden is an obstetrician/gynecologist in a small town. He has been in practice for 26 years, the last 20 of them in his current practice. Most of his patients are healthy young women with low-risk pregnancies. He often sees children he delivered at his grandchildren's school performances. He likes to stop and chat with the women he saw through pregnancy and find out how they and their children are doing. Dr. Redden has been thinking of retiring in the next 7 or 8 years and has been talking to his wife recently about his desire to continue practicing medicine part-time during his retirement.

About 2 years ago Dr. Redden visited his own long-time physician, Dr. Charles Turner, for a regular check-up. Dr. Turner checked Dr. Redden's blood pressure, his cholesterol, and prostate.

"George, you seem to be doing well. All systems are go," Dr. Turner explained. "I did notice one thing that I would like to check into further. I have been seeing a slight tremor in your left hand."

Dr. Redden crossed his right hand over his left and shrugged. In the past few months his hand had begun to tremble uncontrollably when he was resting it on an armchair or just sitting with his hands in his lap. This tremor was embarrassing and becoming more and more difficult to hide. He had found that he if moved his hand immediately or tried to pick up an object sometimes the tremor would stop. But recently his wife had commented on it and he had simply brushed it off as a muscle spasm.

"It seems to be a resting tremor, George. Maybe we should do some further tests," Dr. Turner suggested.

"I think it's just a tremor. You know, we're getting old, Charlie," Dr. Redden explained. "It's not a problem, I'm right-handed anyway, and it doesn't bother me."

"If it gets any worse I want you to come back to me so we can run some tests."

Dr. Redden did not see Dr. Turner again for another 8 months when he came in with a case of strep throat that his granddaughter had brought home from preschool. Dr. Turner swabbed Dr. Redden's throat, and then left to give the sample to the lab to run a culture.

He returned to the exam room and sat down to write a prescription for Dr. Redden.

"George, how is that hand of yours? It seems to be getting worse," Dr. Turner commented as he noticed Dr. Redden's hand sitting in his lap shaking. "I noticed that you seemed a little unsteady, are you having any problems walking?"

"No, I'm fine. Maybe just a little tired today. You know my throat has really been bothering me."

"What about trouble getting out of chairs, or out of the car?"

"No, no problems."

"What about problems with writing or typing?" Dr. Turner asked as he glanced down at the form that Dr. Redden had filled out in the waiting room. The print was incredibly small and difficult to read.

"Charlie, I'm fine. Are you going to give me that antibiotic or not?" Dr. Redden answered tersely.

"George, I think there is the possibility you are not fine. You seem to be progressively losing motor control. You need to see a neurologist. And I think you need to consider the fact that you may not be able to continue delivering babies."

Dr. Redden took the script Dr. Turner offered him, and turned to his friend and colleague, "Dr. Turner, delivering babies is my life, if I have to give that up what will I have to live for? I'll be at my office caring for my patients until the day I can't get out of bed."

Commentary 2

Several medical organizations address physician impairment in their codes of ethics. The American College of Emergency Physicians states that "whenever a colleague or consulting physician is believed to be incompetent or impaired by drugs, alcohol, or psychiatric or medical conditions, there is a duty to report the impaired physician to the chief of service, the chief of medical staff, and appropriate committees or regulatory agencies."¹ The American College of Physicians concurs, stating that "there is a clear ethical responsibility to report a physician who seems to be impaired to an appropriate authority."² The American Medical Association also holds the opinion that "physicians have an ethical obligation to report impaired, incompetent, and unethical colleagues."³

In Dr. Turner's situation, he suspects that his patient, Dr. Redden, has Parkinson's disease and may someday be unable to deliver competent care to his patients. Before Dr. Redden's condition progresses to the extent that he is clearly unfit to practice, what can Dr. Turner do to prevent the unpleasant prospect of reporting his colleague and friend?

"Ignoring it won't make it go away"

As patients, physicians may deny or minimize their own symptoms for fear of what the symptoms mean, a reluctance to interact with the health care system as a patient, and worries over how an illness will affect their practice.⁴ Unfortunately, such tendencies may hinder timely diagnosis and treatment and intensify emotional hardship.

If, as suspected, Dr. Redden has Parkinson's disease, the chronic progressive course of the disease will ultimately interfere with his ability to provide safe and effective care. This is true regardless of whether Dr. Redden chooses to accept or deny his condition. However, neurological evaluation and treatment may slow the course of disease progression and alleviate symptoms, enabling him to engage in meaningful activities for as long as possible.

Knowing how important it is for Dr. Redden to continue caring for his patients, Dr. Turner should acknowledge this immediately. He can also use this as an argument to pursue evaluation and treatment. For example, Dr. Turner can say, "I know how important it is for you to continue delivering babies, George. That's why I think it's best for you to see a neurologist. A neurologist can evaluate your condition and let you know where you stand. She may be able to prescribe treatment to control your tremor or slow the progression of your symptoms. Ignoring your condition won't make it go away, but it could make things harder for you in the long run."

The goal is not only for Dr. Redden to receive evaluation, treatment, and follow-up, but also for him to learn to accept his condition. Once Dr. Redden is willing to accept his condition, he can begin to plan for eventual changes in his lifestyle and practice.

"It's better to take control of a situation than to let it take control of you"

Early planning can help Dr. Redden equip himself emotionally and practically for future changes. In particular, when his motor and cognitive symptoms progress to the extent that he is unable to deliver babies competently, it will be time for him to retire from this aspect of his profession.

Dr. Turner can introduce this issue by asking, "What is it about delivering babies that makes it important to you, George?" Based on Dr. Redden's answers, Dr. Turner can help him explore alternatives that will still provide personal fulfillment. For example, if he enjoys interacting with his patients, can he delegate specific physical tasks to a partner? When he retires from practice altogether, can he interact with former patients and their children by engaging in volunteer work? If he values his identity as a healer, can he contribute through research or teaching? Would he like to preserve the memories of his years in practice by recording them in a journal?

Dr. Turner should help Dr. Redden understand that he has the option to make proactive decisions about his future rather than having changes imposed on him. Dr. Redden can take control of his situation by acknowledging that certain changes are inevitable (eg, "I will someday need to retire from clinical practice), predetermining when to make changes (eg, "I will retire from clinical practice when my neurologist advises me to"), and finding solutions to maintain his quality of life (eg, "When I retire, I will continue to contribute to my community through volunteer work.")

"We will keep our patients from harm"

In the best case scenario, Dr. Redden will agree to retire from practice when he becomes incapable of providing safe and effective care. However, in the event that he resists, Dr. Turner should counsel Dr. Redden, asking him to consider the safety of his patients and pointing out benefits to retirement. For example, Dr. Turner can explain that by planning his retirement, Dr. Redden will have the opportunity to say goodbye to his patients while ensuring that they have continuity of care. Also, he can avoid potential calamities, such as harming a patient, losing patients, or having his medical license revoked.

If all else fails, Dr. Turner should report Dr. Redden to an appropriate regulatory group, such as an institutional committee or a state medical licensing board.^1-3 Such regulatory groups are obligated to protect health care consumers and will consider the well-being of the consumer and the physician in determining a course of action. Because Dr. Turner will have reported Dr. Redden only as a last resort, he should feel confident that he has acted in the best interest of his patient and his profession.