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 3

Dr. Redden, as is often the case, is expressing denial concerning his health. He undoubtedly has served his community as an obstetrician-gynecologist for 26 years with distinction. He plans to continue to practice minimizing an involuntary tremor of his left hand because it is not interfering with his skills and dexterity. The obvious concern is that Dr. Redden's involuntary tremor is a manifestation of a degenerative neurologic disease that might necessitate the modifying of his medical practice. His physician, Dr. Turner, should have insisted on a neurology consultation when the tremor was first recognized. If Dr. Redden refuses the consultation, Dr. Turner should have asked the patient's permission to review his findings and recommendations with Dr. Redden's wife and family. With family encouragement Dr. Redden may have been more cooperative. I believe Dr. Turner initially should have been more persuasive in directing appropriate diagnostic and consultative care.

Physicians do not work unobserved and all "physicians have an ethical obligation to report impaired, incompetent, and unethical colleagues in accordance with the legal requirements of each state."¹ The AMA's Code of Medical Ethics Opinion 9.031 is based on Principle II of the AMA's 9 Principles of Medical Ethics, which states that "a physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities."²

Dr. Redden, unfortunately, has early signs of physical impairment. He deserves a comprehensive neurologic medical evaluation to determine the cause of his tremor and to establish whether he has an impairment that presents a risk to his patients. Since he practices in a hospital, if the test results are positive the chief of obstetrics and gynecology should be informed. Following thorough neurologic evaluation and treatment, a decision concerning Dr. Redden's ability to safely resume his practice will be made. Perhaps, with treatment Dr. Redden's tremor will be significantly subdued and he will be able to return to work. If not, other options can be considered that will maximize Dr. Redden's interests, skills, and ability.

Dr. Redden's family deserves reassurance, and most importantly, so do his patients. It has been my experiences that when doctors, as patients, initially are in denial, extreme gratitude often follows clarification of the issues.