Referrals
The committee should accept referrals concerning a physician from anyone. The referral must be regarded as confidential.
A physician, medical staff member, or anyone referring a physician should be encouraged to contact the committee directly to ensure confidentially protections. Communications made between individuals who are not members of the committee are not afforded the confidentiality protections available under the peer review statute and such communications could be subject to a subpoena.
The committee should then work with the referring individual to gather relevant information, determine the individual's willingness to be identified, and, where appropriate, determine the individual's willingness to assist the committee in confronting the physician, if necessary.
Referrals should be processed as soon as possible to reduce the possibility of hospital gossip.
If the committee determines that there is reasonable basis to believe that a physician may be abusing substances, or that there is any behavioral health or mental health concern, then the director of PHS should be contacted as soon as possible. The committee can work with Physician Health Services in determining the appropriateness of intervention, assessment, treatment, and/or monitoring.
Committee members should be familiar with the mandatory reporting statute, Massachusetts General Law chapter 112, section 5F:
Section 5F requires health care providers to report physicians in violation of the Board's regulations or licensing statutes directly to the Board. There is, however, an exception to the statute for physicians with alcohol or drug abuse problems who agree to participate in PHS' monitoring program or another BRM approved program and there are no allegations of patient harm.
Referral to the hospital committee does not relieve the reporter of his or her obligation. Confirmation must be received by the reporter that the physician is in compliance with PHS, a Board-approved monitoring-program, within 30 days. For this reason, it is important that the reporter inform the physician being referred to PHS of this requirement, so that a consent form is obtained that authorizes PHS to communicate to the reporter.
There may be circumstances where an impaired or an uncooperative physician presents a risk to patients and may not qualify for the exception. In such a case, the person reporting the physician may have an obligation to report to the Board of Registration in Medicine. It is important to note that the committee is obligated to maintain confidentiality, and while a reporter should be made aware of requirements to report to the Board of Registration in Medicine, the Committee does not assume a reporting responsibility.
Intervention
Special care must be taken to respect the anonymity of a referral source who declines to be identified. The director of PHS should be notified to provide possible assistance in determining whether intervention is warranted and/or assist the committee in conducting the intervention.
In addition to providing consultation and intervention in situations involving substance abuse or dependence, behavioral health problems, and mental health concerns, PHS provides assistance with aging physicians who are experiencing age-related symptoms but who are unprepared or resistant to retirement. An older physician who becomes impaired and continues to practice may face disciplinary action by the Board of Registration in Medicine and find that he or she is not subsequently permitted to voluntarily retire under the Board's regulations.
Assessment
The committee may wish to discuss the possibility of having the physician evaluated. PHS recommends that evaluations be conducted in places other than a physician's workplace. PHS has a trained staff experienced in determining whether a physician is suffering from substance abuse, substance dependency, a behavioral health concern, or a mental illness. The director of PHS may also recommend that a case be referred to an independent consultant for an evaluation. PHS resources and experience can be of value while assuring a confidential evaluation for the physician.
Treatment
Physician Health Services will work with a physician in determining an appropriate treatment plan if it is indicated. PHS will assist the physician in locating either inpatient or outpatient care.
Monitoring
The director of PHS will make a determination as to whether the physician is an appropriate candidate for the PHS monitoring program. PHS recommends that physician health committees rely on the PHS monitoring program, as it is the primary monitoring program approved by the Board of Registration in Medicine and one that has been developed over a period of 25 years. If the physician is chemically dependent, PHS may enter into a monitoring agreement designed to guide and document the physician's recovery. The standard monitoring contract requires:
- Documented therapy
- Random urine drug screens
- Support groups
- Regular meetings with a designated PHS physician
- Monitoring by an individual who can attest to the physician's abstinence
The physician is also required to notify his or her chief(s) of service of his or her illness and enlist the chief's (chiefs') support in completing quarterly monitoring reports. The physician's therapist and monitor also complete quarterly reports to document the physician's recovery. A relapse or failure to comply with the monitoring contract will result in a report being made to the Board of Registration in Medicine, chief(s) of service, and the physician's therapist.
Physician Health Services also designs monitoring contracts for physicians with behavioral health concerns that ensure that the physician is complying with his or her treatment plan, and monitors improvement within specified areas of concern.
Compliance Confirmation
Reports of a physician's progress and contract compliance may be made available from Physician Health Services to the hospital committee upon the written consent of the physician.
Download the full "Guidelines for Establishing Hospital and HMO Physician Health Committees" (.pdf, 22 KB).
