Extent of Obligation

You are a physician who is the managing director of a 100-member, multispecialty group practice. There are 290 employees, exclusive of the physicians and other licensed independent practitioners (LIPs). The small human resources department is responsible for non-LIP staff. Your job requires significant involvement in recruiting physicians, credentialing them, and monitoring performance during their first year of associate membership in the group.

About 12 months ago you successfully recruited a surgeon, Dr. F.W. Nieren, who had had a fellowship that included significant experience using the DaVinci robotic surgical system. The DaVinci robot is a programmable device that can perform intricate surgical procedures with results that are usually better and more consistent than those achieved by surgeons who are unaided by the robot. The group had sought to add a surgeon qualified with the DaVinci system for the several years, partially because of competitive pressures, but also because of the prestige and marketing potential having the robot would give. The $3 million device was installed and available soon after Dr. Nieren joined the staff.

Now, after almost 12 months to observe, monitor, and interact with Dr. Nieren you are very disappointed with the mixed quality of outcomes for her patients, the negative reactions of trusted non-LIP members of the staff to working with the Dr. Nieren, and her unpleasant affect and often disruptive behavior. The number of incidents, especially the quality of clinical outcomes, has given you great concern. About a month ago, you asked several senior members of the surgical staff to conduct a full scale review of Dr. Nieren’s clinical work, including the behavioral problems that had been documented. The probationary period of 12 months will end in 2 weeks. The report of the review committee supported your judgement about Dr. Nieren. After consulting with members of the practice’s executive management committee to which you report, you conclude that Dr. Nieren should not become a member of the group and should be asked to leave. Your conversation with Dr. Nieren did not go well. She reacted angrily to the points you made, and alleged that she had been treated unfairly by LIP and non-LIP staff members and the review committee. She stated that she would leave without protest only if she received a laudatory letter of recommendation. Dr. Nieren hinted that she was prepared to retain legal counsel and make life for the group “a living hell.” Your response to Dr. Nieren’s demand for a laudatory letter was that the best you could do would be to write a letter that offered only the dates of her employment, but that provided no information as to her clinical or collegial performance.

Question:

a. Identify the ethical, legal, and quality issues present in the case.

b. What should you do regarding the letter that Dr. Nieren is Demanding?

c. Identify and discuss your obligations to Dr. Nieren's Future patients and the sites at which she might seek clinical privileges.