In Shin v. University of Maryland Medical System System Corporation (pdf), the U.S. Court of Appeals for the Fourth Circuit concluded that a hospital was not required to provide a reduced patient load and “light duty” to an intern with cognitive impairments who repeatedly demonstrated serious patient care deficiencies.  

Dr. Frank Shin, the plaintiff in the case, was employed as a first year medical intern at the University of Maryland Medical System (UMMSC).  Medical interns at UMMSC were rated on a nine-point competency scale.  Although four to six points was deemed satisfactory, interns generally scored between 7.1 and 7.5 by the end of their first year, and interns with scores of five or below were addressed by the Clinical Competency Committee. Dr. Shin’s competency rating was satisfactory in the first month of his internship, but within three months, his overall competency rating was 3 and he had to be "shadowed heavily" by resident physicians to prevent medical errors. Despite additional guidance and an action plan, Dr. Shin’s patient care continued to deteriorate. His errors included misdiagnosing patients, prescribing incorrect medications, failing to follow the orders of residents or attending physicians, and even documenting a living patient as "deceased." One of his supervising physicians stated that Dr. Shin "was dangerous and should no longer be allowed to continue in a direct patient care role."

Dr. Shin's work duties were reduced, his patient care load was limited to three patients, and he was provided a tutor. Despite these accommodations, Dr. Shin’s performance did not improve. Dr. Shin consulted several mental health professionals, all of whom concluded that he suffered from conditions that impaired his cognitive functions. The hospital placed Dr. Shin on a leave of absence while he obtained medical treatment, including medication and behavioral coaching. Dr. Shin’s condition did not improve, however, and ten months into the internship, Dr. Shin’s physician concluded that although he had reached maximum medical improvement, he was unfit to work as a medical intern.

Before being terminated, Dr. Shin requested additional accommodations: 1) fewer patients; 2) additional time to absorb information; and 3) “a more compassionate environment.” The hospital rejected these requests, noting that if Dr. Shin’s patient load were further reduced, he would not work at the level required by the Accreditation Council for Graduate Medical Education (ACGME).  It also pointed out that providing more time to absorb information would not adequately train Dr. Shin in the skills required to become a physician, and that many of Dr. Shin’s colleagues and hospital administrators had already provided him with assistance. Under the circumstances, the hospital concluded that termination was warranted.

In his lawsuit Dr. Shin claimed wrongful termination under the ADA, and failure to provide reasonable accommodation. The Fourth Circuit and the district court agreed that the essential functions of an intern’s position were to provide “competent medical care to patients with efficiency and with reasonable autonomy," and “safe and appropriate care for patients.” Reviewing the evidence, the Fourth Circuit concluded that Dr. Shin had not performed these essential job functions at UMMSC, even with the accommodations the hospital had provided. Even more significantly, the court held that the additional accommodations Dr. Shin requested were unreasonable under the circumstances. Relying on the hospital’s expert, the Fourth Circuit concluded that further reducing his patient load was “not reasonable, in that it could not be offered without seriously compromising the functions of the hospital, the needs of the staff, and patient safety.” Moreover, Dr. Shin’s requested accommodations directly conflicted with the goals of clinical training “to develop the clinical judgment essential to being a physician ... including simultaneously managing multiple patient care situations and dealing with ambiguity.”

With many hospitals, medical practice groups, clinics and individual physicians moving toward employed-physician models, it is important for employers of physicians to understand that employment law principles apply to physician management even where critical patient care decisions are at issue. Although the courts sustained the position of UMMSC, the hospital’s case was clearly strengthened by the documented accommodations it considered and implemented before terminating the plaintiff.

This entry was written by Robert C. Drake.