Appendix A: Sample Request for Adverse Action

June 23, 20XX
John Doe, M.D.
1 Audubon Place
New Orleans, LA 70XXX
Re: Request for Adverse Action
Dear Dr XXXXXXX:
Proposed Action:
After carefully reviewing your nurse, House Officer, student evaluations and discussing your portfolio with a committee of XXXXXX faculty, the XXX Program is recommending non-renewal of your contract (or termination or non-promotion, as the case may be) effective July 1, 20XX.
List of Deficiencies / Reasons for Action:
This recommendation for is based on the counsel of the XXXX committee and is due to your substandard performances in the following competencies:

1. Patient Care:
   1. Weak XXXXX (specialty) knowledge as demonstrated by your substandard in service exam scores both in July 20XX and February 20XX compromising patient care,
   2. Inability to apply your knowledge for both teaching students and interns, and for providing sound patient care. Examples of this include:
      1. XXXX
      2. XXXX
   3. Lack of attention to detail compromising patient care. Examples of this include:
      1. XXXX
      2. XXXX
   4. Poor organizational and time-management skills reflected in:
      1. Inability to write timely and accurate orders. Examples of this include:
         1. XXXX
         2. XXXX
      2. Execute the staff and House Officer's therapeutic plans causing the supervisory House Officers to do much of your work. Examples of this include:
         1. XXXX
         2. XXXX
      3. Inability to work effectively as a team player. Examples of this include:
         1. XXXX
         2. XXXX
   5. Failure to consistently follow through on patient orders that you were specifically instructed to complete. Examples of this include:
      1. Failure to look up the doses. This was seen :
         1. XXXX
         2. XXXX
   6. Use of incorrect or deliberately approximate dosing in critical situations. Examples of this include:
      1. XXXX
      2. XXXX
   7. Failure to follow a specific order on a medicine. Examples of this include:
      1. XXXX Rocephin
2. Medical Knowledge:
   1. Weak XXSPECIALTYXX medical knowledge evidenced by:
      1. Poor performance on xxxxx in-service exams in July 2009 and February 2010
      2. Overall clinical performance on XXXX ward month in October 2009 and the XXXX team wards in June 2010.
      3. Lack of insight into areas of weakness as evidenced by comments made about your performance by peers and supervisory House Officers on "check out "rounds and other rounds where you are directly observed. Specific examples of this include:
         1. XXXX
         2. XXXX
3. Interpersonal Skills/Communication Skills:
   1. Disrespectful, condescending behavior with fellows, House Officers, and students. Examples include
      1. XXXX
      2. XXXX
   2. When questioned about the behavior, you rationalized this behavior as a defense mechanism used for survival. Specific examples of this include:
      1. XXXX
      2. XXXX
   3. Continued disrespectful behavior after counseling by myself and others. This was specifically seen:
      1. XXXX
   4. Lack of insight into your behaviors and performance level as reflected above as reflected in the following examples:
      1. XXXX
      2. XXXX
   5. Rude and abrasive behavior with patients, families and peers as evidenced by:
      1. XXXX
      2. XXXX
   6. Several peers strongly dislike working with you because of your failure to adequately and consistently complete the tasks assigned to you. Examples of this include:
      1. XXXX
      2. XXXX
4. Professionalism:
   1. Rude and disrespectful behavior. Examples include
      1. XXXX
      2. XXXX
   2. Inability of your peers to trust you. Examples include
      1. XXXX
      2. XXXX
   3. Untruthful behavior. Examples include:
      1. XXXX
      2. XXXX
   4. Your cavalier, overconfident behavior without the essential knowledge base is a dangerous combination that many House Officers feel will result in poor outcome for patients if you are not heavily supervised at all times.
   5. Failure to arrive on time.
   6. Unauthorized absences.
5. Practice-Based Learning:
   1. Failure to read assigned materials as seen:
      1. XXXX
      2. XXXX Web MD, XXXXX, etc.
   2. Failure to recognize, reflect on and correct mistakes despite being specifically counseled. Examples of this include
      1. XXXX
      2. XXXX

List of all known documentary materials to be used in a hearing

1. The above listing assumes there would be attached documentation supporting each or many of the listed deficiencies. If so, you would say "see attached documentation."
2. You may add letters, evaluations, or anything collected to prove your point, but they would be added as an addendum if not already in the above-mentioned documentation.
3. If you do not plan to list and attach extensive documentation (a mistake!) then you can simply refer to the "House Officer file" which means you need to introduce the whole thing or select parts and attach them to the request.

List of Witnesses and Expected Testimony

1. It is assumed that in many of the above specific instances a specific person will be named as making the complaint or turning in the evaluation etc. that led to the item being included. If so you can simply state something like, "The witnesses who may testify are included in the charges listed under reasons and will testify to the validity of the information listed in that charge."
2. Otherwise list them and say something brief like "they will attest to the evaluations in the file", or "they will attest the House Officer didn't show up" or "they will attest the House Officer lied", etc.

Sincerely,
Jane Doe
Program Director