I admit to some hesitation in using the term “bad” doctors in the title of this post. Physicians can fall short in many ways, often for reasons that are purely human and forgivable. It doesn’t necessarily mean they’re incompetent or that they are somehow bad for their patients.
Medicine is like any other profession, though. Sometimes a doctor is too impaired to safely take care of patients. In these circumstances, colleagues need to be willing to intervene, not only for the sake of maintaining professional standards but also to protect the public. But judging from a newly published study in the Journal of the American Medical Association, doctors are often very reluctant to blow the whistle.
The authors of the study surveyed 1,891 doctors and found a noticeable gap between what they professed to believe about dealing with impaired colleagues and what they actually did about it. The physicians who participated in the survey represented a variety of specialties, from family practice and pediatrics to surgery, anesthesiology and psychiatry. The majority, 64 percent, said they “agreed with the professional commitment to report physicians who are significantly impaired or otherwise incompetent to practice.”
Seventeen percent personally knew of a colleague who shouldn’t be practicing medicine. In more than two-thirds of these cases, the physicians in the survey said they reported it to the appropriate authority. But this still left close to 30 percent who did nothing. Reasons for failing to take action included a belief that someone else was taking care of it, a belief that nothing would be done about it, and fear of retribution.
These findings are actually not too surprising. It has long been known within inside circles that physicians tend to be reluctant to report a colleague. There’s a lot more under the surface than the arrogance of protecting one’s own, however. Medical Economics magazine explored some of the issues after conducting its own ethics study back in 2002, and found that many factors come into play.
There’s the question of how to deal appropriately and compassionately with addiction or physical or mental illness. Should a physician have his or her license yanked because of an addiction, or should the doctor first be urged to seek treatment? Does a mental health disorder automatically mean someone is unfit to practice medicine? If physicians believe they’ll be punished for having a disease or disability, might it not result in a reluctance to seek help and end up driving these problems underground?
A more challenging issue is when a physician has poor skills or chronically exhibits poor judgment or lapses in ethics. Clinical incompetence can be hard to discern, the article notes:
If you assist someone at surgery or some other highly visible activity, you may be in a position to evaluate his competence. But how do you know whether what someone does in his office meets the standard of care, especially if he’s in a different specialty?
Some outcomes information is becoming available in areas like cardiac surgery. But most doctors don’t use that data in deciding on a referral; in fact, they rarely even check publicly available information on sanctions by state medical boards. So their knowledge of whether a consultant is competent comes mainly from patient feedback, hunches, and hearsay.
Truth to tell, it can also be extraordinarily difficult to rat out one of your own – particularly if you don’t have proof or even if you simply empathize with the colleague whose office is next door to yours. Many physicians, says Medical Economics, might wonder how they would feel if the tables were turned:
Craig Wax can testify to that. When he got out of family practice residency two years ago, he would have been inclined to report any physician he suspected of being impaired. But since then, with both group and solo practice under his belt, he’s decided it would be better to approach an impaired physician privately.
“I’d be afraid of ruining the other doctor’s reputation. I’d also be concerned about earning a reputation as a whistle-blower, he says. “Other doctors may think I’m overreacting and say, ‘Oh, it’s just Charley. He’s always done that, and he’s always managed it. It’s silly to report him.’”
In the Medical Economics survey, 4 percent of the respondents said they would do nothing if they became aware of a colleague whose performance was impaired by drugs, alcohol or a physical or mental illness. Thirty-one percent said they would talk to their colleague privately and 65 percent said they would report the physician to the appropriate authorities.
Ideally, there would be systems in place to monitor physician performance so problems are detected sooner and addressed more quickly. But these can be inadequate or dysfunctional; indeed, they can end up being a case of the fox guarding the henhouse, as Dr. Robert Wachter points out in his incisive analysis of a scandal earlier this year involving a Baltimore cardiologist who placed more than 500 unnecessary stents in patients.
Where was the peer review? Dr. Wachter wonders. And did hospital politics allow the cardiologist a free pass, as long as he kept generating revenue?
Cases like this one are terribly troubling, not just because they harm individual patients but because they do violence to the trust that is so fundamental to the physician-patient relationship. Part of the solution must be more robust oversight procedures, such as mandatory second readings of randomly selected cath films.
But these cases also force us to consider the kind of culture that could allow such a fraud to take root and go on for years – a culture that likely prized the hospitals’ and physicians’ financial health over the clinical health of their patients. If the allegations are true, the penalties should be severe, not only for Dr. Midei but also for leaders who knew – or should have known – what was going on, yet remained silent.
Left unsaid in all of this is what patients are supposed to do if they suspect their doctor is impaired or incompetent, or is engaging in unethical behavior. Is there any reason to think patients don’t face some of the same issues about reporting someone? Patients might fear being wrong, or that the authorities will do nothing about their complaint. They might also fear being labeled a troublemaker, or possibly even dismissed from someone’s practice for registering concern about the physician’s competence.
That fact that most of the physicians in the JAMA survey – more than 80 percent – didn’t personally know of an impaired colleague suggests the majority of doctors are indeed competent. The gaps in the profession’s ability to police and regulate itself are troubling, however. It’s not reasonable to think the public is better equipped to be the enforcers, and turning the responsibility over to government opens up a whole new, and probably undesirable, can of worms. If the medical profession wants to do better, it needs to confront these issues itself.