Hypocritic Oath: Many Docs Ignore Bad Stuff

A new national survey finds that US docs believe that incompetence and mistakes among their peers should be reported. But when confronting these problems, nearly one-half fail to do so, according to the study, which is published in Dec. 4 issue of The Annals of Internal Medicine.

Of more than 1,600 docs, 45 percent with direct knowledge of impaired or incompetent colleagues in their practice didn't always report them, and 46 percent who knew of a serious medical error didn't report it to authorities at least once, according to The Institute on Medicine as a Profession’s Survey on Medical Professionalism. (IMAP, which is affiliated with Columbia University and promotes medical professionalism, supported the research).

"There is a measurable disconnect between what physicians say they think is the right thing to do and what they actually do. This raises serious questions about the ability of the medical profession to regulate itself,” lead author Eric Campbell, associate professor at Massachusetts General Hospital’s Institute for Health Policy and Harvard Medical School, in a statement. In a conversation, he adds that "there are areas of concerns. For instance, I'm troubled and somewhat shocked that not all report incompetency. This isn't about bad people. It's systemic."

Besides the disconnect between physicians’ support for reporting medical errors and the reality that nearly one half do not do what they believe is right for the profession, the authors reported other areas where individual physician behavior is at odds with what they believe is best for patients and the profession, including ordering unnecessary medical tests; managing conflict of interest and informing patients of conflict of interest, according to the IMAP statement. (This is the study, by the way).

The authors surveyed 1,662 docs from six specialties - cardiology, anesthesiology, family practice, surgery, internal medicine, and pediatrics - between November 2003 and June 2004 to measure key domains of medical professionalism endorsed by national and international medical groups. They sought to better understand attitudes toward professional norms, the extent to which physicians conform to those norms in their practice, and the factors that may influence professional behaviors, according to the IMAP statement.

The survey looked at three main areas of professional norms: competence, self regulation, and moral attributes, using standards developed by the American Board of Internal Medicine and other groups under the 2002 Charter on Professionalism. It also gauged the extent to which specialty focus, practice location, and reimbursement factor into professional behaviors. Researchers examined such areas as honesty with patients, improving access to care, maintaining professional competency, protecting patient confidentiality, fulfilling professional responsibilities, and improving quality of care.

In many areas of practice, the study found large gaps between what physicians believe and what they do in practice.

- Although docs say they don’t want to waste scarce medical resources, 36 percent would willingly order unneeded magnetic resonance imaging for back pain not because it was necessary but because the patient requested it;

- Ninety-eight percent believe in minimizing disparities in care due to a patient’s race or gender. However, only 25 percent said that they even look for that gap in their own practice;

- Although 96 percent would put a patient’s welfare above their own financial interest, a large majority would refer patients to an imaging facility with which they had a financial connection. In addition, a quarter of physicians admitted that they would inform their patients of this potential conflict;

- Between 93 percent and 96 percent believe they should report all instances of significant incompetence or medical errors that they observe to the proper authorities, yet nearly half diddn't do so. And 85 percent believe they should disclose significant medical errors to affected patients or their advocates;

- Ninety-three percent believe they should provide necessary care regardless of a patient’s ability to pay. However, only 69 percent are currently accepting uninsured patients in that situation;

Similar gaps were found when it came to attitudes toward professional competency:

- Seventy-seven percent believe they should undergo recertification examinations periodically but only 33 percent have undergone a competency assessment by a provider organization or health plan;

- Nearly all docs believe they should participate in peer evaluations of the quality of care provided by colleagues and should be willing to work on quality improvement projects. But only a little more than half have participated in a formal medical error reduction initiative or have reviewed other physicians’ medical records for quality improvement reasons;

The survey showed that professional behaviors were strongly influenced by practice setting - Docs practicing in staff-model HMOs were least likely to have provided care without expectation of reimbursement in settings serving poor and underserved patients. And solo practitioners were least likely to have participated in a formal medical error reduction program or to have been involved in a quality improvement effort.

“The good news from this survey is that physicians do not need to be convinced about the validity of professionalism standards. They clearly value them,” IMAP president Dave Rothman says in the statement. "The challenge facing the profession and the groups that regulate physicians is to find ways to change behavior and get doctors to conform to those standards before the public sector steps in to do it for them.”