WASHINGTON, DC—A new national survey believed to be the first of its kind has found that physicians' behavior often does not match their own moral and ethical standards for the profession of medicine. The survey of 1,662 responding physicians was sponsored by the Institute on Medicine as a Profession (IMAP), which is affiliated with Columbia University. The results of the survey were published in the Dec. 4, 2007, issue of the Annals of Internal Medicine, and released here at a National Press Club briefing with a panel of experts.
A key finding of the survey is that 46% of physicians who knew of a serious medical error did not report it to relevant authorities on at least one occasion, despite the fact that 92% of physicians agreed that members of their profession should report all significant medical errors. And 45% of physicians with direct knowledge of impaired or incompetent colleagues in their practice did not always report them, despite the fact that 95% of physicians agreed that members of their profession should report all impaired or incompetent physicians to their hospital, clinic, or other relevant authorities.
The survey included physicians in primary care practice (family practice, internal medicine, and pediatrics); anesthesiology; cardiology; and surgery.
“We found large gaps between what physicians espouse and what they do in medical practice,” said Eric G. Campbell, PhD, the study's lead author and Associate Professor at the Institute for Health Policy and the Department of Medicine at Massachusetts General Hospital and Harvard Medical School.
He said that what he termed “normative dissonance” between belief and behavior happens in other professions, and is not unique to medicine. But, he said, “the gaps are really big” in the new IMAP survey.
Gaps Much Too Large
James Thompson, MD, CEO of the Federation of State Medical Boards, agreed that these gaps are much too large. “It is simply not acceptable that bad physicians are not reported to the appropriate authorities,” he said.
But he noted that there are very real, human reasons why such reporting is not done, including: fear of retribution; fear of legal action; and the reluctance of a young physician to report an older and more experienced colleague. Also, the physician in question may already be in a treatment program, such as one for substance abuse.
“'Let the buyer beware' is not an adage that any of us want to take into medicine,” said IMAP President David Rothman, PhD, who is the Bernard Schoenberg Professor of Social Medicine at Columbia College of Physicians & Surgeons and Professor of History at Columbia University.
Dr. Rothman said the purpose of the survey was to focus on how physicians themselves define professionalism in medicine. He noted that IMAP plans a second report on the same topic, and said it is possible that “measuring shortfalls will itself be a force for change,” thus narrowing the gap between attitudes and actions.
“Professionalism is becoming a hot topic because physicians are looking inward under pressure from society; this particular set of gaps needs attention,” said David Blumenthal, MD, MPP, Director of the Institute for Health Policy at Massachusetts General Hospital and a coauthor of the new study. Dr. Blumenthal, who is also Professor of Medicine and Professor of Health Care Policy at Harvard Medical School, said medical professionalism “plays a critical role in our society,” and that neither competition nor regulation can assure professionalism in medicine.
He agreed with Dr. Rothman that caveat emptor is never going to be a sufficient check on professionalism. Medical professionalism is not an abstract concept, he emphasized, stating that it needs to be “a living, breathing force for continuous improvement.”
Medicine is not a guild—i.e., a trade union—emphasized Donald Wesson, MD, Chair of the American Board of Internal Medicine (ABIM) and Vice Dean of Texas A&M College of Medicine in Temple. “Contrary to our being a guild, we are really a profession. We by no means should behave as a guild; practice is a privilege.”
The survey showed that slightly more than half of physicians (53%) have taken part in a formal medical error reduction program in the last three years. It also showed that 21% of physicians had direct personal knowledge of an impaired or incompetent colleague in their practice, and that physicians in health maintenance organizations and those with fewer than 10 years in medical practice were least likely to have direct personal knowledge of an impaired or incompetent physician in their practice.
The strongest support for reporting all medical errors was found among physicians in HMOs (65%) and academic settings (58%).
While 98% of survey respondents said the just distribution of finite resources is important, the survey shows that when it comes to management of those resources, physician actions don't always match attitudes.
For example, when asked if they would order an unnecessary MRI test for a healthy patient with back pain if the patient insisted on it, 14% of physician respondents said they would order the MRI without discussing the issue with the patient; 28% said they would order the MRI but are doing so with reluctance; and 60% said they would refuse to order the MRI.
Defensive medicine and fear of lawsuits are undoubtedly driving some of the disconnect between attitudes and actions in medicine, said Dr. Thompson and other speakers. Asked to comment on how the influential 1999 Institute of Medicine report on medical errors (which found that up to 100,000 US patients die every year due to medical mistakes) has affected the issues tackled in the survey, Dr. Blumenthal said, “I think one of the critical things we need to do is make the health care system safe for professionalism.” He noted that the current tort system focuses on punishment for perceived malpractice, a “gotcha” mentality that discourages reporting of and learning from errors in medical practice.
“I think the current tort system is counterproductive,” agreed Sara Rosenbaum, JD, Chair of the Health Policy Department at George Washington University School of Public Health. She decried the fact that malpractice reform seems to be on hold at the national level.
“Nationally, we've seen how tough it is to enact tort reform; we seem to have reached a sort of stalemate nationally,” she said. “If we wait for the magic of tort reform to turn things around, it's just not going to happen.” Dr. Rosenbaum said the most promise for tort reform is now at the state level.
But Rep. Michael Burgess, MD (R-TX), an obstetrician/gynecologist member of the US House of Representatives who attended the National Press Club briefing, disagreed that national malpractice reform is dead. He said he has introduced a bill, HR 3509, which would translate Texas's experience with strong tort reform (including a cap on malpractice awards) into national law. And while the idea of reporting an impaired or incompetent physician is commendable in theory, he said, “it is almost impossible to get someone bounced from your medical practice.”
The survey also found that:
• While 96% of physicians said they would put a patient's welfare above their own monetary interest, a large majority of physicians said they would refer patients to an imaging facility in which they had a financial interest. Some 25% of physicians said they would inform patients of this potential conflict of interest.
• Some 76% of physicians believe they should undergo recertification exams from time to time, but only 31% of respondents have actually undergone a competency assessment by a provider organization or health plan in the last three years.
• Some 98% of physicians believe in closing disparity gaps in health care due to a patient's race or gender. But only 25% of respondents said they actually look for such a gap in their own practice.