Survey questions doctors on ethics - Nearly half fall short of standard

This report looks at conventional doctors. We note that, based on other data, that certain types of unethical behavior are much more common among psychiatrists, etc than in other specialties. We leave you to draw your own conclusions.

Nearly one of two doctors in a national survey said they didn't turn in a colleague who was clearly incompetent, made a serious medical mistake or was somehow impaired.

The survey, published this month in the Annals of Internal Medicine journal, suggests physicians often fall short of their own ethical standards in dealing with unnecessary medical tests, financial conflicts of interest and peers who might be endangering patients.

About 96 percent of the 1,662 doctors surveyed in 2003 and 2004 agreed they should report other doctors who are clearly impaired or incompetent. But about 45 percent indicated they'd been in situations in the past three years where they hadn't turned in colleagues.

About 46 percent of the doctors said they didn't report serious medical errors that occurred at their hospitals, clinics or medical groups.

"It's not surprising. It's unfortunately not surprising," said Julie D'Angelo Fellmeth, administrative director of the Center for Public Interest Law at the University of San Diego. The published survey didn't define what it meant to be impaired, but Fellmeth worries most about doctors ignoring signs that a colleague is abusing alcohol or drugs.

"Impaired people are often in denial about their condition and their ability to control it," she said. "Even one moment of impairment can mean irreparable harm to patients."

Fellmeth, who monitors healthcare regulation in California, said she believes doctors tend to protect one another because of empathy and fear of repercussions.

State law shields doctors who report peers to the state medical board from civil penalties, but there can be other consequences.

A co-author of the report based on the survey said researchers were flooded with e-mails from doctors who said their careers were ruined because they reported other doctors' violations.

"They were ostracized by their peers. They were forced out of their practices. Their lives were awful," said Dr. David Blumenthal, director of the Institute for Public Policy at Massachusetts General Hospital in Boston. "We need to make it safe for physicians to be honest about what they observe."

Some doctors argue the survey reveals little more than a tendency to try to help peers in trouble rather than report them to authorities.

"Say you thought someone was impaired, and you weren't totally correct," said Dr. Robert Lum, a radiation oncologist from Oxnard and the outgoing president of the Ventura County Medical Association. "You're talking about destroying someone's career. It's not something you do lightly."

Lum said he doesn't believe the implication that many doctors wouldn't report colleagues who were endangering lives.

"If I saw someone who was drunk before surgery, I would turn him in. Obviously, that's not right," he said, suggesting the harder calls involve gray areas, such as an on-call doctor summoned to the hospital after having a drink at a party. "I would say, If you're going in, are you OK?'"

'A code of silence'

Of the 7,259 complaints made last fiscal year to the California agency that regulates doctors, about 327 came directly from doctors and professional groups. About 241 reports to the Medical Board of California came from miscellaneous or anonymous sources.

Doctors say more reports are made to hospitals, clinics or medical societies.

A spokesman for the Federation of State Medical Boards said about two-thirds of the states have so-called "snitch laws" compelling doctors to report possible violations. California doesn't have such a statute.

If a law brought penalties against doctors who fail to report peers, it could make a difference, said Tina Minasian, a patient advocate from Sacramento who has unsuccessfully urged the state medical board to sponsor such legislation.

"There's definitely a code of silence," said Minasian, a patient who lost a lawsuit against a plastic surgeon she believes was impaired by alcohol in a case that is still before the medical board. "Doctors are one of the top income earners in America. For another doctor to report a doctor, you've just blackballed him from the industry."

Actions don't meet standard

Fellmeth and others, however, aren't convinced a snitch law would help, because it's almost impossible to enforce. Many of the states that have such laws don't back them up with sanctions against doctors who don't report violations.

Dr. Ronald C. Thurston argued the survey's most important finding has been camouflaged. If 45 percent of doctors say they haven't reported colleagues at least once, that means 55 percent report all instances when they believe other doctors are impaired or incompetent.

"I think that's a pretty high percentage," said the Ventura psychiatrist and incoming president of the county medical association, suggesting other professions would have difficulty matching that number.

The authors say the survey shows doctors hold themselves to high standards.

About 93 percent of those surveyed said a patient's inability to pay shouldn't affect healthcare, and even more said the patient's interests trump a doctor's financial interests.

Their actions didn't always meet the standard. About 69 percent of doctors said they were accepting uninsured patients who can't pay. About 36 percent said they would order an unnecessary MRI to mollify a patient who insisted the test be done.

'Those are stunning findings'

About 24 percent said they would refer patients to facilities in which they were part owners without disclosing their financial interest. About 11 percent said they had revealed confidential information about patients.

Only 1 percent said they had lied to patients' family members, and 3 percent said they had withheld information.

"My bottom line isn't a simple conclusion that doctors are bad and need to behave better," said survey author Blumenthal, a primary care doctor, noting the study shows the healthcare system makes it hard for physicians to reach their ethical standards.

He called for better training and for systems at hospitals and clinics that emphasize peer review, making it easy and safe for violations to be reported. He said the doctors who might be most prone to falling short of ethical standards are those isolated in solo practices with no access to peer review.

Eric Campbell, another of the survey's authors, said many of the same things but then returned to the finding that 45 percent of doctors hadn't reported colleagues.

"I think those are stunning findings given all the efforts we have put into patient safety," he said.