It is extraordinarily difficult for a consumer to evaluate the clinical competency of a physician. If you don’t believe me, doctors will be the first ones to tell you so! According to researchers James and Hammond, “Only another physician has the necessary knowledge and experience to judge whether a professional colleague adequately discharged his or her fiduciary trust to a particular patient.”[i]
James goes on to state that doctors are so self-protective of their cultural status that “not only do physicians resist attempts of those outside the profession to inappropriately judge medical performance, they also insist on holding one another accountable for their performance within the profession of medicine.”[ii] Evidence suggests otherwise. Though they may “insist” on holding one another accountable, they do very little to honor it.
Policing Their Own Ranks to Protect Patients from Dangerous Doctors
If James’s statement were true, the medical community bears a clear obligation to safeguard its patients’ well-being by policing its ranks. Poor clinical performers, impaired physicians, and unethical practitioners should succumb to peer scrutiny or dramatically change their ways.
Theoretically, there are three levels at which such scrutiny should apply: (1) the peer-review committee of a hospital—which granted hospital-based privileges to the physician in the first place—(2) a state board of healing arts—responsible for ensuring the practice of safe and ethical medicine within the state—and (3) the ethics or disciplinary-action committees of national medical associations.
Unfortunately, a tremendous barrier stands in the way of effective reporting of physicians’ malfeasance: the physicians’ code of silence. Much like the mafia’s omertà, it is an inviolate code of conduct inculcated into trainees early in their education. The message is simple: Don’t attack your colleagues, or you might find yourself ostracized.
If you think I’m exaggerating, listen to what two, nationally known physician-authors have to say on the topic, beginning with Dr. Marty Makary: “Doctors and nurses know of docs who are reckless, but it takes moving a mountain to do something about it. Not reporting incompetence among peers is part of medical culture and has been for centuries. Medicine is poorly policed. Getting fired takes an action so egregious or offensive to hospital administration that I have only seen it happen twice among all the hospitals in which I’ve worked and trained.”[iii]
Dr. Otis Brawley, Chief Medical Officer for the American Cancer Society, shares Dr. Makary’s sentiment. “I know doctors who are just plain bad. Why do they continue to practice without impediment? The answer is simple: because no one is looking over their shoulders, no one files a disciplinary complaint, no tribunal of peers punishes them unless they do something spectacularly awful.”[iv]
Peer Review: A Perfect Path to Burying Problems
When the level of suffering, injury, or unnecessary death inflicted by a colleague weighs too heavily on the conscience of some physicians, they can turn to peer review. The peer-review committee provides a venue for discussing and investigating allegations of inappropriate conduct by members of the medical staff. These allegations can run the gamut from violating standards of surgical appropriateness to boundary violations with patients.
In theory, peer review provides a fair and informed method for assessing the clinical or nonclinical behavior of a physician and the resulting potential for harm to patients. The proceedings are safeguarded against legal discovery—with the intent of promoting open, honest, and corrective dialogue.
Far from being effective, “such internal peer reviews are a little like the Russian parliament under Stalin,” finds Makary. “No matter how much discussion there is, the results seems foreordained . . . any doctors who might raise probing questions are well aware that they can pay a heavy price for challenging their peers.”[v] In those rare times when action is taken, the physician is often given the opportunity to simply resign their medical-staff privileges at a hospital or health system. By so doing, their misdeeds go unrecorded and they move across town to wreak havoc elsewhere.
I’ve seen physicians who fall asleep in the midst of complex surgeries, others who open up purportedly blocked arteries with multiple interventions—despite no discernible evidence of coronary disease. Some physicians knowingly inflict pain—either because they are sadistic or, more likely, because they don’t want to waste time waiting for the effects of anesthetic agents to kick in.
The most outrageous case I know of involved a physician performing a circumcision on a two-year-old. The parents, waiting in a nearby room, heard their child screaming in pain. When later they asked the physician what had caused such a violent reaction in their child, he responded, “the injection of an anesthetic.” In reality, he provided the child with no anesthetic—after all, it was a simple, quick procedure. In my mind there is a fitting punishment for such behavior on the part of the physician . . . and it is no mere slap on the wrist.
Finally, there are those who are blind drunk when operating. Such behavior is tolerated day in and day out in American medicine. To do otherwise would be to break the code of silence.
There are physicians who hold themselves to a higher code—one that demands owning responsibility for their actions. One such physician, Dr. Peter Elias, writing in the New York Times’ Sunday Dialogue, offered this advice to his colleagues regarding medical error: “As a practicing family physician for thirty-six years, I have come to believe in the seven essential Rs of an apology: it should be Rapid (as in right away when the error is discovered), show true Remorse, Recognize explicitly the error, accept Responsibility, acknowledge the Repercussions for the patient, offer Restitution or repair, and close with a Repetition of the opening words: I’m sorry.”[vi]
State Medical Boards Receive an F for Failing to Protect Us
A second “safeguard” against dangerous physicians should be state medical boards, which oversee licensure and disciplinary action. But they are not, according to Alan Levine, who provides oversight of the medical boards on behalf of the United States. Inspector General Levine indicates that many of these boards serve the vested interest of physicians to a far greater extent than they serve the public good.[vii]
Though the accounts are anecdotal, I’ve heard many physicians suggest that these boards are partly populated by dangerous physicians. It’s a case of the fox guarding the hen house. If there’s bad news coming down the pike regarding a physician’s practice, a position on the board will ensure that the physician will be first to hear it and attempt to squelch it.
In a recent review of state medical boards conducted by the consumer advocacy group Public Citizen, only two states were given an A rating. The vast majority received a Fs. What was particularly disturbing was the variance seen among these boards. “The most recent three-year average state disciplinary rates (2009–2011) ranged from 1.33 serious actions per thousand physicians (South Carolina) to 6.79 actions per thousand physicians (Wyoming), a 5:1–fold difference in the rate of discipline between the best and worst state doctor disciplinary boards.”[viii]
Sidney Wolfe, MD, founder of Public Citizen, noted that there was no evidence to suggest that the rates of inappropriate behavior by physicians vary dramatically between states. Therefore, the variations observed by Public Citizen can only be attributable to the manner in which individual boards manage physician disciplinary issues. He goes on to state that “there is considerable evidence that most boards are underdisciplining physicians.”[ix]
Wolfe’s research concludes that the average serious disciplinary rate, for any cause, is only 3.06 per one thousand . . . or 0.3 percent. Yet we know that there are a tremendous number of impaired physicians wreaking havoc on patients every day—physicians who obviously go either undetected or unpunished.
As Dr. Marty Makary points out in his book, Unaccountable, “There are also grossly impaired physicians [and] doctors with horrible skills, hazardous judgment, [and] ulterior motives or who suffer from substance abuse or other problems that make them dangerous. Society ought to be able to deal with this better, not sweep it all under the rug.”[x]
Do such physicians represent the proverbial needle in the haystack and thus only affect an infinitesimally small portion of the population? Makary asks us to consider what it would look like if 2 percent of our doctors had a major impairment due to drugs, alcohol, or other causes. He then calculates that there would be twenty thousand impaired physicians in America treating up to ten million people per year.[xi]
That’s a lot of needles and haystacks.
If Makary’s estimates sound absurdly high, consider the conclusions reached by researchers Eugene Boisaubin, MD, and Ruth Levine, MD, as published in the American Journal of Medical Sciences. “Approximately 15 percent of physicians,” they find, “will be impaired at some point in their careers.”[xii]That’s not to suggest that these physicians will, de facto, endanger their patients, but it certainly indicates a higher level of risk than might be suggested by the rate of disciplinary actions taken by state medical boards.
Caveat emptor to all patients: as Dr. Wolfe has demonstrated, “most states are not living up to their obligations to protect patients from doctors who are practicing medicine in a substandard manner.”[xiii]
The Abdication of Responsibility by Professional Societies
The final level of protection from malevolent, incompetent, or impaired physicians resides in their professional associations—most prominently the AMA. The AMA’s Code of Ethics states that “a physician shall deal honestly with patients and colleagues and strive to expose those physicians deficient in character or competence or who engage in fraud or deception.”[xiv] The question becomes whether such standards are ever enforced. “After asking around,” Makary found, “it became clear that the only time that a doctors’ association would ever consider taking action against a doctor was if a state medical board had already done so.”[xv]
Professional societies exist not merely for the benefit of their members but to uphold the standards of the profession. Yet Otis Brawley, MD, questioned whether medicine even conforms to the definition of a profession. “A profession,” he notes, “is a group of people who police themselves and put the welfare of their clients above their own. In many respects, people within medicine have forgotten what the word profession means.”[xvi]
One can seek comfort in the belief that problematic physicians are few and far between, but the comfort will be short-lived. “An average American’s combined exposure to quality failure from providers’ underuse, overuse, and misuse of services is roughly 50 percent for preventive, acute, and chronic care services.”[xvii]
It’s Time to Step Up to the Plate: The Need for Physician-Defined Standards of Competency and Reporting Requirements
It is abundantly clear that there is a crying need to restore the fundamental trust between patients and physicians. A good starting point would be for the medical community to define criteria on which physicians’ performances would be evaluated, as well as the degree to which such information would be transparent to the public. Right now, “there is no agreed-upon definition of competence that encompasses all important domains of professional medical practice.”[xviii]
Doctors Epstein and Hundert, in an article published in JAMA, suggested a definition that, on the surface, appears quite cogent: “We propose that professional competence is the habitual and judicious use of communication, knowledge, technical skills, clinical reason, emotions, values, and reflection in daily practice for the benefit of the individual and community being served. Competence builds on a foundation of basic clinical skills, scientific knowledge, and moral development.”[xix]
The authors go on to discuss the importance of the following measures of competency:
- Acquisition and use of knowledge
- Integrative aspects of care: “It is defined by the ability to manage ambiguous problems, tolerate uncertainty, and make decisions with limited information.”[xx]
- Building therapeutic relationships: “The quality of patient-physician relationship affects health and the recovery from illness, costs, and outcomes of chronic diseases by altering patients’ understanding of their illnesses and reduction patient anxiety.”[xxi]
- Affective and moral dimensions: “Moral and affective domains of practice may be evaluated more accurately by patients and peers than by licensing bodies or superiors.”[xxii]
Epstein and Hundert also point out deficiencies in current methods for assessing competency: “Few assessments use measures such as participatory decision making that predict clinical outcomes in real practice. Few reliably assess clinical reasoning, system-based care, technology, and the patient-physician relationship.”[xxiii]</indent>
Finally, they point out, “Standardized test scores have been inversely correlated with empathy, responsibility, and tolerance.”[xxiv] Perhaps you should disregard what I said about MCAT scores.
In an interview in September 1997, I asked one of the physicians I revere the most how one finds a great doctor. Elisabeth Kübler-Ross, never shy of opinions, offered thoughts about why it is difficult to find a good doctor: “You have to be an A student. That eliminates 90 percent of the good people. Then you have to have lots of money—that eliminates the other few percent. That means it is pure coincidence if you get one good apple in the whole basket. Then you train them to cure, you don’t train them how to be physicians.”[xxv]
DISCOVER FAR MORE STARTLING FACTS ABOUT THE HEALTH CARE SYSTEM by reading:
The Myths of Modern Medicine: The Alarming Truth About American Health Care. It is available on Amazon.com or directly from the publisher, Rowman & Littlefield.
[i] James and Hammond, “The Challenge of Variation,” 1001.
[ii] Ibid., 1001.
[iii] Makary, Unaccountable: What Hospitals Won’t Tell You, 102.
[iv] Brawley, How We Do Harm, 125.
[v] Makary, Unaccountable: What Hospitals Won’t Tell You, 100.
[vi]Peter Elias, “Sunday Dialogue: Handling Medical Errors,” New York Times, October 18, 2013, http://www.nytimes.com/2013/10/20/opinion/sunday/sunday-dialogue-handling-medical-errors.html.
[vii] Makary, Unaccountable: What Hospitals Won’t Tell You, 103–104.
[viii]Sidney M. Wolfe,Cynthia Williams, and Alex Zaslow, “Public Citizen’s Health Research Group Ranking of the Rate of State Medical Boards’ Serious Disciplinary Actions, 2009–2011,” Public Citizen, last modified May 17, 2012,http://www.citizen.org/documents/2034.pdf.
[x] Makary, Unaccountable: What Hospitals Won’t Tell You, 97.
[xi] Ibid., 96.
[xii]E. V. Boisaubin and R. E. Levine, “Identifying and Assisting the Impaired Physician,” American Journal of Medical Sciences322, no. 1 (July 2001): 31–6,http://www.ncbi.nlm.nih.gov/pubmed/11465244.
[xiii] Wolfe, Williams, and Zaslow, “Public Citizen’s Health Research Group.”
[xiv] Lundberg, Severed Trust, 10.
[xv] Makary, Unaccountable: What Hospitals Won’t Tell You, 102.
[xvi] Otis Brawley, MD, chief medical and scientific officer of the American Cancer Society, in discussion with the author, August 16, 2013.
[xvii]Arnold Milstein and Nancy E. Adler, “Out of Sight, Out of Mind: Why Doesn’t Widespread Clinical Quality Failure Command Our Attention?” Health Affairs22, no. 2 (2003): 119–27, http://www.ncbi.nlm.nih.gov/pubmed/12674415.
[xviii]Ronald M. Epstein and Edward M. Hundert, “Defining and Assessing Professional Competence,” Journal of the American Medical Association287, no. 2 (January 9, 2002): 226–35, doi:10.1001/jama.287.2.226.
[xix] Ibid., 226.
[xx] Ibid., 227.
[xxi] Ibid., 228.
[xxii] Ibid., 228.
[xxiii] Ibid., 230.
[xxv] Elisabeth Kübler-Ross, MD, author of On Death and Dying, in discussion with the author, September 4, 1997, Carefree, Ariz.