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Many doctors in the United States are failing to conform to professional guidelines. A survey sponsored by the US Institute of Medicine found that doctors often fail to conform to accepted norms in areas of self regulation, managing conflicts of interest, and ordering of unnecessary tests.
Moreover, although most respondents thought they should report colleagues who were not competent, almost a half said that in the past three years they had known of a doctor who was “impaired or incompetent” but had failed to report the doctor to a relevant authority (Annals of Internal Medicine 2007;147:795-802).
The survey of 3167 randomly selected and eligible doctors, 1662 (52%) of whom responded, showed a substantial gap between what the doctors say they believe is appropriate professional behaviour and how they act.
The doctors were asked about their support of professional norms as established by the charter on professionalism promulgated in 2002 by the American Board of Internal Medicine and other groups to address problems of “cost, access, and quality in the US healthcare system” that have not been resolved through legislation or competition, the authors wrote.
Over 90% of doctors who responded agreed with eight of 12 statements regarding professionalism. Despite this strong support, most respondents said they would, for example, refer patients to a local imaging facility in which they had a financial interest, and a quarter said they would make the referral without informing the patient of the conflict of interest. Such referral could be illegal under federal statutes, the authors say.
Doctors were also reluctant to report medical errors: 46% had direct personal knowledge of at least one “serious medical error” in the past three years that they did not report.
A substantial portion of doctors also deviated from professional guidelines regarding “just distribution of finite resources.” In response to a scenario in which a patient presents with two days of low back pain “without neuromuscular signs or symptoms” yet who insists on magnetic resonance imaging, 36% of the doctors said they would order the test.
There were bright spots. Only 1% of doctors said they had not been honest with patients and their families about medical issues in the past three years, and three quarters said that they treated poor patients without “anticipation of reimbursement.”
Donald Berwick, professor of health policy and management at the Harvard School of Public Health, said that failure to report doctors who behave unprofessionally or whose performance is impaired, such as “a surgeon who throws an instrument across the operating room, or who lies, or has undiagnosed Alzheimer’s disease,” puts patients at risk. Doctors, said Dr Berwick, need to be prepared to put patients first and to identify impaired colleagues.
However, Dr Berwick said, medical errors need a different approach. “You need a system that doesn’t focus on blame or personal reprisal,” he said. “Usually it’s a good hearted, well intended staff person who has been trapped in a broken process.”
(See News doi: 10.1136/bmj.39415.492164.DB.)