Survey: Physicians falling short on professionalism

Doctors agree on the basic tenets of medical professionalism, but they frequently fail to live up to those ideals in practice, according to a survey of more than 1,600 physicians in the Dec. 4 Annals of Internal Medicine.

Nearly all of the physicians surveyed agreed doctors should use medical resources appropriately, tell patients the truth, minimize disparities, see patients regardless of their ability to pay, maintain board certifications, evaluate peers' care, avoid sex with patients, work on quality initiatives, disclose conflicts of interest, report impaired or incompetent physicians, and report medical errors.

But more than half of doctors told investigators that they failed to report a serious medical error they observed, or a colleague who was impaired or incompetent, to authorities in the last three years. And more than a third of the doctors said they would order an unnecessary magnetic resonance imaging scan to mollify an insistent patient.

Lead author Eric G. Campbell, PhD, was especially disappointed by the 24% of doctors who said they would refer patients to a facility in which they had a financial stake without disclosing the conflict. Such a referral could be illegal under Stark and anti-kickback rules.

"This is beating a dead horse," said Dr. Campbell, assistant professor of medicine at the Massachusetts General Hospital-Harvard Medical School Institute for Health Policy. "This shouldn't happen anymore."

Physicians, ethicists and regulators said the findings show that great progress has been made in spreading new norms of medical professionalism. But more should be done to reduce the legal and cultural impediments that often can dissuade doctors from doing the right thing, they said.

"The good news is that physicians clearly want to adhere to the highest ethical standards, and this report makes clear that we need to remove barriers that may prevent physicians from following through on their good intentions," AMA Board of Trustees Chair Edward L. Langston, MD, said in a statement responding to the study.

"The AMA is working to help physicians by removing barriers to reporting medical errors, eliminating health care disparities, measuring and improving quality of care, and improving the medical liability system," Dr. Langston said.

The Association was a major backer of 2005 national patient-safety legislation, still being implemented, that would allow physicians to report medical errors confidentially without fear of liability actions. The AMA also has worked with state medical boards to transform treatment of physicians with substance use or mental health problems to emphasize rehabilitation rather than discipline.

Robert Baker, PhD, author of American Medical Ethics Revolution, published in 1999, said he was amazed by physicians' unanimity on the ideals of professionalism.

The study shows a "higher level of acceptance than anyone in his right mind had any reason to believe," said Dr. Baker, director of the bioethics program at the Mount Sinai School of Medicine in New York. "If [the survey] is accurate, it means the reform efforts of the last decade or two have really paid off."

These efforts include substantial amendments to the AMA Code of Medical Ethics, widespread adoption of the AMA's Declaration of Professional Responsibility (published in 2001) and the 2004 publication of a charter on medical professionalism endorsed by foundations of the American Board of Internal Medicine and the American College of Physicians.

It is not surprising, Dr. Baker said, that doctors diverge from lofty statements of principle when it comes to reporting physician colleagues who become impaired or commit errors.

"Turning in your buddies is the hardest thing to do," Dr. Baker said. "There is an ethics of loyalty to your peers that is very deep. ... Then there's a more formal ethics of professionalism, and these things come into conflict. Personally and emotionally, these things are wrenching."

James N. Thompson, MD, CEO of the Federation of State Medical Boards, said doctors should know that reporting impaired colleagues need not mean ending their careers.

"We need to educate physicians to a greater extent on the notion that they can get remediation and get help without losing their licenses," Dr. Thompson said. "Our purpose is to protect the public, and it is in the public's interest to get doctors back practicing safely and effectively."