Physicians reluctant to report impaired colleagues, study says

One in three doctors who personally knew of an incompetent or impaired physician colleague failed to report the doctor to a hospital, clinic, professional society or other authority, according to a recent national survey of nearly 2,000 physicians.

A variety of medical professional ethics codes, including the American Medical Association's, say physicians have a duty to report other doctors whose substance abuse, mental health or other problems could endanger patients. But the survey, whose results were published in the July 14 Journal of the American Medical Association, found that just 64% of physicians completely agreed that they had an obligation to report all impaired or incompetent doctors. The rest of the physicians either "somewhat agreed" that they were obliged to report problem colleagues or disagreed that they had such a responsibility.

"Self-regulation is one of the primary ways we have, at this point, for physicians who need help to be referred for that help and for patients to be protected from a physician who shouldn't be practicing," said Catherine M. DesRoches, PhD, lead author of the study and assistant professor of medicine at the Massachusetts General Hospital's Mongan Institute for Health Policy in Boston. "If you're a patient, you want that number [of physicians reporting] to be 100%."

The survey results "constitute a frontal assault on a basic premise of medical professionalism," said a companion JAMA editorial authored by Matthew K. Wynia, MD, MPH, director of the AMA Institute for Ethics, a research center.

"Reporting impaired or incompetent colleagues is a clear-cut professional obligation," Dr. Wynia said in an interview. "We should absolutely enforce that and make it as easy as possible for doctors to do the right thing."

The most common reason for not reporting incompetent or impaired colleagues was physicians "thought someone else was taking care of the problem," the study said. Some physicians said reporting would be fruitless, while 12% feared retribution.

Doctors from seven specialties -- anesthesiology, cardiology, family medicine, general surgery, internal medicine, pediatrics and psychiatry -- were surveyed. Psychiatrists were the most likely to report incompetent or impaired colleagues, with 77% having done so in the last three years. Pediatricians were the least likely to report a problem colleague; 46% with direct knowledge of an impaired physician failed to report the doctor.

Physicians from underrepresented minorities, international medical graduates and physicians in solo or two-doctor practices were less likely to report than were other physicians. Researchers did not query doctors about how their specialty, minority status or practice size affected their willingness to report problem colleagues.

A Dec. 4, 2007, Annals of Internal Medicine study, conducted by the same group of Boston researchers, found that 45% of more than 1,600 physicians surveyed said they had "always reported incompetent or impaired colleagues" during the previous three years.

But DesRoches said the results were not comparable with the new study because of changes in the wording of survey questions.

Assuring competence

DesRoches said doctors need to be better educated on how to report problem colleagues and their ethical responsibility to do so. She added that doctors who report should be kept in the loop on how a colleague's case is progressing, and that the reporting process should be confidential.

AMA Board of Trustees member Edward L. Langston, MD, agreed that more should be done to address barriers to reporting, but said that few of the physicians surveyed for the JAMA study failed to report impaired colleagues. He noted that just 5% of all the physicians surveyed did not report problem doctors when they should have, due to the fact that only 17% of respondents had direct knowledge of an impaired or incompetent physician.

"This study shows that the vast majority of physicians are doing the right thing," said Dr. Langston, a Lafayette, Ind., family physician. He added that peer reporting is not the only way to protect patients.

"There are extensive federal and state regulations, evidence-based clinical measures on health care conditions, patient safety organizations, credentialing and continuing medical education for physicians," he said.

Dr. Wynia agreed that the way physician quality is monitored has changed. "That's where the profession has moved over the last 20 years, to recognize that we need a complex set of overlapping and interlocking quality assurance mechanisms," he said, referring to CME, maintenance of board-certification requirements and more. "It's not just a matter of doctors peeping over each other's shoulders."