{"id":306,"date":"2014-10-16T10:18:51","date_gmt":"2014-10-16T15:18:51","guid":{"rendered":"http:\/\/leiferreport.com\/?p=306"},"modified":"2014-10-16T10:18:51","modified_gmt":"2014-10-16T15:18:51","slug":"protecting-bad-doctors","status":"publish","type":"post","link":"https:\/\/leifer.com\/?p=306","title":{"rendered":"WHO IS PROTECTING US FROM BAD DOCTORS?"},"content":{"rendered":"

\"Caduceus<\/a>Physician Self-Evaluations<\/span><\/b><\/p>\n

It is extraordinarily difficult for a consumer to evaluate the clinical competency of a physician. If you don\u2019t believe me, doctors will be the first ones to tell you so! According to researchers James and Hammond, \u201cOnly 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.\u201d<\/span>[i]<\/span><\/a><\/p>\n

James goes on to state that doctors are so self-protective of their cultural status that \u201cnot 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.\u201d<\/span>[ii]<\/span><\/a> Evidence suggests otherwise. <\/span>Though they may \u201cinsist\u201d on holding one another accountable, they do very little to honor it.<\/span><\/span><\/p>\n

\u00a0<\/span>Policing Their Own Ranks to Protect Patients from Dangerous Doctors<\/span><\/span><\/b><\/p>\n

If James\u2019s statement were true, the medical community bears a clear obligation to safeguard its patients\u2019 well-being by policing its ranks. Poor clinical performers, impaired physicians, and unethical practitioners should succumb to peer scrutiny or dramatically change their ways.<\/span><\/p>\n

Theoretically, there are three levels at which such scrutiny should apply: (1) the peer-review committee of a hospital\u2014which granted hospital-based privileges to the physician in the first place\u2014(2) a state board of healing arts\u2014responsible for ensuring the practice of safe and ethical medicine within the state\u2014and (3) the ethics or disciplinary-action committees of national medical associations.<\/span><\/p>\n

Unfortunately, a tremendous barrier stands in the way of effective reporting of physicians\u2019 malfeasance: the physicians\u2019 code of silence. Much like the mafia\u2019s omert\u00e0<\/i><\/span><\/span>, it is an inviolate code of conduct inculcated into trainees early in their education. The message is simple: Don\u2019t attack your colleagues, or you might find yourself ostracized.<\/span><\/span><\/p>\n

If you think I\u2019m exaggerating, listen to what two, <\/b><\/span><\/span>nationally known physician-authors have to say on the topic, beginning with Dr. Marty Makary: \u201cDoctors 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\u2019ve worked and trained.\u201d<\/span><\/span>[iii]<\/span><\/a><\/p>\n

Dr. Otis Brawley, Chief Medical Officer for the American Cancer Society, shares Dr. Makary\u2019s sentiment. \u201cI 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.\u201d<\/span>[iv]<\/span><\/a><\/p>\n

Peer Review: A Perfect Path to Burying Problems<\/span><\/b><\/p>\n

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.<\/span><\/p>\n

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\u2014with the intent of promoting open, honest, and corrective dialogue.<\/span><\/p>\n

Far from being effective, \u201csuch internal peer reviews are a little like the Russian parliament under Stalin,\u201d finds Makary. \u201cNo 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.\u201d<\/span>[v]<\/span><\/a> 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.<\/span><\/p>\n

I\u2019ve seen physicians who fall asleep in the midst of complex surgeries, others who open up purportedly blocked arteries with multiple interventions\u2014despite no discernible evidence of coronary disease. Some physicians knowingly inflict pain\u2014either because they are sadistic or, more likely, because they don\u2019t want to waste time waiting for the effects of anesthetic agents to kick in.<\/span><\/p>\n

The most outrageous case I know of \u00a0<\/span><\/span>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, \u201cthe injection of an anesthetic.\u201d In reality, he provided the child with no anesthetic\u2014after 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.<\/span><\/span><\/p>\n

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.<\/span><\/p>\n

There are physicians who hold themselves to a higher code\u2014one that demands owning responsibility for their actions. One such physician, Dr. Peter Elias, writing in the New York Times<\/i><\/span><\/span>\u2019 Sunday Dialogue, offered this advice to his colleagues regarding medical error: \u201cAs 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: <\/span>I\u2019m sorry<\/span><\/i>.\u201d<\/span><\/span>[vi]<\/span><\/a><\/p>\n

State Medical Boards Receive an F for Failing to Protect Us<\/span><\/b><\/p>\n

A second \u201csafeguard\u201d 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.<\/span>[vii]<\/span><\/a><\/p>\n

Though the accounts are anecdotal, I\u2019ve heard many physicians suggest that these boards are partly populated by dangerous physicians. It\u2019s a case of the fox guarding the hen house. If there\u2019s bad news coming down the pike regarding a physician\u2019s practice, a position on the board will ensure that the physician will be first to hear it and attempt to squelch it.<\/span><\/p>\n

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. \u201cThe most recent three-year average state disciplinary rates (2009\u20132011) ranged from 1.33 serious actions per thousand physicians (South Carolina) to 6.79 actions per thousand physicians (Wyoming), a 5:1\u2013fold difference in the rate of discipline between the best and worst state doctor disciplinary boards.\u201d<\/span>[viii]<\/span><\/a><\/p>\n

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 \u201cthere is considerable evidence that most boards are underdisciplining physicians.\u201d<\/span>[ix]<\/span><\/a><\/p>\n

Wolfe\u2019s 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\u2014physicians who obviously go either undetected or unpunished.<\/span><\/p>\n

As Dr. Marty Makary points out in his book, Unaccountable<\/i><\/span><\/span>, \u201cThere 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.\u201d<\/span><\/span>[x]<\/span><\/a><\/p>\n

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.<\/span>[xi]<\/span><\/a><\/p>\n

That\u2019s a lot of needles and haystacks.<\/span><\/p>\n

If Makary\u2019s 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<\/i><\/span><\/span>. \u201cApproximately 15 percent of physicians,\u201d they find, \u201cwill be impaired at some point in their careers.\u201d<\/span><\/span>[xii]<\/span><\/a>That\u2019s 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.<\/span><\/span><\/p>\n

Caveat emptor to all patients: as Dr. Wolfe has demonstrated, \u201cmost states are not living up to their obligations to protect patients from doctors who are practicing medicine in a substandard manner.\u201d<\/span>[xiii]<\/span><\/a><\/p>\n

The Abdication of Responsibility by Professional Societies<\/span><\/b><\/p>\n

The final level of protection from malevolent, incompetent, or impaired physicians resides in their professional associations\u2014most prominently the AMA. The AMA\u2019s Code of Ethics states that \u201ca 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.\u201d<\/span>[xiv]<\/span><\/a> The question becomes whether such standards are ever enforced. \u201cAfter asking around,\u201d Makary found, \u201cit became clear that the only time that a doctors\u2019 association would ever consider taking action against a doctor was if a state medical board had already done so.\u201d<\/span>[xv]<\/span><\/a><\/p>\n

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. \u201cA profession,\u201d he notes, \u201cis 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<\/i><\/span><\/span> means.\u201d<\/span><\/span>[xvi]<\/span><\/a><\/p>\n

One can seek comfort in the belief that problematic physicians are few and far between, but the comfort will be short-lived. \u201cAn average American\u2019s combined exposure to quality failure from providers\u2019 underuse, overuse, and misuse of services is roughly 50 percent for preventive, acute, and chronic care services.\u201d<\/span>[xvii]<\/span><\/a><\/p>\n

It\u2019s Time to Step Up to the Plate: The Need for Physician-Defined Standards of Competency and Reporting Requirements<\/span><\/b><\/p>\n

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\u2019 performances would be evaluated, as well as the degree to which such information would be transparent to the public. Right now, \u201cthere is no agreed-upon definition of competence that encompasses all important domains of professional medical practice.\u201d<\/span>[xviii]<\/span><\/a><\/p>\n

Doctors Epstein and Hundert, in an article published in JAMA<\/i><\/span><\/span>, suggested a definition that, on the surface, appears quite cogent: \u201cWe 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.\u201d<\/span><\/span>[xix]<\/span><\/a><\/p>\n

The authors go on to discuss the importance of the following measures of competency:<\/span><\/p>\n