Many doctors fall short of new professional standards, survey finds

By Liz Kowalczyk, Globe Staff

Nearly half of doctors say they have failed to report an impaired or incompetent colleague or a serious medical error, and more than one-third say they would order an unneeded MRI scan for an insistent patient -- though these actions conflict with what they consider the heart of their professional obligations.

The survey results, being published in tomorrow's Annals of Internal Medicine, are part of the first comprehensive study of whether physicians believe in the values of their profession -- and whether they adhere to them in practice.

Physicians' actions were most consistent with their near unanimous belief that doctors should be honest with patients and tell them about all significant errors; less than 1 percent said they had lied to a patient's family and just 3 percent reported withholding important information during the last three years. But researchers and physicians who reviewed the results said they were surprised that in other areas doctors' behavior did not reflect the standards they endorsed.

"Given all of the work that has been put into patient safety, the fact that half of doctors don't report impaired colleagues, I find absolutely astonishing,'' said Eric Campbell, of the Massachusetts General Hospital Institute for Health Policy and the lead author of the study.

"I was struck by the idea that virtually all physicians believe doctors shouldn't waste scarce resources,'' Campbell added, yet 36 percent of doctors surveyed said they would order an MRI for a patient with low back pain who demanded the test, even if the doctor believed the test was useless.

Several physicians, however, said that today's emphasis on patient satisfaction often puts doctors in a no-win situation when a patient insists on something that is unnecessary; the physician must either waste resources or risk an unhappy patient who might drop them as their doctor. This dilemma can be especially difficult for a doctor whose employer uses patient satisfaction surveys to help evaluate their work.

Dr. David Blumenthal, director of the health policy institute and an author of the study, said he did not expect doctors to always live up to their beliefs. But he was surprised that 25 percent said they would refer patients to an imaging facility in which the doctor had a financial interest, because doing so is usually illegal.

The survey is the first broad attempt to measure the success of a new movement called "medical professionalism.'' Arguing that government regulation, financial incentives and public reporting alone will not improve the quality and efficiency of medical care, physicians groups in the past several years have been promoting a new code of professional values, meant to modernize the ancient Hippocratic Oath.

"This is a new definition of professionalism,'' said Dr. Donald Berwick, president of the Institute for Healthcare Improvement, a non-profit group based in Cambridge that advises hospitals and doctors on how to improve quality. "It's not just about being a solo operator now. It's about being a member of a collective and a system.''

The original Hippocratic Oath, written 2,400 years ago, states that doctors must not harm patients, or give them deadly drugs or provide abortions, and stresses secrecy regarding all that is seen while treating patients. It does not address issues such as financial conflicts-of-interest, use of technology, medical mistakes and racial inequalities in care.

In one of the most prominent efforts to update the oath, two American and one European group several years ago created a professional charter of modern standards that has been widely distributed to doctors around the world.

The survey, conducted between Nov. 2003 and June 2004, was intended to measure whether physicians believe and behave in accordance with this new physician charter developed by the American Board of Internal Medicine, the American College of Physicians, and the European Federation of Internal Medicine.

The authors mailed the survey to 3,504 US internists, family practitioners, pediatricians, surgeons, cardiologists and anesthesiologists, and 1,662 responded. They were asked whether they agreed with 12 specific statements about fair distribution of limited resources, improving access to and quality of care, managing conflicts of interest, and self-policing by doctors.

More than 90 percent agreed with 8 of the 12 statements, including that physicians should minimize inequalities in care, put the patient's welfare above the doctor's financial interests, and report all instances of significantly impaired or incompetent colleagues to hospital, clinic or other authorities. Agreement fell below 80 percent for only one statement: "Physicians should undergo recertification examinations periodically throughout their career.''

Dr. Christine Cassel, president of the American Board of Internal Medicine, said the results indicate physicians "really do believe in these values.'' Now, she said, the challenge is getting them to put them into practice consistently.

Dr. David Bates, chief of general internal medicine at Brigham and Women's Hospital, said he was "really surprised" that 45 percent of doctors said that in the last three years they had direct personal knowledge of impaired or incompetent colleagues but that they did not always report them to a hospital, clinic, professional society or other relevant authority.

Bates said physicians may worry that authorities will come down too hard on a doctor, although he has reported an impaired colleague and felt regulators handled the situation sensitively.

He also said that physicians generally are reluctant to report errors. "Part of it is that they're busy,'' said Bates, a patient safety leader. "Part of it is that they're uncomfortable doing that. One of the best measures of a culture of safety is willingness to report, so a figure that low is disappointing.''

Berwick said that most physicians are not trained in medical school or as professionals to handle difficult situations involving colleagues. Or, ''it can be an issue of knowing you yourself have made errors, and feeling that people in glass houses shouldn't throw stones,'' he said.

Berwick said that when he was a young resident rotating from hospital to hospital, he knew a caregiver "who everyone seemed to know was using anesthetics dangerously and incompetently. I remember noticing but didn't do anything about it. I felt I was there as a guest. In the long run, the medical staff edged him out gradually.''

Campbell said that while the study has limitations, including that the researchers had to rely on doctors to accurately describe their behavior, he said the specialties might be able to learn from each other. Anesthesiologists, for example, had the highest rate of reporting impaired or incompetent colleagues; 68 percent said they always did.

Blumenthal said the Mass. General group is developing follow-up studies to determine the obstacles that keep doctors from consistently following professional tenets. One clue in the current research is that doctors in solo or small practices are less likely to report problems than those in universities or large HMOs.