Physicians Are Reluctant to Report Their Peers On the surface, physicians seem to be in agreement: Four out of five say they would report an impaired colleague, according to Medscape's most recent ethics survey.[1] But listen a little harder, and you'll hear discordant undertones that include a lot of questions and caveats. In fact, research shows although most doctors say they'd report an impaired colleague, when confronted with the situation, many fail to do so. "There are complicated reasons why people don't report," says Catherine DesRoches, DrPH, an associate professor at Harvard Medical School. In a 2010 survey published in JAMA, Dr DesRoches and her colleagues found that one third of physicians who encountered an impaired physician in their group or hospital did not report them.[2] That reticence to report comes even as patient safety advocates are calling for random drug screening for physicians. It also defies ethical guidance from the American Medical Association that exhorts physicians to "intervene in a timely manner to ensure that impaired colleagues cease practicing and receive appropriate assistance from a physician health program" and to "report impaired colleagues in keeping with ethics guidance and applicable law."[3] Why are so many physicians reluctant to report their impaired peers? It's complicated by the fact that many physicians feel that they are taking the positive and more helpful course of action by not reporting. Why Doctors Don't Report Colleagues More than 10% of physicians will develop an addictive disorder over the course of their career, and approximately one third will have a condition that could impact their ability to practice with reasonable skill and safety at some point in their career, according to the Federation of State Physician Health Programs.[4] Given those high percentages, there's a high probability that many physicians at some point in their careers will encounter a colleague whose performance is at some point impaired by drugs, alcohol, or illness. Would they report them? Nearly 4 out of 5 (78%) of the 7500 physicians responding to Medscape's most recent ethics report say they would. Another 18% aren't so sure. A small minority (4%) say they would not. Reasons for Not Turning In a Colleague In elaborating on their answers, doctors who said they might not report a colleague provided a number of reasons: How impaired is impaired? Many doctors implied there would be some sort of calculus to their decision. "How impaired?" "How occasionally?" "Has he or she produced harm?" Still others noted that their decision would be based on their own professional assessment of a colleague's impairment. "Depends on their ability to perform as required," wrote an anesthesiologist. A mental health professional said that the decision depends on how it "impacts their professional capacity to function." "Depends on my confidence level in their impairment," noted a pathologist. The problem with those shades-of-gray arguments, says Michael Munger, MD, president of the American Academy of Family Physicians, is that "very few things in this life are truly clear-cut." Just as a physician wouldn't wait for a suspect piece of equipment to fail before reporting the potential danger, "when we are dealing with the potential safety of patients and the impact on patient care as a whole, we must hold ourselves to the highest levels of professionalism. I know that's kind of hard-nosed, but it's important that we always keep this framed around patient care," he says. Other Barriers to Reporting Cause of impairment. Many physicians tell Medscape that their decision to report a colleague would depend on the cause. "Drugs or alcohol, probably, but if it was related to mental health, I won't report them," writes one pediatrician. "Mild impairment by illness is one thing, but gross impairment by drugs/alcohol should be reported," writes another. "Definitely for alcohol or drugs; for illness, I would first encourage them to take time off and get treatment," says a mental health professional. That distinction is troubling, says Lisa Merlo, PhD, an associate professor in the department of psychiatry and the University of Florida College of Medicine and research director for Florida's Physician Health Program. "I think there is still some lack of understanding about what is impairing," says Dr Merlo, who says that training pertaining to substance use disorders should be incorporated into medical education. Professionalism as a barrier. Many physicians say they would hesitate to report a colleague out of concern that they would be severely punished or would not receive the help they needed. Thomas Gallagher, MD, associate chair of the department of medicine and a professor in the Department of Bioethics and Humanities at the University of Washington, says there are a lot of parallels between physicians' hesitation to report an impaired colleague and their reticence to reveal a colleague's medical error or point out an aging physician's deteriorating skills. Part of the problem, he says, traces its roots to the Hippocratic Oath and an overdeveloped sense of professionalism and collegiality. "We rely heavily on our colleagues for patient care; there are often financial relationships—we rely on colleagues for referrals—and we worry about our own reputations among our peers," he says. Those relationships can make physicians reticent to speak up and are frequently compounded by numerous other forces. For example, doctors may feel they shouldn't report a potential problem because they don't know the whole situation, or they may excuse a physician's apparent impairment by laying blame on systemic problems, such as a stressful workplace. Distrust of the system. In a similar vein, many physicians say they don't trust the system to address a colleague's impairment fairly and effectively. A general surgeon referred to formal reporting as "unleashing the hounds," and an internist stated that "the system is too punitive as it stands without me adding to physician suicide numbers." Even some physicians who have reported impaired colleagues in the past lament that they did not feel they could predict the consequences of their actions. "The problem is the jeopardy in doing this. The problem is the authorities and how they handle it," writes an orthopedist who reported an impaired colleague. An emergency medicine physician agrees: "I have [reported an impaired colleague]; however, I feel the physician's problem was poorly handled by the state board. He did not get the treatment he needed, and he lost his license. Very sad case." A family medicine specialist expressed a similar concern. "Our state boards can be very punitive, especially about mental illness, such as depression. Some people are forced into monitoring programs that are really set up for people with substance abuse, when that has never been an issue. I would try very hard to make sure that someone's career would not be unnecessarily adversely affected, while ensuring their safety and most especially patient safety." Helping Physicians Come Forward What's more, even though a majority of Medscape respondents say they would report an impaired colleague, chances are those numbers are high, speculates Dr DesRoches. "When you ask people a hypothetical question, you'll often get an idealized answer," she says. One third of the physicians she surveyed for the 2010 JAMA study who had direct personal knowledge of an impaired colleague during the previous 3 years failed to report them because they believed someone else was taking care of the problem (19%), didn't think reporting the problem would make a difference (15%), feared retribution (12%), felt it wasn't their responsibility to report (10%), or worried that the physician would be excessively punished (9%). "What surprised me was how few physicians said they felt prepared to deal with this situation," she says. "Normally, physicians are a very confident group, but only two thirds of respondents felt they were prepared to deal with the situation, so it seems like there's an opportunity to start early and prepare physicians in residency and medical school to help them understand their responsibility and to act on it." Dr Gallagher says that means reframing the definition of professionalism to better focus on patient safety. Medical schools need to train students to speak up, and healthcare institutions need to improve their peer review processes. Physicians often hesitate to voice their concerns because they fear that a colleague will be treated too harshly, that they will not get the assistance they need, or that the system will be biased for or against them in some way. To overcome those concerns, transparent, impartial systems that encourage proactive intervention are needed. "If we could communicate how peer review works, physicians will have fewer reservations about coming forward," Dr Gallagher believes. Peer reviewers also need to communicate results, Dr DesRoches says. In today's rapidly changing healthcare environment, physicians "feel under siege," she says. "They're burned out and fatigued, and the perception that reporting an impaired colleague amounts to 'unleashing the hounds' plays into that sense of feeling under siege." "I think we need to be developing and evaluating systems that allow physicians an easy way to report someone, but we also need data around the effectiveness of the programs," she continued. Physicians are evidence-based decision makers, so "that data feedback has to be built into the loop." Source
