Hello everyone - I hope you all enjoyed the session with Paul Hoffman last week. It is amazing how broad a range of ethical issues there are to consider/manage as a healthcare professional - from any vantage point.
I saw this article come over the AP new wire today and it made me thing about Paul's point about inconvenient truths. Here is a link to the article and a small piece of the intro. What do you think is driving this behavior by physicians and what would it take to compell have a more ethically appealing approach?
Kim
http://news.yahoo.com/s/nm/usa_doctors_incompetence_dc
Nearly half of all U.S. doctors fail to report incompetent or unethical colleagues, even though they agree that such mistakes should be reported, researchers said on Monday.
They found that 46 percent of physicians surveyed admitted they knew of a serious medical error that had been made but did not tell authorities about it.
"There is a measurable disconnect between what physicians say they think is the right thing to do and what they actually do," said Eric Campbell of Massachusetts General Hospital and Harvard Medical School in Boston, who led the survey.
Doctors are also surprisingly willing to order unnecessary -- and often expensive -- tests such as magnetic resonance imaging or MRI scans. Just 25 percent said they were looking out to ensure they did not unintentionally treat someone differently because of their sex or race, the survey found.
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6 comments:
I came across this article too, and was struck by the contrast between what physicians in this study said they should do, versus what they report that they actually do. It is clear that they know what is appropriate. One question this raises for me is what systems are in place for remediation? A lack of appropriate systems, combined with a fear of reporting, could promote a culture of under- reporting. I'm interested to know what happens to doctors who report errors (logistically & culturally).
The other phenomenon reported in this article was recommending and ordering unnecessary procedures. This reminds me of the previous article about physician pharma reps: the for-profit nature of our medical system creates misaligned incentives, and quality of care is not always #1 for all players. Even if doctors do their absolute best, they will find themselves pulled between competing interests, and may feel that they have less choice than we think they do. I would be interested to hear more about this, too.
I agree with Julia's comment about how the incentives that are in place can encourage all players in the health care sector to act outside the patient's interest. This seems like another call for Pay for Performance and other such initiatives that incentivize physicians to provide quality care.
I'm also interested to hear what our physicians in the group think about all the media attention on medical errors...
Thanks Julia and Katie for your thoughtful posts. I will try to respond to both—briefly there is a huge movement by physicians to get pharmaceutical reps out of the health care field through hospital policy changes and even through proposed legislation. I personally can’t stand them! Check out www.nofreelunch.org to learn more about this topic. It is highly debated, especially in the world of graduate medical education.
It’s an interesting article—I had a slightly adverse reaction to the article because it, like many other articles about medical errors, sensationalize and present the story in a superficial manner. The big question is why there is such a chasm between opinion and actually practice. It is a complex issue that ties in many of the themes we study in health policy and management. I personally believe that medical errors absolutely should be shared with the patient and their family. But it is an art in terms of conveying the information. Errors are usually not simple mistakes and are often a result of complicated interactions to provide care for a patient. From a physician perspective, the culture of litigation I think is one of the reasons why not all “errors” are reported. If errors did not adversely affect patients, I think physicians are less likely to report them because of the potential negative consequences of telling the patient outweigh the ethical duty. Moreover, from my experience, when an error is made by any other member of the health care team, such as a nurse or technician, the physician is the one who is asked to go and explain to the patient what happened an apologize for the error. I have been put in this position many times, with allied staff stating that I know the patient best and therefore would be the best person to convey this information. However patients cannot separate “who is to blame” for errors, and often point at physicians even if it was not the physician’s fault. Most people just don’t understand the workings of a hospital. Physicians are often targeted as the root of a variety of problems, from difficult parking, to the rude receptionist, to the inpatient pain medications not administered on time, to a delay in surgical start time, to waiting too long in the ER. In each of these cases, the physician is not the one responsible for these difficulties.
The medical field is an interesting profession because in today’s health care, I feel that physicians are both praised and criticized, both trusted and viewed with a suspicious eye, fully responsible for patients while also only being partly responsible. People want physicians to act altruistically at all times while working in a market-driven, consumer-focused, highly litigated, fragmented system. One interesting line in the article is the statement “While 93 percent of doctors said they should provide care regardless of a patient's ability to pay, only 69 percent actually accepted uninsured patients who cannot pay”. Most people still choose to become a physician because of altruistic reasons. The flip side of this line in the article is to look at the number of physicians who care for patients who are uninsured/Medicaid. I recently met with a medical director for one of my informational interviews and the reason he went in to a management position was because his pediatric practice went out of business because he was committed to practicing in an underserved area where the reimbursements simply could not offset the costs of running a practice.
Yes, doctors do not always practice what they preached ethically. I think it’s partly a reflection of the system doctors are forced to work in, and not necessarily a reflection that doctors are unethical individuals, but rather ethical, altruistic people who are trying to work in an environment that is constantly pulling them away from these principles.
When it comes to under-reporting medical errors made by collegues, I think this is partly driven by professional respect and partly driven by the fact that in some areas medicine is still more of an art rather than a science. While certainly standards of care lend some clarity to the "right" decision, there is still quite a bit of room for professional opinion to enter the equation. In addition, so many factors go into making a medical decision, that collegues may feel they do not have all of the information necessisary to evaluate the correctness of a decision. I guess this may sound like justification for unacceptable behavior...I think there is also a feeling of territory that goes along with medicine; as in don't interfere with MY patients unless I ask for your help and I'll do the same for you which could be driving this phenomenom. It seems like standards of care and review should go a long way to alleviate this problem, but there always needs to be room for professional judgement and extenuating circumstances as well...
Thanks Rita for your thoughts, as a doctor. It sounds like what often happens is that doctors are held responsible for everything that happens in a clinic or hospital because they are the visible face of medicine. It sets up a dynamic where doctors are kind of "middle-men", who are blamed for situations that are often beyond their control such as systems issues simply because of their visibility, while in fact the people who should be held accountable are unreachable (board of directors, ceo, pharma and technology companies, insurance industry, etc).
This reminds me of some theory I heard while doing anti-racism work. A quick summary is that there are major players who stand to benefit from the continuance of oppression (usually multi-billion dollar industries like gun manufacturers, prison developers, security companies, credit cards and predatory lenders, etc.), but they keep themselves fairly invisible, so that anti-racism and anti-oppression activists get confused about where power really lies, and often end up blaming the middle-agents who are trying to fix things, such as teachers, social workers, local political leaders, each other, etc. Those who invest billions of dollars in maintaining the status quo are often beyond reproach because they are hidden and/or inaccessible.
I'd love other people's thoughts on this.
I thought the finding that Rita highlighted, "While 93 percent of doctors said they should provide care regardless of a patient's ability to pay, only 69 percent actually accepted uninsured patients who cannot pay," was also very interesting, since there could be many different factors and pressures contributing to this. This seems to be another area where geographic disparities can really be an issue -- I know in some parts of Massachusetts for example, it's extremely difficult to find a provider who will take Medicaid -- it seems that in some situations it's because there's no one who can bear the cost, and in others, it's preference. I agree that the article doesn't get deep enough into the reasons why to avoid unfairly blaming physicians or portraying them as unethical. But given all the media coverage of conflicts of interest in medicine, I can see why the reporter would take this angle -- it just fits too neatly into that box.
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