Survey Shows Doctors’ Individual Behavior at Odds With Their Own Ethical Standards for the Profession

WASHINGTON, D.C. -- The first national survey to broadly examine attitudes and behaviors related to medical professionalism finds that U.S. physicians overwhelmingly believe that incompetence and mistakes among peers should be reported.  However, when face-to-face with these problems, nearly one-half fail to do just that, which can have harmful and even fatal consequences. 

A survey of more than 1,600 physicians published in the Dec. 4 issue of the Annals of Internal Medicine shows that 45 percent of doctors with direct knowledge of impaired or incompetent colleagues in their practice did not always report them.  Forty-six percent of physicians who knew of a serious medical error did not report it to authorities at least once, say findings from the Institute on Medicine as a Profession’s (IMAP) Survey on Medical Professionalism. IMAP, a New York-based organization affiliated with Columbia University that promotes medical professionalism, supported the research and an accompanying Chartbook with more detailed findings.

“There is a measurable disconnect between what physicians say they think is the right thing to do and what they actually do,” says lead author Eric Campbell, PhD, associate professor at Massachusetts General Hospital’s Institute for Health Policy and Harvard Medical School. “This raises serious questions about the ability of the medical profession to regulate itself,” he adds.

Besides the disconnect between physicians’ support for reporting medical errors and the reality that nearly one-half do not do what they believe is right for the profession, the authors reported other areas where individual physician behavior is at odds with what they believe is best for patients and the profession, including:

 -- Ordering unnecessary medical tests

 -- Managing conflict of interest

 -- Informing patients of conflict of interest 

Campbell and Institute co-authors David Blumenthal, MD, Susan Regan, PhD, and Timothy Ferris, MD, conducted the study with researchers at Yale University’s School of Public Health and the University of Melbourne’s Center for Medical Research in Australia. They surveyed 1,662 physicians from six specialties (cardiology, anesthesiology, family practice, surgery, internal medicine, and pediatrics) between November 2003 and June 2004 to measure key domains of medical professionalism endorsed by national and international medical groups.  They sought to better understand attitudes toward professional norms, the extent to which physicians conform to those norms in their practice, and the factors that may influence professional behaviors.  

The survey looked at three main areas of professional norms: competence, self regulation, and moral attributes, using standards developed by the American Board of Internal Medicine and other groups under the 2002 Charter on Professionalism. It also gauged the extent to which specialty focus, practice location, and reimbursement factor into professional behaviors. Researchers examined such areas as honesty with patients, improving access to care, maintaining professional competency, protecting patient confidentiality, fulfilling professional responsibilities, and improving quality of care. 

In many areas of practice, the study found large gaps between what physicians believe and what they do in practice.

Although physicians say they don’t want to waste scarce medical resources, 36 percent said they would willingly order unneeded magnetic resonance imaging for back pain not because it was necessary but because the patient requested it.

Nearly all (98 percent) physicians believe in minimizing disparities in care due to a patient’s race or gender. However, only 25 percent said that they even look for that gap in their own practice.

Although 96 percent of physicians said they would put a patient’s welfare above their own financial interest, a large majority of physicians also said they would refer patients to an imaging facility with which they had a financial connection.  In addition, a quarter of physicians admitted that they would inform their patients of this potential conflict.

Between 93-96 percent of physicians said they believe they should report all instances of significant incompetence or medical errors that they observe to the proper authorities, yet nearly half did not do it.  A large majority of physicians (85 percent) believe that they should disclose significant medical errors to affected patients or their advocates.

Most physicians (93 percent) believe they should provide necessary care regardless of a patient’s ability to pay. However, only 69 percent are currently accepting uninsured patients in that situation.

Similar gaps were found when it came to attitudes toward professional competency.

More than three quarters (77 percent) of physicians believe they should undergo recertification examinations periodically but only 33 percent have undergone a competency assessment by a provider organization or health plan.

Nearly all physicians believe they should participate in peer evaluations of the quality of care provided by colleagues and should be willing to work on quality improvement projects. But only a little more than half have participated in a formal medical error reduction initiative or have reviewed other physicians’ medical records for quality improvement reasons.

The survey showed that professional behaviors were strongly influenced by practice setting.  For example: 

-- Physicians practicing in staff-model HMOs were least likely to have provided care without expectation of reimbursement in settings serving poor and underserved patients.

-- Solo practice physicians were least likely to have participated in a formal medical error reduction program or to have been involved in a quality improvement effort.  

“The good news from this survey is that physicians do not need to be convinced about the validity of professionalism standards.  They clearly value them,” says Institute on Medicine as a Profession President David Rothman, PhD. “The challenge facing the profession and the groups that regulate physicians is to find ways to change behavior and get doctors to conform to those standards before the public sector steps in to do it for them.” 

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