Posted on January 31, 2019 at 9:00 AM
Through special arrangement with Taylor & Francis, AJOB posts its editorials on bioethics.net. This essay and the articles it references are also available on the publisher website.
by Ross E. McKinney
These are trying times in regard to public trust. In an era when the Catholic Church chose to protect pedophilic priests rather than young congregants, many traditionally trusted figures in our society (doctors, presidents, police) have faced increased scrutiny. As DuBois and colleagues demonstrate in their article, there are numerous cases involving physicians where close scrutiny appears to be justified. Physicians are given access to people’s lives and vulnerabilities, and there is an expectation that concomitant with that access the physician will hold their patients’ best interests first. That trust is violated when instead the physician acts in a self-interested way to obtain sex, drugs, or money. What can be done to prevent, or at least limit, serious ethical violations by physicians?
As a logistical model, schools of medicine and residency training programs would appear to be situated where they would have an initial opportunity to make a difference. It would seem logical that schools of medicine should teach ethics, screen for students with unprofessional behaviors, and consider not giving diplomas to students who have serious behavioral problems. The same should hold for hospitals and residencies. In 2005, Papadakis and colleagues reported that individuals from three medical schools who were subsequently disciplined by a state medical board had a threefold higher odds ratio for reports of unprofessional behavior while they were students than a control group that wasn’t cited or disciplined. The problem with the Papadakis data is that it’s in the wrong direction, retrospectively but not prospectively valid. We want to know which students are going to demonstrate unprofessional behavior after they graduate based on their work as students, and while it seems logical that unprofessional students may become unethical practitioners, the crystal ball is beyond murky. In the Papadakis study, 19.2% of the control physicians (physicians who were not disciplined by their state medical boards) displayed unprofessional behavior while in medical school, versus 39.1% of the disciplined physicians. We do not have tools to identify errant individuals while they are still students with an adequate degree of specificity.
Given that the problem of physician bad behavior seems to be real, and that as DuBois and colleagues, point out, the common core seems to be physicians acting in a self-interested way, how should we ameliorate this problem? There are basically three strategies: identification (at all levels, training through practice), prevention, and rectification.
In terms of identification, I’ve already noted the challenge of picking out future perpetrators while students are in training. Additionally, according to DuBois, 32% of the offenders did not graduate from a U.S. medical school, so the standards of those schools may vary from the norms of U.S. schools. The Papadakis article makes it clear that U.S. graduates may also be a problem, since it studied graduates of three medical schools who were disciplined by state medical boards but provided evidence that identification in a prospective way will be difficult. Because of these issues, and the fact that offenders were more likely to be over 40 years old, sorting out the problem physicians may need to come after the training period. Late identification becomes a challenge, given that most of the offenders are in nonacademic settings with “oversight problems.” And because of the infrequency of offenders in the population of physicians, finding the signal amid the noise is always going to be an issue.
Strategies to prevent bad physician behavior could take the form of training and instruction on norms or could take the form of removal from the community of physicians. The underlying pathology in most cases is probably a personality disorder, perhaps characterological, and that type of pathology makes the likelihood that training will work to prevent the errant behavior relatively improbable. The best training is often experience, and the fact that many of the cases involved repeat offenders affirms a characterological diagnosis: Even after having been caught, the offenders engage in the same behavior again. There is a fundamental lack of insight, or if there is insight, an inability to control the behavior, and those two problems mean that training focused on awareness is unlikely to work. Even fear of punishment may not be sufficient.
In contrast to attempting to teach the future perpetrators good behavior, another possibility is community training. Medical schools and residencies could teach their trainees how to identify physician misbehavior so that they can notify supervisory authorities that there is a problem. The general types of self-interested behaviors—seeking drugs, sex, or money—should be evident to peers. Unfortunately, too often physicians and support staff identify these problems but do not take the appropriate step of alerting institutions or senior officials. In medicine, a culture shift to putting patients first over peers is necessary but surprisingly difficult.
One group of individuals who could logically help identify and deal with problem physicians is the institutional supervisory hierarchy—department chairs, hospital staff managers, and the like. Interestingly, a high proportion of the physicians in DuBois’s study are in unsupervised positions. Did they choose those positions because of concerns that they might be caught, because they prefer to follow their impulses regardless of how self-interested or problematic, or are they socially maladapted and self-isolating? Regardless, it does add to the challenge of identifying individuals after their training period.
What are we to do with the problem physicians once they’ve been identified? This is a challenge state medical boards deal with constantly. Can the physicians be reformed, or should their licenses just be removed or withdrawn? DuBois’s data suggests that reformation may be problematic. As the article notes, nearly all cases involved repeated instances (97%) of intentional wrongdoing (99%). In 70%, the wrongdoing persisted 2 years or more, and in 33%, 5 years or more. The characterological nature of the behaviors makes it unlikely reform will work. At some level, individuals have to want to change to make reform work, and if they do want to change, they have to be able manage their impulses. Nothing in the DuBois article makes good outcomes seem likely. Obviously, the cases need to be considered individually, and an ability to control substance abuse might rectify other behavioral problem, but it seems unlikely that physicians who exploit patients for sex can be reformed, or that society will be willing to take that chance. Doctors who are willing to do unnecessary procedures for money probably should not be allowed to practice, since they’ve demonstrated that they value money over their patients’ lives.
Is there any low-hanging fruit that could be plucked to ameliorate this persistent problem? At the medical school level, schools should monitor for evidence of problems with professionalism, particularly with regard to lack of self-awareness, substance abuse issues, and irresponsibility. Schools should be willing to fail students, which is often not the case since too much attention is given to accumulated debt on the part of the students and school rankings and graduation rates for the schools. The same willingness to dismiss problem residents should also be present at the residency level. Schools should teach trainees how as community members they can respond if they see inappropriate behavior. And administrators should create a culture that empowers other physicians and staff to raise concerns when there are physicians with noticeable problems. However, no one should be fooled into thinking this will be an easy problem to solve, as DuBois and colleagues make all too clear.