Many physicians do not accept responsibility to report incompetent, impaired colleagues

The report from the Mongan Institute for Health Policy at Massachusetts General Hospital (MGH), published in the July 14 Journal of the American Medical Association, also finds that substantial numbers of physicians feel unprepared to report or otherwise deal with impaired or incompetent colleagues.

"Our findings cast serious doubt on the ability of medicine to self-regulate with regard to impaired or incompetent physicians," says Catherine DesRoches, DrPh, of the Mongan Institute, who led the study. "Since physicians themselves are the primary mechanism for detecting such colleagues, understanding their beliefs and experiences surrounding this issue is essential. This is clearly an area where the profession of medicine needs to be concerned."

Many states and professional organizations -- including the American Medical Association -- require physicians and other health professionals to report colleagues whose ability to practice medicine is impaired. In spite of increased attention to and concern about medical errors in professional circles and in the media, studies have shown that fewer impaired physicians are being reported than would be expected. The current study was designed to examine physicians' beliefs about the obligation to report, their preparedness to report, and their experiences with and actions taken when confronted with impaired or incompetent colleagues.

A larger survey of medical professionalism taken in 2009 included a group of questions focused on beliefs and behaviors regarding impaired or incompetent colleagues. The survey was sent to 3,500 physicians -- 500 each in internal medicine, family practice, pediatrics, cardiology, general surgery, psychiatry and anesthesia. Participants were asked to rate their agreement that "physicians should report all instances of significantly impaired or incompetent colleagues." They also were asked how prepared they felt to deal with such a colleague and whether they had direct knowledge of an impaired or incompetent colleague in the past three years. Those with such knowledge were asked whether they had reported the most recent incident and also if, within that three-year period, particular reasons were associated with a failure to report.

Almost 1,900 surveys were returned, and only 64 percent of the respondents agreed that physicians should always report impaired or incompetent colleagues. About 70 percent of respondents indicated feeling prepared to deal with an impaired colleague, and 64 percent felt prepared to deal with an incompetent colleague in their practice. Pediatricians were the least likely to report feeling prepared to deal with impaired or incompetent colleagues, while psychiatrists and anesthesiologists felt most prepared. Direct, personal knowledge of an impaired or incompetent physician during the past three years was indicated by 17 percent of respondents, but only 67 percent of those with such knowledge actually had reported the colleague.

"This study underscores the need for the medical profession to educate its members on their reporting obligations to ensure safe and competent care to patients," says John A. Fromson, MD, associate director of Postgraduate Medical Education, MGH Psychiatry, and a co-author of the report. "Those obligations include referring colleagues to physician health programs that can guide and monitor their recovery from substance use and mental disorders."

The most frequently cited reason for not reporting was the expectation that someone else would report, indicated by 19 percent, followed by the belief that nothing would happen because of the report, cited by 15 percent, and a fear of retribution, 12 percent. Among factors associated with not reporting were belonging to one- or two-person practices and being a member of an underrepresented minority or a graduate of a foreign medical school. Whether respondents came from a state with high, medium or low rate of malpractice claims was not associated with failure to report.

"Our results imply that the current system of reporting is functionally inadequate; many physicians are afraid to access it or believe that reporting will not be effective," says Eric G. Campbell, PhD, research director for the Mongan Institute and senior author of the JAMA report. "Improvements to the system need to include helping physicians understand their professional responsibility to report impaired and incompetent colleagues, enhancing protections for reporting physicians and providing confidential feedback about outcomes." Campbell is an associate professor of Medicine, DesRoches an assistant professor, and Fromson an assistant clinical professor at Harvard Medical School.

Additional co-authors of the study -- supported by a grant from the Institute on Medicine as a Profession -- are Sowmya Rao, PhD, Lisa Iezzoni, MD, MSc, and Christine Vogeli, PhD, Mongan Institute for Health Policy at MGH; and Robert J. Birnbaum, MD, PhD, MGH Psychiatry.