There’s an old nurses’ joke that goes like this:
- Q: What do you call the medical student who finishes dead last in every one of his classes all through med school?
- A: “Doctor”
But what happens when these docs are eventually let loose upon the unsuspecting public as professionals with the letters MD after their names? Who keeps an eye on substandard doctors?
The alarming results of a study published in the Journal of the American Medical Association reveal that, although most physicians believe that their medical colleagues who are “significantly impaired or incompetent to practice medicine” should be reported, the reality is that a disturbing number actually chose instead to sit by and do nothing even when they admitted they had “direct personal knowledge” of such incompetence.
Last year, researchers at Massachusetts General Hospital in Boston surveyed almost 3,000 physicians working in anaesthesiology, cardiology, family practice, general surgery, internal medicine, pediatrics, and psychiatry. Here’s what they found:
- 64% of surveyed physicians agreed with the professional commitment to report physicians who are significantly impaired or otherwise incompetent to practice.
- 69% reported being prepared to effectively deal with impaired colleagues in their medical practice
- 17% reported having direct personal knowledge of a physician colleague who was incompetent to practice medicine in their hospital, group, or practice. Of those with this knowledge, only 67% reported this colleague to the relevant authorities.
- physicians who are under-represented minorities and graduates of foreign medical schools were less likely than their counterparts to report, and physicians working in hospitals or medical schoolswere most likely to report.
By now, you may be asking yourself: if 64% of physicians believed that it is their “professional commitment to report physicians who are significantly impaired or otherwise incompetent to practice”, why didn’t they take action when they did have “direct knowledge”?
The Boston study found that the most frequently cited reasons for taking no action were:
- the belief that someone else was taking care of the problem (19%)
- the belief that nothing would happen even if they did report (15%)
- fear of retribution (12%).
There are a number of alarming results in this study: first of course is that frightening admission that almost one third of docs who have “direct personal knowledge” of significant impairment or incompetence among their fellow docs do not report these dangerous situations.
But what also caught my eye was the very first finding reported, that 64% of surveyed physicians agreed with the professional commitment to report physicians who are significantly impaired or otherwise incompetent to practice.
This sounds like pretty good news until you realize what it really means: that over one third of physicians do not agree with the need to report colleagues who are significantly impaired by drugs or alcohol, or incompetent to practice medicine.
If this is indeed true, why isn’t that the news headline?
A physician who knowingly protects a colleague who is unfit to safely treat patients should be considered equally incompetent.
Read more about this study called Physicians’ Perceptions, Preparedness for Reporting, and Experiences Related to Impaired and Incompetent Colleagues published in the Journal of the American Medical Association. (July 14 2010 JAMA. 2010;304(2):187-193. doi:10.1001/jama.2010.921)
The Ethical Nag 
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I too find this alarming, but I am not even slightly surprised by the findings of this Boston study. I’ve been retired from nursing for several years, but during my long career as a ward nurse you would not believe what I have observed with my own eyes. Docs live in a closed “old boys club” that closes rank around any problem member and does not encourage any disloyalty or squealing from its private club members. And so resolution is often left up to patients who have been hurt by these incompetent or impaired docs, and by then it’s almost impossible to lodge formal complaints that will actually be followed up by hospital authorities which is why pts are forced to file lawsuits or criminal charges in many cases. I don’t think the problem has improved in more recent times,as this study suggests. But I do believe that this problem is even more widespread than this study shows – and don’t forget that study questions relied on doctors’ self-disclosure: “Would you turn in an impaired colleague?” “Oh, definitely, I sure would!” RIGHT!!! I question the stats here – they are likely far worse in reality.
Frightening info, but understandable given this profession’s belief in their own infallibility. Thanks for this update.
“…17% reported having direct personal knowledge of a physician colleague who was incompetent to practice medicine in their hospital, group, or practice. Of those with this knowledge, only 67% reported this colleague to the relevant authorities..”
THIS MEANS THAT ONE THIRD STOOD BY AND DID ABSOLUTELY NOTHING TO PROTECT PATIENTS! THEY ARE AS GUILTY OF MALPRACTICE AS THE IMPAIRED/INCOMPETENT!
Many state medical boards punish physicians severely simply for getting sick or injured (they treat all different types of illness as “potentially impairing”), and in turn treat all types of “impairment” as if they were criminal offenses.
Most physicians prefer to keep their personal health problems private for this very reason. Everybody gets sick from time to time. Medicine is the only profession I know of where its members are required to either hide this fact (including working while sick and/or avoiding appropriate treatment) or risk public ridicule (public allegations of “impairment”) and permanent loss of livelihood (formal disciplinary action and license suspension/revocation).
Guess what? Doctors are people too!!! We get colds and flu and fevers and arthritis and insomnia and depression and cancer and kidney stones and morning sickness and diabetes and heart attacks and ulcers and athlete’s foot and all the pain and suffering and frailty that our patients do. If I were to report every potentially impairing physician illness to my medical board for “investigation”, nearly every physician I know would be rendered unable to practice medicine for months to years while under investigation, and quite a great number would be found “guilty” of having an illness that could potentially impair their ability to practice medicine (hey, have YOU ever tried to be sympathetic towards everybody else’s little problems when your feet really REALLY itch?!)
If I become aware that a colleague is struggling because of personal illness, I try to make sure that they get appropriate HELP (not an inappropriate referral to a criminal justice system like a state medical board). Most sick physicians do get the help they need, they do get better, and they are still able to practice medicine with reasonable skill and safety.
Illness does not equal impairment, nor does impairment from illness equal incompetence or misconduct — especially in the negligent or criminal sense. Punishing doctors who get sick serves mostly to discourage sick doctors from getting the help they need to become well.
Thanks for your perspective, Dr. Haney. This particular study, however, specifically addresses docs who are “significantly impaired by drugs or alcohol, or otherwise incompetent to practice” – not those with really really itchy feet. Any physician (or airline pilot, or police officer, or bus driver) whose illness, incompetence or impairment is significant enough to be obvious to one’s peers should be accountable for addressing personal health and competence issues. But if they’re not, somebody needs to step up and protect the innocent whose health and safety is at stake.
Dr Haney,
If you’re reading this——I respectfully submit that perhaps you didn’t understand the OP.
I’d like to repeat that the issue is not “Everybody gets sick from time to time.”
Of course they do. Whether a doctor should be working while incubating a flu (and seeing people who are already sick with something) is also not the issue, although—– should he/she?
It’s about doctors who are actually drunk or using recreational drugs while working. It happens, we both know.
It’s about doctors who are incompetent and do not recognize a serious condition when the patient has been in his/her office several times. That also happens, we both know.
And yes, they DO have to (should have to) respond to their patients even when their feet are really really itchy! Or go home before the ‘itch’ is so bad that they can’t take care of their patients.
Again, though—– the issue isn’t ‘itchy feet or morning sickness or insomnia’. It’s INCOMPETENCE no matter the reason.
Why a doctor is incompetent doesn’t matter to a patient that might die because of it.
We had a family member die due to incompetent medical care and no one in my family will discuss it. They would rather act like there is something wrong with me.
In my small town emergency department practice a few years ago, out of 8 doctors covering the ER 24 hours a day 7 days a week, we had one doctor with diabetes and early renal failure, one in early pregnancy with morning sickness, one with bipolar disorder (in treatment), one with grief from the recent death of her husband, one with severe back pain, one recovering from ankle surgery, one recovering from meningitis.
It was not an option for us to close down the emergency department. There are not enough doctors in this country to provide emergency care (or primary care, or specialty care) without accommodating doctors with illness and/or disability.
Of course it’s not OK to come to work when drunk or stoned. But is it OK for a physician to come to work when sleep-deprived, hungry, depressed, stressed out, or in pain? If your answer is no, you are deluding yourself about the fact that doctors are people too. We suffer with all of the same medical and personal problems that our patients do.
Hello again, Dr. H. I agree that docs, like all the rest of us, come to work when sleep-deprived, hungry, depressed, etc. But once more, this study focused on physicians who were “significantly impaired or otherwise incompetent to practice medicine” – not just tired or hungry.
What if the ER doc who sent me home in mid-heart attack – “You’re in the right demographic for GERD!” (despite clear textbook MI symptoms like central chest pain, nausea, sweating and pain down my left arm) was drunk or stoned or simply no longer competent to practice medicine? What’s the price that patients are paying day in and day out because of examples like this? We already know the catastrophic burden of medical error that patients are bearing – what in your opinion would be the solution, other than turning a blind eye to incompetence?
“There’s an old nurses’ joke that goes like this:
Q: What do you call the medical student who finishes dead last in every one of his classes all through med school?
A: “Doctor” “
============================
This is so unfair.
There are 2 doctors I know very well who were maybe not last of their classes but who didn’t perform very well at examinations.
It turns out that they are both highly appreciated by their peers and patients as outstanding practicionners.
Which means examinations are not the gold standard.
Ucelli, medical examinations are indeed important, but are only one predictor of a physician’s competence. Whenever health care professionals’ interpersonal skills are criticized, for example, the standard defense is that they are, at least, very good diagnosticians/surgeons/experts/technicians. But I have always maintained that expecting them to be both well-trained (hence the exam significance) AND demonstrate social skills is no more unrealistic than it is in any other profession where consumers expect both competence and personality. Having just one or the other is simply no longer acceptable.
The focus of this article, however, is on the doctor who is “significantly impaired or incompetent” (and those other docs who decide to say nothing even when they are well aware of such colleagues, even though patient safety is at risk).