In the Literature
While most physicians agree with standard principles of professionalism and ethics in medicine, many fail to live up to these same standards in practice, finds a survey of physicians published in Annals of Internal Medicine.In "Professionalism in Medicine: Results of a National Survey of Physicians" (Dec. 4, 2007), Eric G. Campbell, Ph.D., of Massachusetts General Hospital, and colleagues report results from a survey of physicians about attitudes toward certain professional and ethical standards—like those relating to honesty with patients or to management of conflicts of interest—as well as their actual behaviors in practice. As the researchers found, the two did not always match up: while 96 percent of respondents agreed that physicians should report impaired or incompetent colleagues to the authorities, 45 percent who knew of such individuals had failed to make reports on at least one occasion.
The study was funded by the Institute on Medicine as a Profession, founded in 2003 with support from the Open Society Institute. Russell L. Gruen, M.D., Ph.D., a 2002–03 Commonwealth Fund Harkness Fellow in Health Care Policy at the Harvard School of Public Health, now based at the University of Melbourne, coauthored the study.
The researchers surveyed 1,662 physicians in internal medicine, family practice, pediatrics, cardiology, anesthesiology, and general surgery between November 2003 and June 2004. First, the physicians were questioned about their attitudes toward professionalism. The vast majority agreed with statements like "Physicians should minimize disparities in care due to patient race or gender," and "Physicians should be willing to work on quality improvement initiatives." Agreement fell below 80 percent on only one statement—"Physicians should undergo recertification examinations periodically throughout their career," which garnered 77 percent agreement.
The survey found, however, that behaviors were not always consistent with attitudes. Gaps were greatest in the area of self-regulation. Forty-five percent of respondents who knew that a physician was impaired or incompetent did not always report that per-son to the authorities, even though 96 percent said they believed physicians should report all such behavior. Similarly, 93 percent said all medical errors should be reported, but 46 percent of physicians who knew about a medical error did not report it on at least one occasion.
One-quarter of doctors said they would refer a patient to a facility in which he or she had a financial investment without disclosing the investment, even though 96 percent had agreed with a statement that said duty to patients outweighed financial concerns. "Such behavior could be illegal under federal Medicare statutes concerning self-referral," say the authors. "This suggests that physicians may not be adequately aware of the legal restrictions on their behavior."
There were also gaps between physicians' attitudes toward quality improvement and their participation in such activities. However, other factors can play a role in these decisions, note the authors. "[I]t is not a physician's sole responsibility if a policy of the organization in which he or she works limits his or her participation in certain professional behaviors, such as caring for the poor or undergoing competency assessment," they say.
In other domains, attitude and behavior were more closely aligned. Fewer than 1 percent of physicians reported telling a patient something that was untrue, and only 3 percent reported that they had withheld information that a patient or family member should have known. Eleven percent reported breaching patient confidentiality.
There was some level of variation by specialty. For instance, cardiologists, surgeons, and anesthesiologists were significantly more likely to report being prepared to evaluate new clinical information. Surgeons and cardiologists were more likely to have provided care without reimbursement in a setting that serves poor and underserved patients in the past three years, while pediatricians and family practitioners were more likely to currently accept patients on Medicaid, uninsured, or those unable to pay. "This suggests," the authors say, "that the focus of programs encouraging professionalism may need to vary accordingly.""Our findings give reason for both optimism and concern," they conclude. "Professional leaders, private managers, and public officials might find reassurance in the near-universal acceptance of key professional norms. At the same time, however, our findings suggest opportunities for increasing levels of professional conformance to these norms, at least in the selected areas we probed."
Professional Behaviors of Surveyed Physicians, Selected Measures
|Domain||Percentage of Respondents|
|Honesty with patients|
|In the last three years, have you told a patient's family member something about a medical issue that wasn't true?||< 1% answered "Yes"|
|Improving access to care|
|In the last three years, have you provided care, with no anticipation of |
reimbursement, in a setting serving poor and underserved patients?
|< 74% answered "Yes"|
|Improving quality of care|
|In the last three years, have you participated in a formal medical error reduction initiative in your office, clinic, hospital, or other health care setting?||< 53% answered "Yes"|
|Maintaining trust by managing conflicts of interest|
|Scenario: You and your partners have invested in a local imaging facility near your suburban practice. When referring patients for imaging studies, would you: 1) Refer your patients to this facility? 2) Refer your patients to this facility and inform patients of your investment? 3) Refer patients to another facility?||< 24% selected answer 1|
|Fulfilling professional responsibilities, including self-regulation|
|In the last three years, have you had direct personal knowledge of a physician who was impaired or incompetent in your hospital, group, or practice? If yes, how often did you report that physician to a hospital, clinic, professional society, or other relevant authority? (1. Always, 2. Usually, 3. Sometimes, 4. Never)||45% selected answer 2, 3, or 4, indicating that they had not reported at least once|
|Source: Adapted from E. G. Campbell, S. Regan, R. L. Gruen et al., "Professionalism in Medicine: Results of a National Survey of Physicians," Annals of Internal Medicine, Dec. 4, 2007 147(11):795-802.|