Monday, January 23, 2006

Spotting the Bad Ones Early

In my hospital I serve on the committee of the Board that reviews and approves the credentials of physicians and other professional staff. The actual work is done by a group of physicians, the Credentials Committee of the medical staff. We meet with them, oversee their work, raise our own questions, and then act on behalf of the Board. Thus, it was of interest to me to learn that in December of last year the "New England Journal of Medicine" published an article on the behavior of physicians. It seems there is a correlation between misbehavior in medical school and professional misbehavior after physicians are out in practice.

You can read the article on line if you like. In brief, those medical students who were found guilty in medical school of unprofessional behavior were up to three times as likely as physicians to be brought before state medical boards for unprofessional behavior. That might seem so predictable as to be trivially true; but the study, written by faculty members of three medical schools, documents it.

Note that these are not suits filed against doctors. "Anyone can file a suit," as the saying goes, and a suit may represent honest mistakes, uncontrollable circumstances, true acts of God, or greed or fraud on the part patients or attorneys. It is much less common and usually much more serious for a physician to be brought before and disciplined by a state medical board. A physician could be entirely professional and have a series of bad outcomes. At the same time, a sharp clinician can show unprofessional, even criminal, behavior. That can become the stuff of art. Recall the surgeon played by Alec Baldwin in “Malice,” or the organ-stealing Jefferson Institute in Robin Cook’s “Coma.”

I spoke of this to several physicians. All thought the study interesting, but also predictable. One I spoke to said, “Medical schools have focused so much on tests and grades. So, they get very smart people. And there are a lot of really smart people out there who are sociopathic.” Now, I’m not inclined to agree with a blanket condemnation of “smart people.” Sometimes I even like to think I’m one of them. At the same time, I do think there is something about medical training – how we choose who will enter, and how we train those in the process – that can bring out the worst. To enter and attend medical school can require a powerful drive to succeed. For some, the drive, the ambition, can overwhelm emotional maturity and moral sensibility. It is only half in jest that I sometimes celebrate the physician who has come through medical school “and is still a person.” It is a tribute to human resilience, I think, that, really, there are so few physicians who are so troubled.

Now, as one of those who reviews and approves the credentials of physicians, and as chair of the hospital’s Ethics Committee, I find myself wondering whether and how I should incorporate this information. Professional behavior on the part of the physician is important in protecting the patient. And yet, how shall we take this into account? How shall we even learn of it? By the time they come for review, they are past medical school and through residency. They have all graduated, and as the old joke goes, the last person in any class at medical school is still called “Doctor.” We require references, and they could be helpful; but who asks a reference from a person without some expectation the reference will be favorable?

No, the information reflected in the study is of most help to medical schools and state boards. With it perhaps some limits can be set, and schools can catch the worst offenders before they have the opportunity to enter practice. What we can do in our own setting is to listen. We can listen to our patients, both at the bedside and in those customer satisfaction surveys we ask of them. We can listen to the physicians as they review their colleagues, noting those things that concern them. We can listen to our nurses and professional staff, paying attention to their experiences. We can listen and celebrate that great majority of physicians who work conscientiously for their patients and for their profession. And when we encounter that rare physician who can do so much harm, we can act on behalf of patients and profession, and expose the unprofessional behavior. Still, how much better could it be if we could know ahead of time that the clues to this behavior were available long before.

2 comments:

Bill said...

Not an easy thing, is it? Working in the Community Relations department of my local hospital, I see the results of rude, unprofessional physicians.

Yes, you would think that someone wouldn't ask for a letter of recommendation from someone who has told you in advance that it wouldn't be a good idea. Every once in a while it happens, however.

My father once wrote a letter of recommendation for a graduate student he had told not to use him as a reference. I though it was a classic.

He said, "When you get to know Mr. Jones the way I know Mr. Jones, you will esteem him the way I esteem him."

Marshall said...

Bill, I see what you mean. I've also been asked to give references when I felt marginal. I tend to send evaluations, doing my best to accurately show both opportunities and limitations. I can usually do that in a way that I can authentically share with the person. Sometimes, though, it feels like damning with faint praise.

In my small hospital there are really few doctors who have no personality. There are complaints about bedside manner, of course, but not more than one could expect; there will always be some patients who can't be pleased. Over all, though, I'm quite pleased with our staff.

However, I always note the problems that can happen. They make the news, and they aren't good for the institution involved. We have good management, and have been blessed, and so haven't had such a situation, at least in my time.