The Impaired and/or Incompetent Colleague

Out today, in JAMA, study results that one editorialist says "constitute a frontal assault on a basic premise of medical professionalism." The issue is the self-policing function that is allowed the medical profession, and the degree to which this function is ignored.

Physicians' Perceptions, Preparedness for Reporting, and Experiences Related to Impaired and Incompetent Colleagues

Catherine M. DesRoches, DrPH; Sowmya R. Rao, PhD; John A. Fromson, MD; Robert J. Birnbaum, MD, PhD; Lisa Iezzoni, MD, MSc; Christine Vogeli, PhD; Eric G. Campbell, PhD

JAMA. 2010;304(2):187-193. doi:10.1001/jama.2010.921

Context Peer monitoring and reporting are the primary mechanisms for identifying physicians who are impaired or otherwise incompetent to practice, but data suggest that the rate of such reporting is lower than it should be.

Objective To understand physicians' beliefs, preparedness, and actual experiences related to colleagues who are impaired or incompetent to practice medicine.

Design, Setting, and Participants Nationally representative survey of 2938 eligible physicians practicing in the United States in 2009 in anesthesiology, cardiology, family practice, general surgery, internal medicine, pediatrics, and psychiatry. Overall, 1891 physicians (64.4%) responded.

Main Outcome Measures Beliefs about and preparedness for reporting and experiences with colleagues who practice medicine while impaired or who are incompetent in their medical practice.

Results Sixty-four percent (n = 1120) of surveyed physicians agreed with the professional commitment to report physicians who are significantly impaired or otherwise incompetent to practice. Nonetheless, only 69% (n = 1208) of physicians reported being prepared to effectively deal with impaired colleagues in their medical practice, and 64% (n = 1126) reported being so prepared to deal with incompetent colleagues. Seventeen percent (n = 309) of physicians had direct personal knowledge of a physician colleague who was incompetent to practice medicine in their hospital, group, or practice. Of those with this knowledge, 67% (n = 204) reported this colleague to the relevant authority. Underrepresented minorities and graduates of non-US medical schools were less likely than their counterparts to report, and physicians working in hospitals or medical schools were most likely to report. The most frequently cited reason for taking no action was the belief that someone else was taking care of the problem (19% [n = 58]), followed by the belief that nothing would happen as a result of the report (15% [n = 46]) and fear of retribution (12% [n = 36]).

Conclusion Overall, physicians support the professional commitment to report all instances of impaired or incompetent colleagues in their medical practice to a relevant authority; however, when faced with these situations, many do not report.

Author Affiliations: Mongan Institute for Health Policy (Drs DesRoches, Rao, Iezzoni, Vogeli, and Campbell); Biostatistics Center (Dr Rao); and Department of Psychiatry (Drs Fromson and Birnbaum), Massachusetts General Hospital, Boston.

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A slightly more fleshed-out summation of the JAMA article, from PhysOrg:

"Many states have mandatory reporting statutes, requiring physicians and other health care professionals to report to appropriate authorities those physicians whose ability to practice medicine is impaired by alcohol or drug use or by physical or mental illness," the authors write. But data suggest that the rate of reporting by physicians is far lower than it should be, given the estimated numbers of physicians who become impaired or who are otherwise incompetent to practice at some point in their careers, according to background information in the article.

Catherine M. DesRoches, Dr.P.H., of Massachusetts General Hospital, Boston, and colleagues conducted a study to assess physicians' beliefs, preparedness, and actual experiences related to colleagues who are impaired or incompetent to practice medicine. Data for the study was derived from a nationally representative survey of 2,938 eligible physicians practicing in the United States in 2009 in anesthesiology, cardiology, family practice, general surgery, internal medicine, pediatrics, and psychiatry. Overall, 1,891 physicians (64.4 percent) responded. Physicians were questioned regarding their beliefs about and preparedness for reporting and experiences with colleagues who practice medicine while impaired or who are incompetent in their medical practice.

Among the findings of the survey, 64 percent (n = 1,120) of surveyed physicians agreed with the professional commitment to report physicians who are significantly impaired or otherwise incompetent to practice; overall, 69 percent (n = 1,208) of physicians said they were very or somewhat prepared to deal with impaired colleagues; 64 percent (n = 1,126) of physicians overall reported being prepared to deal with colleagues who were incompetent in their medical practice, and preparedness varied by specialty and professional age. Seventeen percent (n = 309) of physicians reported having direct personal knowledge of an impaired or incompetent physician colleague in their hospital, group, or practice in the last 3 years, and 67 percent of these physicians (n = 204) reported that individual to a hospital, clinic, professional society, or other relevant authority.

According to the researchers, underrepresented minority physicians were significantly less likely than other physicians to report, as were international medical graduates compared with graduates of U.S. medical schools. Physicians working in hospitals or medical schools were more likely to report than physicians working in small practices. The most frequently cited reasons for not reporting an impaired or incompetent colleague included the belief that someone else was taking care of the problem; the belief that nothing would happen as a result of the report; fear of retribution; the belief that reporting was not their responsibility; or that the physician would be excessively punished.

"These national data regarding physicians' beliefs, preparedness, and actual experiences related to impaired and incompetent colleagues raise important questions about the ability of medicine to self-regulate. More than one-third of physicians do not completely support the fundamental belief that physicians should report colleagues who are impaired or incompetent in their medical practice. This finding is troubling, because peer monitoring and reporting are the prime mechanisms for identifying physicians whose knowledge, skills, or attitudes are compromised," the authors write.

The researchers offer several suggestions for improving physician reporting systems, including making external regulation stronger; designing and maintaining reporting systems to protect the confidentiality of the reporting physicians; and to provide physician reporters with confidential feedback about the outcomes of any actions taken based on the report to address the concern that nothing will happen as a result of the report.

"All health care professionals, from administrative leaders to those providing clinical care, must understand the urgency of preventing impaired or incompetent colleagues from injuring patients and the need to help these physicians confront and resolve their problems. The system of reporting must facilitate, rather than impede, this process. Reliance on the current process results in patients being exposed to unacceptable levels of risk and impaired and incompetent physicians possibly not receiving the help they need," the authors conclude.

I will keep my eye open for discussions of the study in the medical blogosphere.