Doctors Who Know Better—But Do the Wrong Thing

On Health Care Renewal , Dr. Roy Poses reports on a disturbing new study just published in The Annals of Internal Medicine contrasting physicians’ attitudes toward professional norms with their self reports of whether they acted in conformity with these norms.

Poses does an excellent job of summarizing, so I’m re-posting his piece in full below:

“In brief, the authors developed a survey which asked physicians whether they agreed with various professional norms organized according to the 2002 ABIM/ ACP/ ESIM Physician Charter. They also asked them about whether they acted in conformity with these principles in terms of their recent actions, or in responses to scenarios. Physicians surveyed were primary care practitioners (family medicine, general internal medicine, and pediatrics), cardiologists, anesthesiologists, and general surgeons. The overall response rate was 52%.

“In general, large majorities of physicians agreed with the ethical norms. How often they reported acting in agreement with these norms varied. In particular, nearly all physicians reported treating patients honestly (less than 1% reported telling a patient’s family member something untrue in the last 3 years, 3% reported withholding information from a patient or a family member.) However, although 96% agreed that "physicians should put the patient’s welfare above the physician’s financial interests," 24% would refer a patient to an imaging facility in which the physician was an investor, without revealing this conflict of interest.

“Some commentators suggested that external pressures may prevent
physicians living up to the standards they themselves have endorsed.
For example, physicians interviewed in a Washington Post article
suggested that the current emphasis on patient satisfaction may
conflict with the physician’s ethical obligation to avoid wasting
resources when a patient demands an unnecessary but not clearly harmful
test. The Congressional Quarterly reported
quoted the CEO of the Federation of State Medical Boards saying that
physicians "were penned in by the American the health care system,
fighting giant bureaucracies while fearing legal action if they make a
mistake."

“However, there was not much more discussion of the sorts of external
pressures that might push physicians to forsake their values. Yet
readers of Health Care Renewal might be able to come up with more
examples.

“For example, consider the pressures on young medical school faculty,
who are under tremendous pressure from their academic leaders to become
"taxpayers," i.e., [“rainmakers”] who bring in more money from external
funding sources than they consume (See this post, in which the Dean of a prominent medical school ranked such "taxpayers" above all other faculty.)

“Since government and foundation research support is tight, this leads
many faculty to seek research support from pharmaceutical,
biotechnology, and device companies. Once they get such support, they
may find it hard to turn down offers of consulting positions, speakers’
honoraria, advisory board positions and the like from such companies.
Spurning such positions may cost them their research support. And their
academic superiors often set the example that it is fine to accept such
payments. (See this post
about the prevalence of such financial arrangements among medical
school department chairs.) Under these circumstances, preaching to
young faculty about conflicts of interest seems to be just adding
insult to injury.

“I am most reminded of an article about business ethics we discussed
back in July. The theme was that business students understand ethical
principles, and know what they ethically ought to do. The problem is
that they have trouble actually doing it.

“The new article by Campbell et al also suggests that physicians know
what they ethically ought to do. They thus don’t need new statements of
ethical principles, or more instruction about what they ought to do.

“Instead, physicians need to focus on the discrepancy between what they know they ought to do and what they actually do.

“Some of these discrepancies no doubt arise from their own human failings.

“But absent in most of the current discussion is the enormous pressures
physicians feel, often from leaders of powerful organizations with
strong (usually economic, sometimes political or ideological) vested
interests that may conflict with the admirable values embodied in the
Physician’s Charter.

“It’s easy to say that individual physicians always ought to do the
right thing, regardless of external pressure. Maybe the individual
physicians who feel uncomfortable being pressured into doing the wrong
thing might get better organized to resist this pressure.

“It would be even more helpful if medical and health care leaders could
actually support physicians who want to do the right thing. Given that
many medical and health care leaders have vested interests that push
them in opposite directions, they may not jump at this opportunity.”

11 thoughts on “Doctors Who Know Better—But Do the Wrong Thing

  1. I operated my practice without compromising my integrity for two plus years.
    my reward? I lost my car, my home, and had to file bankruptcy. I was literally homeless twice in two years! Justification for compromising integrity? When I closed 1500 people where left without a physician, maybe I should have compromised in the name of being able to provide at least some care to some people, rather than no care to anybody!

  2. What distinguishes business ethics from medical ethics is that businessmen know they aren’t fooling anybody; their own self-interest comes first and when they cross the line they seldom can blame anyone but themselves. Physicians, on the other hand, are often intoxicated by their own narcissism; if you see yourself as a selfless servant of humanity there is a tendency to put yourself above criticism and be oblivious to crossing ethical lines. Similarly when a narcissist is faced with his failures, he blames others and “the system” rather than himself.

  3. What distinguishes business ethics from medical ethics is that businessmen know they aren’t fooling anybody; their own self-interest comes first and when they cross the line they seldom can blame anyone but themselves. Physicians, on the other hand, are often intoxicated by their own narcissism; if you see yourself as a selfless servant of humanity there is a tendency to put yourself above criticism and be oblivious to crossing ethical lines. Similarly when a narcissist is faced with his failures, he blames others and “the system” rather than himself.

  4. Dr. Stone,
    I could hardly disagree more with “What distinguishes business ethics from medical ethics is that businessmen know they aren’t fooling anybody; their own self-interest comes first and when they cross the line they seldom can blame anyone but themselves. Physicians, on the other hand, are often intoxicated by their own narcissism;” Business ethics often follow along lines of legality, in general business if it is legal it is ethical, in medicine “we” (I assume you have) have sworn to do no harm, sending patients from my office who had poor or no insurance in a community where there was a three month wait to get a doctor would be, by all definitions, doing harm. Business ethics, and medical ethics cannot really be compared. Deciding to “cross the line” to protect yourself such that you can stay in business and thus provide care is a decision that I have seen a multitude of doctors struggle with and lose sleep over day in and day out, hardly reaches the definition of Narcissism. In fact, I submit that if all doctors, accepted all patinets and did only what was necessary and medically proven many would be joining me at the shelter, then no one could get care, where are the ethics now doc.

  5. v.Marc, Dr. Matt and Rick ,
    I’m sure we all agree that there are doctors and there are doctors.
    Some doctors call themselves businessmen (or entreprenuers) and openly scoff at the notion that medicine is a service profession.
    Shortly after Katrina, Dr. David Kessler, who is president of the med school at UCSF gave a speech to the incoming class in which he talked about the doctors who had stayed in the hospitals in New Orleans, with their patients, under dangerous conditions.
    And Kessler said to the incoming students (and here, I’m parphrasing): “If you don’t feel you would do that–there’s the door.”
    I’ve told this story to a number of med students and doctors and about half say something like “that’s ridiculous.” YOu can’t expect a doctor to do something like that. What if I died? Then I couldn’t help other patients in the future.”
    One doctor explained that “puttig the patient’s interest first” means arguing with the insurance company to make sure the patient gets . . .” another round of chemo, or whatever the doctor wants to prescribe, ignoring the fact that said doctor also may be putting his own financial interest first.
    Admittedly, Kessler is setting the bar for putting your patient first pretty high.
    But I also do think that many doctors tell themselves a story about how they are serving the patient’s interests when in fact thay have put themselves in a situation where there is a conflict of interest.
    Many orthopedists do take consulting fees from a device maker and then only use that manufactuer’s device.
    And I can’t agree, Rick, that a corrupt and broken system is forcing them to do that. Unlike many family docs, orthopods make a very good living. They don’t need to take these extra fees.
    The problem is that when doctors put themselves into a conflict of interest situation it is then very toknow for sure, even in your own mind, what your motives are.

  6. Shortly after Katrina, Dr. David Kessler, who is president of the med school at UCSF gave a speech to the incoming class in which he talked about the doctors who had stayed in the hospitals in New Orleans, with their patients, under dangerous conditions.
    And Kessler said to the incoming students (and here, I’m parphrasing): “If you don’t feel you would do that–there’s the door.”
    What a freakin blowhard. Thats a load of ridiculous tripe.

  7. Joe Blow-
    I’m not sure what you are objecting to.
    Do you think the doctors in New Orleans shoudn’t have stayed with their patients?
    Or do you think that Kessler should not have reminded incoming students that, as doctors, they might find themselves in catastrophic situations?
    Unlike most of us, docs really do take a “vow”: this means that they have agreed to put their patients’ needs ahead of their own.

  8. The system is broken; that’s a given and nobody denies it. too many people at the trough.
    No easy answers, unfortunately, and each profit-driven, self-serving part of the broken system will have to be laboriously teased out. Legislation is the answer, but, alas, the sectors will fight anything that drags them away from the financial largess.
    AND, there are other factors which may not be entirely self-serving: 75% of our health care dollar is spent on the last six months of life. Is that the best choice for the best use of our money? In Scotland, for an example, they will not do dialysis on people who are over 0 years of age.
    Our new, technology – miracle that it is – drives costs up. CT scans and MRI’s are so common now, and they aren’t cheap. Of course, we all want the best information and these tests are effective, but they do cost money — money that we used not to spend.

  9. The system is broken; that’s a given and nobody denies it. too many people at the trough.
    No easy answers, unfortunately, and each profit-driven, self-serving part of the broken system will have to be laboriously teased out. Legislation is the answer, but, alas, the sectors will fight anything that drags them away from the financial largess.
    AND, there are other factors which may not be entirely self-serving: 75% of our health care dollar is spent on the last six months of life. Is that the best choice for the best use of our money? In Scotland, for an example, they will not do dialysis on people who are over 0 years of age.
    Our new, technology – miracle that it is – drives costs up. CT scans and MRI’s are so common now, and they aren’t cheap. Of course, we all want the best information and these tests are effective, but they do cost money — money that we used not to spend.

  10. Bill Flowers–
    Welcome, and tanks for commenting. I agree that all of the profit-driven aspects of our health care system will have to be teased out–and that means doing research that tests the efficacy of many profitable but not necessarily useful test, drugs and treatments.
    Do you remember the time when half of all American children had their tonsils removed?
    It turned out that this was unnecessary treatment–and there never was good medical evidence behind it.
    Many doctors suspected as much.
    An older doctor told me that when he was in medical school in the 1950s and the professor asked: “What are the pre-conditions for a tonsillectomy?” one brave student replied: “$1,000 and a pair of tonsils.”
    There are lots of tonsillectomies today–things that we do because we can, because someone makes money if we do and so has been selling the treatment, and selling it hard. But we have no idea whether it does any good.
    Even our high-tech tests are not all that they are cracked up to be. Fairly recent studies have shown that if you autopsy patients who die in the hospital, an incredibly high percentage were mis-diagnosed, and then treated for the wrong thing. Some would have lived if diagnosed correctly.
    And — this is what is mind-blowing–autopsies show the same rate of mistakes as years ago, before we had MRIs, etc. (Dr. Atul Gawande has written about this in the New Yorker.)
    As for end-of-life care, that’s very tricky. The problem is, as one palliative care specialist pointed out to me “We don’t know who is in their final six months of life until they die. And since they are our sickest patients, it makes sense to give them as much care as we think might save them.”
    The key of course is “might save them.” Again, we need more medical reserach doing head to head comparisons showing what happens if you try treatment X instead of treatment Y. Which treatments are effecctive? Or are both futile under certain circumstances?
    But I agree that with some patients–where it is clear that they are 99.99% certain to die quite soon– there is no point in spending hundreds of thousands of dollars to extend life for a few months.
    Here, the problem could be corrected by the FDA. Today, the FDA frequently approves drugs which, at best, extend life by weeks or months. Why? What is the point?
    The only reason to approve them is so that the manufacturer can make money on frightened people who are dying and despereate to hang on for a few weeks. (We might better spend the money giving those patients palliative care that would calm them.)
    Often, it isn’t the patient, but rather guilt-ridden relatives who urge doctors to “do everything–just so he can be with us for a few more weeks.”
    Often these products that add a few weeks could be valuable in clinical reaserch (i.e. randomized clinical trials) so that researchers can learn more about how they work, and eventually, develop a better, more effective product.
    But I see no reason to sell these products for a profit on the open market.
    Finally, I agree about thinking twice before doing organ transplants and other very aggressive very expensive procedures on elderly people.
    Medical ethicists talk about “late innings”–the theory is that if people have had a long life, it doesn’t make sense to pour money into treatment during the final innings when that money might be used to spare children who haven’t yet had a chance to go around the track.
    We need to have panels of physicians and medical ethicists laying out guidelines (not rules but guidelines) for treating elderly patients. The people on these panels must have no financial stake in their recommendations.