AddThis Feed Button "Frequently Copied, Never Duplicated"

Saturday, December 08, 2007

The Lost Art in Medicine

Maybe this is a sign of these times?

By John Gever, Contributing Writer, MedPage Today
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine.

BOSTON, Dec. 4 -- Although physicians pronounce that the integrity of medicine requires observance of the highest standards of professionalism, many concede that their own behavior falls short of this goal.

In short, found Eric G. Campbell, Ph.D., of Massachusetts General Hospital, and colleagues, in a survey of 1,662 physicians and surgeons, doctors don't always practice what they preach when it comes to professional conduct.

For example, 96% agreed that a physician who was impaired or incompetent should be reported to authorities but 45% said they had failed to do so, found the survey, reported in the Dec. 4 issue of Annals of Internal Medicine. Action Points

Explain that the study found that while most physicians embrace strong standards of professional conduct, they do not always follow them in their own practices.

Point out that physicians often must follow policies set by others and may not have complete freedom in their medical decisions.
"Physicians report behaviors that are consistent with the tenets of being honest with patients and protecting patient confidentiality," the authors wrote. "However, for other norms, there were gaps between physician beliefs and what they reported doing."

The investigators sent a two-part professionalism questionnaire to 3,504 physicians in family practice, internal medicine, cardiology, pediatrics, surgery, and anesthesiology, with a 58% response rate.

The first part addressed nine categories of professional standards, asking for agreement or disagreement with the need to encourage participation of patients in clinical trials (83% agreed) and the desirability of periodic recertification (77% agreed).

The second part dealt with specific behaviors corresponding to the general standards. For example, doctors were asked whether they had actually encouraged a patient to participate in a clinical trial in the past three years (41% said they had), and whether they had undergone a competency assessment by a provider organization or health plan (33% said yes).

Another disparity between agreement and adherence was in the category of fair distribution of finite resources, a concept that 98% agreed was a valid standard. But asked whether they would order a clinically unnecessary MRI scan for a patient who insisted on one, 36% said they would.

Also, 93% of respondents agreed with the general principle that physicians should provide necessary care without regard for payment, Yet 69% said they were accepting patients who are unable to pay, and 74% said they had provided care to poor and underserved patients in the past three years without expectation of payment.

Responses varied according to certain physician characteristics, such as their specialty, practice setting and payment system.

For example, 44% of cardiologists and 43.2% of FPs said they always reported personal knowledge of impaired or incompetent colleagues. But 57.4% of pediatricians said they did so.

Physicians in staff-model HMOs were less likely to have provided care without expectation of payment (28.3%), while those in solo practice less frequently participated in a formal medical error reduction program (43.5%) than those in group practices (56.3%).

Similarly, salaried physicians were less likely than those in capitation payment plans to have undergone a competency assessment.

Dr. Campbell and colleagues suggested that some deviation from professional standards could be attributed to employment arrangements. "It 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 assessments," they said.

"Our findings give reason for both optimism and concern," they concluded. On the plus side, "the near-universal acceptance of key professional norms" is reassuring.

"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."

The group said their survey could not capture all behaviors that reflect on professional standards. Also, relying on physician self-reports "probably resulted in over-reporting of socially desirable activities," they acknowledged.

"We do not regard our data on self-reported behaviors as sufficient to judge the overall professionalism of respondents or to conclusively assess their adherence to particular norms," the group said.

Harold C. Sox, M.D., the journal's editor, agreed in a commentary with the survey's overall mixed review of the medical profession.

"We can -- indeed we must -- improve our performance in many of these areas," Dr. Sox said.

The Institute on Medicine as a Profession funded the survey. The survey researchers and Dr. Sox had no relevant financial disclosures.

Primary source: Annals of Internal Medicine
Source reference:Campbell E, et al "Professionalism in medicine: results of a national survey of physicians"Annals of Internal Medicine 2007; 147: 795-802.
Professionalism in Medicine: Results of a National Survey of Physicians
right arrow Eric G. Campbell, PhD; Susan Regan, PhD; Russell L. Gruen, MD, PhD; Timothy G. Ferris, MD, MPH; Sowmya R. Rao, PhD; Paul D. Cleary, PhD; and David Blumenthal, MD, MPP

4 December 2007 | Volume 147 Issue 11 | Pages 795-802

Background: The prospect of improving care through increasing professionalism has been gaining momentum among physician organizations. Although there have been efforts to define and promote professionalism, few data are available on physician attitudes toward and conformance with professional norms.

Objective: To ascertain the extent to which practicing physicians agree with and act consistently with norms of professionalism.

Design: National survey using a stratified random sample.

Setting: Medical care in the United States.

Participants: 3504 practicing physicians in internal medicine, family practice, pediatrics, surgery, anesthesiology, and cardiology.

Measurements: Attitudes and behaviors were assessed by using indicators for each domain of professionalism developed by the American College of Physicians and the American Board of Internal Medicine. Of the eligible sampled physicians, 1662 responded, yielding a 58% weighted response rate (adjusting for noneligible physicians).

Results: Ninety percent or more of the respondents agreed with specific statements about principles of fair distribution of finite resources, improving access to and quality of care, managing conflicts of interest, and professional self-regulation. Twenty-four percent disagreed that periodic recertification was desirable. Physician behavior did not always reflect the standards they endorsed. For example, although 96% of respondents agreed that physicians should report impaired or incompetent colleagues to relevant authorities, 45% of respondents who encountered such colleagues had not reported them.

Limitations: Our measures of behavior did not capture all activities that may reflect on the norms in question. Furthermore, behaviors were self-reported, and the results may not be generalizable to physicians in specialties not included in the study.

Conclusion: Physicians agreed with standards of professional behavior promulgated by professional societies. Reported behavior, however, did not always conform to those norms.


* Whether practicing physicians conform to norms of professionalism is unknown.


* This survey of 3504 practicing physicians in the United States found that most physicians agreed with principles regarding fair distribution of resources, access to and quality of care, conflicts of interest, and self-regulation that were proposed by professional societies in 2002. Self-reported behaviors, however, showed that about one half did not follow self-regulation principles and that about one third would order unneeded magnetic resonance imaging for back pain in response to a patient's request.

* Although physicians generally agree with proposed professional norms, they do not always follow all of them.

—The Editors

Author and Article Information
From Massachusetts General Hospital, Institute for Health Policy, Boston, Massachusetts; School of Public Health, Yale University, New Haven, Connecticut; and University of Melbourne, Center for Medical Research, Royal Melbourne Hospital, Parkville, Victoria, Australia.

Acknowledgment: The authors acknowledge the contributions of Drs. Janice Ballou and Frank Potter for Mathematica Policy Research.

Grant Support: By a grant from the Institute on Medicine as a Profession.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Eric G. Campbell, PhD, Institute for Health Policy, 50 Staniford Street, 9th Floor, Boston, MA 02114; e-mail,

Current Author Addresses: Drs. Campbell, Regan, Ferris, Rao, and Blumenthal: Massachusetts General Hospital, Institute for Health Policy, 50 Stanford Street, 9th Floor, Boston, MA 02114.

Dr. Gruen: University of Melbourne, 6th Floor, Center for Medical Research, Royal Melbourne Hospital, Parkville, Victoria 3050, Australia.

Dr. Cleary: Yale University, School of Public Health, 60 College Street, New Haven, CT 06513.

No comments: