*Annals of Internal Medicine, tip sheet, April 3, 2001
“Medical Profession Must Do More to Self-Regulate and Self-Police”
“The medical profession has not done a good job recently of self-regulating, self-monitoring and self-disciplining members, says the author of a Perspective piece (p. 587). It has set up “pseudoaccountable” regulatory procedures that look real but don’t do an effective job. If the medical profession does not set and enforce high standards, government and others outside the profession will step in.” **
AFAIK: Doctors set and enforce high standards through the various qualifying examination (M-SAT and state license boards) and peer-review.
From the TV programs I’ve seen the peer-review process is held behind closed doors or doctors wouldn’t feel safe about discussing errors, and groups do like these (doctors evaluating doctors) have some authority?
I’m stuck with an awful vision of the FBMSI (Federal Bureau of Medical and Surgical Investigation)sending guys with gray suits and short haircuts into the operating room with me while I have my appendix out.
So, who would you pick to set and enforce high standards for the medical profession?
Jois
*Annals of Internal Medicine is published by the American College of Physicians-American Society of Internal Medicine (ACP-ASIM), an organization of more than 115,000 internal medicine physicians and medical students. The following highlights are not intended to substitute for articles as sources of information. For an embargoed fax of an article, call 1-800-523-1546, ext. 2656 or 215-351-2656.
**AFAIK: Doctors set and enforce high standards through the various qualifying examination (M-SAT and state license boards) and peer-review. **
Doctors set high standards, but do they enforce them? This is the problem with dual roles - when doctors are both advocating for and responsible for disciplining themselves, it is a conflict of interest. As an example, would you feel more comfortable if landlords set up self-regulation, or would you like the Bureau of Licensing and Inspections to keep checking to make sure your apartment is up to code?
**From the TV programs I’ve seen the peer-review process is held behind closed doors or doctors wouldn’t feel safe about discussing errors, and groups do like these (doctors evaluating doctors) have some authority? **
The problem is that unless there is significant disciplinary action, the incident remains confidential. Patients have no real way of learning the quality of their doctors. Personally, if a doctor has had 30 complaints against him, I wouldn’t go to him, even if none of the complaints ended with suspension, etc. But I can’t find that out.
**I’m stuck with an awful vision of the FBMSI (Federal Bureau of Medical and Surgical Investigation)sending guys with gray suits and short haircuts into the operating room with me while I have my appendix out. **
And that’s not going to happen. Any investigation would occur, um, after something bad happened. (On a side note, as states license doctors, it wouldn’t be a federal agency policing doctors.)
And what is so unusual about outside regulation? Is OSHA evil?
So, who would you pick to set and enforce high standards for the medical profession?
State agencies.
At the rate various responsibilities and authorities have been “Federalized” over the last century, I wouldn’t be at all surprised to see the Federal Government step in and take over the medical licensing role from the States.
I have a problem with this statement. While I recognize that professional self-regulation in general falls short of meeting public needs, I believe that 1) it’s an essential component of professional responsibility, and 2) that physicians probably do the best job of any profession in policing their own, including peer review setups, specialty recertification exams and self-inspections to ensure compliance with federal regulations (i.e. the Clinical Laboratory Improvement Act).
I don’t know the composition of every state medical board, but it isn’t just physicians who weigh in on disciplinary matters. Contrast that with the disciplining of attorneys, who to my knowledge answer only to other lawyers.**
So if a couple of patients with grudges decide to orchestrate a groundless campaign against a doctor, that complaint record should wind up on a website? If we’re talking about records of malpractice suit losses and settlements (with appropriate added information as to legal problems for physicians in comparable practices) that’s a different story.
When it comes to comparing self-regulation among doctors and lawyers (Hell, Sua, it’s irresistable), my experience is that lawyers get a freer ride. For instance, the New York State Bar Association in a recent year cited 250 disciplinary actions taken by the courts against attorneys (N.Y. at last count had about 100,000 lawyers). By contrast, the N.Y. State Medical Board issued
414 “serious” disciplinary actions over a comparable period. I don’t know exactly how many doctors there are in N.Y., but it’s surely less than 100,000. And I can find out if a given doctor has been disciplined online. I haven’t been able to access that kind of info for the state’s lawyers.
Here in Texas, there’s a controversy over adequate representation for accused criminals in death penalty cases, including allegations that defense attorneys have slept through portions of trials. What with all the fuss, I don’t recall hearing much about disciplinary actions being taken against these guys.
Merely adding on new regulations does not, in my opinion, substitute for vigorous enforcement of the disciplinary measures we now have. To give an example of a ludicrous regulation, Texas M.D.s now have to fulfill an ethics course requirement at every license renewal. The legislators who dreamed this up no doubt are puffing out their chests and bragging about how they’ve increased physician accountability. The only thing the courses do is create a pain in the ass. If by the point of getting a license you have ethics problems, this particular hurdle will do squat to make you less of a sleaze.
Jack, Jack, Jack -
I thought you understood, we lawyers make the rules, so obviously they don’t apply to us.
Seriously, you are absolutely right that lawyers shouldn’t be self-regulated either. I personally believe that any group or organization with the dual purpose of advocating and regulating an industry will due a piss-poor job. The two goals are in conflict - it’s hard to say what a great bunch of folks these people are while at the same time tossing a bunch of them out on their arse. This doesn’t just apply to doctors and lawyers; the FAA comes to mind.
As for lawyers, I am often very pissed at the slap on the wrists doled out. I was recently following a case in Florida in which, to settle a lawsuit, the defendants paid a “consulting fee” to the plaintiff’s lawyers. No one told the plaintiffs, and the lawyers ended up getting about 60% of the total settlement. The judge ordered payments to the plaintiffs, and such discipline as ethics courses, etc. But my thinking was that these attorneys committed grand larceny against their clients, and should have gone to jail. That, unfortunately, doesn’t happen.
As for your point about patients with grudges, if the published information shows that all complaints against a doctor come from just a few people, that problem would go away. BTW, I wouldn’t rely on malpractice statistics. Too many weak cases result in a settlement just to make the case go away.
Part of what interested me about this issue was that it was being published in a professional magazine (*Annals of Internal Medicine is published by the American College of Physicians-American Society of Internal Medicine (ACP-ASIM), an organization of more than 115,000 internal medicine physicians and medical students), that is was one of their concerns about their own profession. What are they seeing that we as outsiders do not see?
As for state agencies re: setting and enforcing high standards, can’t states only set minimum standards? This
is the least you can score on a medical or nursing or real estate test and practice your profession in this state.
When you go to have surgery or some special medical treatment or test, it is a nurse who evalutes the doctor’s request and says whether or not the insurance company will pay. Seems like that is a minimal effort, here’s an opportunity to evaluate care, but instead some one is probably working with a cheat-sheet and going by the numbers.
How are hospitals accredited?
How well does does the stae do with nursing homes or child care providers?
In my state, oversight is by the Medical examining board. This is a group of physicians and laypeople appointed by the governor of the state. In today’s climate, the success or failure of a medical examining board is often judged by how many doctors they discipline. This is public record in all states, and lately there’s been a bit of competition between states to see who can discipline a higher percentage of physicians under its jurisdiction. The public likes to hear of bad docs getting spanked, the Governor is pleased that the public likes what his board is doing, and everybody is happy. Except the doctors who get disciplined. And some of those doctors are bad doctors, some are good ones who made a mistake, or had a bad outcome, and some are doctors who just really got screwed.
The medical board here really does have a set of priorities which is admirable in its ideal form. The board wants to
Protect the public.
rehabilitate/educate the physician
Discipline the physician.
But often unspoken is the Zeroth law:
Don’t embarrass the governor!
BTW, I’ve worked with the board in my state for over 15 years, appearing before them to give testimony, both in support of and against individuals, and I’ve worked with the board attorney in charge of pursuing “bad” doctors. It’s not an ideal system, and a lot of politics are involved, but it works, after a fashion.
Of course, with the new cookbook approach to medicine, with one recipe fitting all, everyone wants to second-guess the doctor, and see how the doc deviated from what the cookbook says.
I was damaged by medical malpractice,but I was to sick and broke to realize how badly I had been treated and sue.
The tort system should not be replaced by any regulations.
A better method would be to look into deaths - just as airplane crashes are investigated, but mostly you get cover-ups.
