As you heard on this week's episode of White Coat, Black Art, MDs don't like to blow the whistle on incompetent colleagues. But it turns out they sure love to diss each other in front of patients! Click on the link below while I unpack one of medicine's weird little contradictions.
We know this because of a recent and a crafty little study
published in the Journal of General Internal Medicine. Researchers from the University of Rochester recruited three actors who pretended to be ill with cancer and sent them off to nineteen family doctors and twenty cancer specialists. The actors were coached about their diseases. They also brought with them bogus but authentic-looking health records of their 'previous' treatment. The encounters were surreptitiously recorded and analyzed by the researchers.
Of thirty-four doctor-patient encounters, forty-one percent had the doctor making comments about the previous physician's care. There were forty-two comments made; twenty-eight of them (that's two thirds) were critical of the previous physician.
It would be reassuring if the doctors who dissed their fellow physicians did so because they found legitimate flaws in the previous treatments. But in this study, the researchers were really sneaky. The fake records that the actor-patients brought with them had records of previous treatment that experts consulted for the study consider to be completely acceptable and well within the standard of care. In other words, there was no good ethical reason why the doctors in this study criticized the work of their colleagues. They were simply throwing other doctors under the bus rather gratuitously.
Why these doctors said nasty things about the previous physician is a matter of speculation. I think the reasons have to do with ego and insecurity. The ego part is easy to understand. There is something singular about the culture of medicine that attracts MDs who believe they are smarter than their colleagues. When they examine the work of a colleague, they have a compulsion to offer criticism.
But behind the bravado lurks a fair dollop of low self esteem. In this study, the researchers tested cancer specialists. Thinking of that specialty, if you're a doctor who has to tell a patient they have cancer or that they have a bad prognosis, you might anticipate some disbelief and anger on the patient's part. Having another doctor to blame - for instance, for taking a longer than necessary to make the diagnosis - helps deflect those feelings.
Stress is another factor. In the ER, when a patient gives me heat for the amount of time it takes to get a CT, it might be irresistible for me to say "Well, your doctor took his or her dear sweet time sending you here." On occasion in the ER, I have said nasty things about a referring physician who sends a patient to the ER with a note that says the patient should be seen by a specialist but hasn't arranged the referral themselves. If the patient expects the referral and I find that the specialist isn't obliging me, I have sometimes said to the patient, "If your doctor expected the referral, he or she should have arranged it."
It happens rarely, and when it does, it's not my proudest moment.
The authors of the study say that sort of grumbling and undermining behaviour may affect how satisfied patients are with their treatment. It may also affect their well-being. You'd probably feel bad if you undergo a year's worth of cancer treatment and some doctor says out loud or maybe just hints subtly that you've taken the wrong course of action. More than that, a 2013 Medscape survey
of thirty-five hundred doctors on medical malpractice found concluded that one doctor denigrating the work of another is a key reason why patients sue doctors. That is especially true when hospital-based physicians say nasty things about family doctors and others who work in the community.
If at times, there must be valid reasons for one doctor to criticize another. More than that, most professional doctor organizations and the provincial Colleges of Physicians and Surgeons place an ethical duty on doctors to report colleagues who are incompetent or impaired. But, a study of two thousand doctors by researchers at Massachusetts General Hospital found a third of them objected to that.
So, to summarize, doctors aren't comfortable reporting incompetent doctors - but find it easy to casually diss colleagues even before they've spoken to the doctor and assembled all of the facts. The authors of the study published in the Journal of General Internal Medicine say they have launched a program to coach doctors not to deal with their personal frustrations by throwing colleagues under the bus. Maybe they should add a session on reporting colleagues who make serious mistakes.
It's just one of those bizarre things that are part and parcel of the culture of modern medicine.