The Role of the Medical Profession in Physician Discipline

This issue of THE JOURNAL includes 2 articles on physician discipline that add substantially to the knowledge base about this important, yet disturbing phenomenon. The first article, by Dehlendorf and Wolfe,¹ uses a national database to examine trends and characteristics of 761 physicians who had disciplinary orders for sexual misconduct entered from 1981 through 1996 by a state or federal agency. The authors found that the proportion of all disciplinary orders taken against physicians that were sex related increased significantly, from 2.1% in 1989 (47 orders involving 42 physicians) to 4.4% in 1996 (154 orders involving 147 physicians), that 75% of sex-related offenses involved patients, and that disciplinary action for sex-related offenses was more severe than discipline for other offenses. In the second article, Morrison and Wickersham² examine information on 375 physicians disciplined over an 18-month period by the California State Medical Licensing Agency, the Medical Board of California. Among the most frequent reasons for disciplinary action were negligence or incompetence (34%), substance abuse problems (14%), inappropriate prescribing practices (11%), and inappropriate or sexual contact with patients (10%). Taken together, these articles raise sobering questions regarding the behavior of members of the medical profession and, just as important, how to deal with and prevent these behaviors to the fullest extent possible.

After reading these 2 articles, physicians may be left with the impression that the profession of medicine is deteriorating as the result of misconduct. However, what is missing from that conclusion is that the medical profession itself is becoming less tolerant of physician misconduct and that the public is better informed about reporting physician misconduct. Also, as physicians are better educated and prepared for the practice of medicine, the bar for expectation of high performance and ethical behavior is being raised. Nonetheless, while the articles by Dehlendorf and Wolfe¹ and by Morrison and Wickersham² indicate that formal disciplinary action is taken against less than 1% of physicians in the United States each year, even 1% is still far too many. Neither article, of course, deals with physician negligence, incompetence, or misconduct that was not reported or did not result in disciplinary action.

The role of the medical profession has been and continues to be one of leadership in addressing this troublesome problem. For instance, through its opinions of the Council on Ethical and Judicial Affairs (CEJA), policies on education and standard setting, and use of its communications and media relations, the American Medical Association (AMA) has tried to increase physician and public awareness of appropriate ethical behavior by physicians.

CEJA has previously issued opinions on 2 major issues that are germane to the articles by Dehlendorf and Wolfe¹ and by Morrison and Wickersham.² First, sexual contact with a current patient constitutes sexual misconduct. Also, a sexual or romantic relationship with a former patient is unethical "if the physician uses or exploits trust, knowledge, emotions or influence derived from the previous professional relationship."³ Second, in the case of physicians' responsibility to consider the character of their colleagues, the Council has called on the profession to abandon the "conspiracy of silence" surrounding unprofessional behavior, and has noted, "Incompetence, corruption, or dishonest or unethical conduct on the part of members of the medical profession is reprehensible."³ Furthermore, in dealing with knowledge of a colleague's misconduct, "A physician should expose, without fear or loss of favor, incompetent or corrupt, dishonest or unethical conduct on the part of members of the profession."³ Enhancing professionalism and addressing physician misconduct should remain major agenda items for organized medicine, with particular focus on strengthening the medical profession's responsibility and accountability.

By law and by tradition in the United States, formal disciplining of physicians is a function of state licensing boards. These licensing boards have become better equipped to identify and manage physician misconduct. As a result, more actions and more severe sanctions may be applied to physicians, particularly for sexual violations, than in the past. Therefore, examining sexual misconduct, as in the study by Dehlendorf and Wolfe,¹ may reflect increased reporting of disciplinary actions rather than an increased occurrence of misconduct. Licensing boards take their responsibilities very seriously. In fact, as the result of due process and the likelihood of litigation, it is more difficult for a board to remove a medical license than to issue one. Accordingly, it should be the goal of each licensing board to ensure that their processes at the front end, before they issue a license, as well as their processes for license renewal, are such that, in an ideal world, the board should never have to remove a license from a physician for misconduct. The responsibility is to guard the profession and safeguard the public from the relatively small proportion of problem physicians, and to prevent these physicians from practicing not only in the state taking the disciplinary action, but also in other jurisdictions.

The recommendations contained in the 2 articles^{1 - 2} in this issue of THE JOURNAL deserve careful attention. The Federation of State Medical Boards has begun a vigorous effort to improve analyses and reporting of disciplinary actions to the profession, to the National Practitioner Data Bank, and to the public. This effort is commendable, as it improves the ability to continue to examine determinants and descriptors of physician misconduct and provides opportunities to intervene before unethical physician behavior or misconduct occurs, and before harm comes to patients. As suggested by Dehlendorf and Wolfe,¹ the legal system does have an important role to play. State licensing boards and state medical societies should be encouraged to work together to pursue legislation that incorporates principles of the AMA Code of Medical Ethics⁴ into state medical licensing laws.

In addition, all medical students and resident physicians should learn the principles of medical ethics, as embodied in the Code of Medical Ethics.⁴ We are concerned that many medical schools do not have a required curriculum in medical ethics.⁵ Although we do not wish to intrude on the prerogatives of faculty to set the curriculum, we would strongly encourage them to consider the inclusion of medical ethics in their teaching, especially the principles espoused by CEJA.

Misconduct of any kind by any physician has no place in medicine. Of all professions, we believe medicine is the most noble and learned. Although many features distinguish a profession, one of the most important is responsibility for the conduct of its members. Medical organizations, along with licensing boards, academic leaders, and others charged with certifying the character of physicians, have a responsibility and an obligation to patients and to the public to ensure that physician misconduct, when it occurs, is identified and dealt with appropriately. Fulfilling this vital responsibility through concerted efforts and strong commitments is essential for ensuring that the profession of medicine is protected, preserved, and enhanced.