The Role of Professionalism and Self-regulation in Detecting Impaired or Incompetent Physicians

The term professional is used in various ways. A professional might be a certified expert, someone devoted to the continuous study (“practice”) of a complex craft, or someone granted the authority to carry out tasks and provide services that others are not allowed to perform. A professional might subsume personal interests to pursue a client's or the public's good. Or a professional, as compared with an amateur, might simply be someone paid for what he or she does.

Given this range of meanings, questions about which occupations are professions, and what comprises professional behavior, are long-standing.¹ Yet medicine is almost universally recognized as a “classic” profession.² Moreover, regardless of how profession is defined, professionalism, like other “-isms” (consumerism, humanism, egotism, Catholicism, and the like), is a belief system. Specifically, professionalism can best be understood as an ideology declaring an important role for professions and professionals in organizing and delivering certain goods and services in society.

The word professional provides some insights into this ideology. To profess, from the Latin pro-fatērī, means to speak forth or “to declare aloud or publicly.”³ A profession, then, is a group of individuals speaking out, together, to declare and make public the shared values and standards that govern their work. A professional is a member of this group and professional actions are those that are in conformance with the shared and declared standards and values of the group. These standards are usually articulated in such public documents as codes of ethics, which aim to create an explicit covenant of trust between professionals, their clients, and society.⁴

The particular ideology of medical professionalism holds that medical practitioners, working together, are best suited to establish the standards and values that govern their practice and to monitor each others' adherence to these standards. In fact, proponents of the ideology of medical professionalism often claim that medical care should, or even must, be organized around professional autonomy and self-regulation because of the nature of medical work, including the unique vulnerabilities of patients, the complexity of medical tasks and relations, and other barriers to effective external monitoring.^{4 - 6} In other words, self-regulation is central to the ideology of medical professionalism.⁷

Thus, it is the core of medical professionalism that seems to face a direct challenge in the survey results reported by DesRoches et al in this issue of JAMA.⁸ The main findings are jarring: more than one-third of physicians were not completely certain of their obligation to report a colleague who is impaired or incompetent to practice, one-third reported that they are unprepared to deal with such colleagues, and many appear to follow through on this lack of conviction and knowledge with a lack of action. Among the 17% of physicians who reported being aware of an impaired or incompetent colleague in the last 3 years, one-third said that they did not report that colleague to a hospital, clinic, professional society, or other relevant authority.

These findings are sobering, even though it is possible, as with any survey, to quibble over how certain questions were asked. Why ask about “significantly impaired” in some items and just “impaired” in others, for example? Some of the authors' interpretations also might be questioned. For instance, a remarkably high proportion (56%) of physicians in solo or 2-person practices who were aware of an incompetent or impaired colleague failed to report that colleague, but is this really because they are more dependent on referrals and susceptible to financial repercussions, as the authors suggest, or might other factors be at play? Could these physicians be more geographically isolated, concerned about losing a coworker, or less certain of their own judgment about their colleagues' performance? Perhaps they have a smaller collegial network and are more connected to other physicians as friends, creating a wrenching personal as well as professional dilemma.

There is also a “glass half full” interpretation of these data. A solid majority of physicians (64%) “completely” agreed that they are obliged to report all significantly impaired or incompetent colleagues and, presumably, some number of those who did not agree completely would have agreed “somewhat.” Also, among those who failed to report their impaired or incompetent colleagues, the most common reason given was that someone was already handling the situation, which could be a reasonable explanation.

Still, it is impossible to escape the implication that these survey results constitute a frontal assault on a basic premise of medical professionalism. Despite any minor flaws, this research is proof that individual physicians cannot always be relied on to report colleagues who threaten quality of care.

Recognizing this, there are 2 additional issues to consider that provide important context for understanding this research. First, modern professional self-regulation has become increasingly complex. Self-regulation today, as it always has, entails an obligation of individual physicians to report incompetent or impaired colleagues so that they can receive care, remediation or other appropriate action. This obligation is not always met and all possible should be done to facilitate and reinforce that obligation. But self-regulation also includes a number of other professional obligations and self-regulatory structures that DesRoches et al⁸ did not explore.

It might no longer be the case, as DesRoches et al suggest, that individual peers reporting on each other is “the prime mechanism for identifying physicians whose knowledge, skills, or attitudes are compromised.”⁸ Today there are multiple complementary methods, developed by the profession, to monitor competence and detect impairment. A full portrait of current self-regulation in the medical profession should also describe, for example, clinical performance measurement⁹ ; continuing physician professional development requirements, including novel performance improvement CME programs¹⁰ ; new and evolving maintenance of certification programs¹¹ ; and new methods of reporting patient safety events to certified patient safety organizations.¹² These contemporary methods of self-regulation have been created by the profession in part due to increasing recognition that sole reliance on individual physicians to report colleagues' performance, even if it were 100% reliable, still would not be enough to meet shared obligations for quality assurance and patient safety.

Second, assuming that DesRoches et al have proven that professional self-regulation does not work perfectly, it should also be recognized that the realistic alternative to self-regulation is not a perfect regulatory system, but increasing use of other, external regulatory mechanisms. External regulatory mechanisms have some strengths, but they also have weaknesses and flaws.¹³ For example, professionalism is a distinct ideology from consumerism, in which regulation of medical practice would be based primarily on expectations established by medical “consumers” and implemented through competitive marketplace mechanisms. With regard to incompetent physicians, the ideology of consumerism would hold that patients or their agents, provided with data on physician performance, would recognize and avoid incompetent physicians, thus driving them to either improve or leave the profession. There are a number of other reasons to be honest and transparent with patients,¹⁴ but many studies of providing patients and others with data on physician performance have provided very little evidence to support adopting this strategy as a primary alternative to professional self-regulation for quality assurance in medicine.¹⁵

Both professionalism and consumerism can also be contrasted with bureaucratic ideologies, such as statism or managerialism, which hold that bureaucrats are best suited to establish practice standards for physicians and to implement mechanisms of holding physicians accountable to these standards. But state and corporate regulation of medical practice each have their own widely acknowledged practical and political weaknesses, which were heatedly discussed in the recent context of health system reform and need not be detailed here.

Finally, each of these alternative “-isms”—professionalism, consumerism, statism—is what Freidson called an “ideal type.”¹³ Like all ideologies, their pure forms are theoretical models that do not exist in nature. For the regulation of medical practice, in reality, a combination of professional self-regulation, market mechanisms, and bureaucratic mechanisms are used to monitor physicians.^{2 ,5 - 6} Moreover, these ideologies tend to blend together, especially insofar as well-established professions develop relations with the state in which licensure and other state-based methods are used to enforce profession-established performance standards.

One message of the study by DesRoches et al,⁸ therefore, is that there is a need to buttress a specific aspect of professional self-regulation. There is solid evidence that some physicians are unprepared or unwilling to report their impaired or incompetent colleagues, which proves that this aspect of self-regulation is imperfect. Calls for more education, improved socialization into the norms and obligations of professionalism, and better protections for whistle-blowers should be heeded. Yet the study by DesRoches et al is also a reminder that physicians are always seeking to perfect the complex web of interactive processes used for quality assurance in medicine. That, too, is in the nature of medical professionalism.