Journal of the New Zealand Medical Association, 16-December-2005, Vol 118 No 1227
Attitudes of hospital medical practitioners to the mandatory reporting of professional misconduct
Sumit Raniga, Phil Hider, David Spriggs, Mike Ardagh
In New Zealand and many other Western countries the medical profession exercises self–regulation under the auspices of defining legislation. Critical to the success of this approach is the willingness of doctors to report their peers. Recent events including the Cartwright Report1 and the Gisborne Inquiry2 have drawn attention to the need for the medical profession and society to consider how well the profession undertakes this key function.
Arguably a practitioner’s peers are in the best position to observe and recognise episodes of poor professional practice.3 Despite this, complaints by doctors about the professional competence of their colleagues are relatively uncommon. Indeed, only 45 (17%) of the 267 doctors whose competence was reviewed by the Medical Council of New Zealand between 1996-2002 were reported by their colleagues.4
New legislation, the Health Practitioners Competence Assurance Act (HPCAA) 2003, now requires that all doctors must notify the Medical Council of New Zealand (MCNZ) when their own or a colleague’s mental or physical fitness is in doubt, although it encourages rather than demands that doctors should report colleagues whose competence is in question. In addition, there also exists an ethical duty on practitioners to report colleagues who are practising below an acceptable standard.5
The Good Medical Practice Guide of the MCNZ advises doctors that ‘you must protect patients when you believe a doctor’s or other health colleague’s health, conduct or performance is a threat to them’.6 Similarly the ethical code of the New Zealand Medical Association requires that doctors must ‘take appropriate steps to ensure unsafe or unethical practices on the part of colleagues are curtailed and/or reported to relevant authorities without delay.’7
The Code of Health and Disability Services Consumers’ Rights requires, in Right 4(2), that providers comply with ‘ethical and other relevant standards’. Indeed, the Health and Disability Commissioner has stated that health professionals have an ethical duty, enforceable via the Code, to report concerns about a poorly performing colleague to management or a senior colleague (Tauranga Hospital Inquiry Report www.hdc.org.nz/opinions 18 Feb 2005)
The term ‘whistle-blowing’ has been used to describe any health professional who raises concerns about the performance of a colleague.3 Although it could be argued that taking concerns through the proper channels is not technically whistle-blowing it will be used here to describe any reporting of concerns by a health professional irrespective of the route taken.8
While it can be appreciated, on one hand, that it is clearly the right thing that doctors should protect the public interest when confronted by a potentially unsafe colleague, in reality this choice is often more complicated. Whistle-blowers frequently report wrestling with an agonising ethical dilemma between personal loyalty and public safety before taking action.9
The feeling that whistle-blowers are betraying their colleagues illustrates a societal norm that is especially strong among professionals whose collegial loyalty underpins their sense of professional practice.10 Another issue for practitioners is their difficulty in confidently recognising cases of substandard care when the incompetence is not gross or extreme. Similarly, the subjective nature of practitioners’ perceptions of professional incompetence have raised concern that some allegations could even be made by professionals who are motivated by greed, envy, or dislike.11,12
Increasing the reservations of a potential complainant, examples exist of difficult circumstances befalling the personal and professional lives of whistle-blowers.9,13,14 In the face of these difficulties, few jurisdictions around the World have adopted mandatory reporting for medical errors or issues related to the competence of colleagues.15 Instead, many have chosen to strengthen their legislative support for whistle-blowing professionals16 whilst at the same time allowing regulating bodies to be more proactive about maintaining standards and enhancing reaccreditation requirements for medical professionals.17
Despite the important issues and the major changes that surround whistle-blowing, relatively few surveys have documented the attitudes of doctors to this activity and their willingness to report errant colleagues.18
The aim of the current study was to examine the attitudes of a range of hospital-based medical practitioners towards mandatory reporting of colleagues who fail to achieve the required professional standards either due to their health, conduct, or incompetence.
Questionnaire design—The attitudes of medical practitioners towards mandatory reporting of deficient practice were assessed by means of a written questionnaire. The questionnaire was designed with the aim of providing accurate, relevant information. To improve compliance the questionnaire was made relatively short and was based on three short fictitious scenarios. The scenarios were intended to be realistic and thought-provoking. Questions examining the attitudes of doctors towards mandatory reporting were appended after each scenario.
An initial draft of the questionnaire was peer-reviewed by a panel of four senior, experienced clinicians.
The questionnaire was specifically designed to address the following issues related to deficient practice:
In order to improve compliance and aid objective analysis, graded series of responses were provided to most questions and respondents were required to circle the most appropriate response. Doctors were asked to indicate their level of agreement with various statements related to each of the scenarios. In order to foster honest reporting, no information about the identity or clinical speciality of respondents was requested in the survey. However, all participants where given the opportunity to make any comments using free text on any aspect of the study.
Sampling and analysis—Questionnaires were distributed via the internal mail system to medical practitioners employed to work in two tertiary New Zealand teaching hospitals. The questionnaire was sent to all medical officers (including house staff, registrars, and consultants) in each organisation using the addresses that were currently available on the records at the payroll office at each location. A letter requesting participation and providing background information, as well as a self-addressed envelope was included in the questionnaire pack. No identifying information was recorded on the questionnaire, and personal follow-up requests to complete the survey could not be made.
The survey was conducted between December 2003 and March 2004.
A total of 650 questionnaires where distributed, and a response was received from 339 (52%) of the doctors. Of respondents, 177 (52%) were consultants, 131 (39%) were registrars, and 31 (9%) were house officers.
Overall, most (332, 98%) respondents agreed that with the statement that all doctors make (and will continue to make) clinical errors, thus it is important that there be an attitude in the profession that promotes open discussion of mistakes and the lessons that can be learnt. Notably, a higher proportion of consultants (74%, 131)—compared with registrars (63%, 83) or house staff (55%, 17)—strongly agreed with the above statement.
Views on mandatory reporting were less uniform. Only 153 (45%) doctors agreed with the statement that mandatory reporting represents an important element in the process of oversight, put in place to promote high standards of medical practice; 112 (33%) of practitioners were not sure, and 74 (22%) disagreed with the statement.
Responses were broadly similar between the three groups. Most participants (272, 80%) consistently across the three groups of medical staff supported the view that doctors are professionally responsible for the actions of colleagues and they should be prepared to act if a colleague is failing to achieve the required professional standards. The majority of doctors (251, 74%) considered that they were unsure whether the MCNZ competence assessment process is fair and effective. A higher number and proportion of consultants (23 and 13%) relative to their colleagues (6 and 5% of registrars and 0 house staff) concluded that the process was not fair or effective.
Scenario A involved the case of an alcohol impaired and inappropriate practitioner and asked respondents to indicate their willingness to report his behaviour. Most respondents (260, 77%) indicated that they would report his activities to a senior colleague, although some (45, 13%) would try and counsel the doctor themselves. Most doctors would still report their colleague even when it was suggested that the practitioner’s behaviour was transient (262, 77%).
However, respondents were less certain about their course of action when it was suggested that their colleague had made sexually inappropriate remarks to a nurse. Only 191 (56%) indicated their intention to report their colleague, and 97 (29%) and 51 (15%) were either unsure or would not make a complaint. Most doctors (269, 79%) were aware of the process they should follow to report a colleague, but junior doctors were relatively less familiar with the steps (15 or 48% had no idea what to do compared with 39 [12%] registrars and 16 [9%] consultants).
Scenario B concerned a senior practitioner with recent behavioural change and increasing signs of confusion. Even in the absence of any patient complaints, 197 (58%) doctors indicated that they would still report their colleague to a senior team member—although a significant number (92, 27%), especially consultants (69, 39%), would themselves attempt to counsel the doctor.
Most respondents (233, 69%) disagreed with the statement that this situation lay beyond their responsibility, and the majority (246, 73%) were not reluctant to raise the issue even if it may adversely affect their relationship with senior staff. More junior staff, however, signalled their greater difficulty with this situation—as relatively more house officers (9, 29%) and registrars (39, 30%) compared with consultants (18, 10%) indicated that the issue was beyond their responsibility, while 14 (45%) house officers and 25 (19%) registrars recognised that they were unlikely to raise the matter as it would adversely impinge on their relationships with senior staff.
Finally, most (289, 85%) doctors agreed that they would seek a second opinion after an informal appeal to the doctor was met with denials about any problem.
Scenario C considered the case of a surgeon with racist views. Among the respondents and across the groups there was almost uniform agreement (324, 96%) that the behaviour of the surgeon by denying the patient proper informed consent on the basis of their race was unacceptable. Participants were equally divided though as to whether they would counsel the doctor themselves (141, 41%) or report him to a senior colleague (141, 41%).
Most (266, 79%) of the doctors who completed the questionnaire indicated that they would still seek a second opinion or take other steps to report the doctor (28, 8%) after a colleague warned that they should not proceed any further with the matter. Similarly most respondents (233, 69%) were not deterred by the suggestion that they should not take any action as it may jeopardise their future careers. A higher proportion of house officers (26%) compared with either registrars (11%) or consultants (4%) reported that they were less likely to pursue the matter in this context.
Most (272, 80%) medical staff at two tertiary, teaching hospitals supported the view that doctors were professionally responsible for the actions of colleagues and agreed that they would act if a colleague was failing to achieve the required professional standards. This result mirrors the findings from a recent study of young doctors in the United Kingdom (UK) that examined the attitudes on a number of professional issues including whistle-blowing.
The UK study similarly concluded that most (90%) doctors believed they were corporately responsible for the actions of their colleagues, and agreed that they would act if a colleague was falling below acceptable professional standards.19 Furthermore, in the current study, the willingness to report colleagues whose competence was below an acceptable standard was generally expressed across all groups of doctors including consultants, registrars, and house staff. However, although the results were consistent they were not unanimous and some young doctors, in particular, expressed difficulty with reporting colleagues, particularly when the dysfunctional clinician was more senior.
This finding is consistent with the results from focus groups in the UK which have documented that young doctors were sometimes reluctant to report examples of unethical behaviour they witnessed among their peers or teachers.20 It is perhaps not surprising that some doctors have difficulty with reporting defective colleagues given that some cultural mores in the community still decry the actions of whistle-blowers.13,20 Furthermore, other surveys have reported that some established formal training programmes have failed to improve medical students ethical performance during their training.21
Confronted by these findings, medical schools have recently reconsidered how they select their students and redefined the nature and the content of the ethical training they provide, especially in relation to whistle-blowing.22
Another important finding is confirmation that most (332, 98%) doctors in the survey recognised that doctors make clinical errors and that there was therefore the need for an attitude in the medical profession that promotes ‘open discussion of mistakes’ and the lessons that can be learnt from them. The willingness of practitioners to openly discuss medical error is a vital foundation in any efforts to identify adverse events and introduce processes to avoid them.23 This finding supports efforts by various professional, organisational, and government bodies to promote the open discussion of medical error among practitioners and to consider a system-oriented rather than an individual-blaming approach to quality improvement.24
High rates of acceptance for the open discussion of error among consultants in this survey, and the power of medical role models to influence young doctor behaviour,25 suggests that an open approach to medical error could become the professional norm in this country.
While most (272, 80%) respondents believed that they should be prepared to act if a colleague is failing to achieve the required professional standards, only 153 (45%) agreed that mandatory reporting represents an important element in the process of oversight and 112 (33%) were unsure. Several explanations exist for doctors’ reluctance to accept mandatory reporting.
Many are aware that whistle-blowing often does not leave the perpetrator unscathed and internal conflict exists between the duty to report and the fear of repercussions.14 It has also been argued that opposition to mandatory reporting represents rejection of the means of achieving an outcome rather than the outcome itself.5 The statutory duty to report to an external agency could be regarded by practitioners as creating a punitive atmosphere and a culture of fear.26 The absence of a statutory obligation may be more likely to foster the appropriate atmosphere to engender honest discussion within an organisation about error and encourage organisational interventions.5,26
Finally, another important possible explanation is provided by the finding that 251 (74%) doctors expressed uncertainty about whether the competence assessment process was fair. If practitioners do not believe the assessment process to be fair it is possible that they may not wish to participate. Overcoming this perception is a challenge for the MCNZ and other professional organisations. Assisting the change in this perception are recent amendments to Accident Compensation Corporation (ACC) legislation that remove the concepts of medical error and medical mishap and thereby no longer require blame to be attached to individuals for harms related to the provision of healthcare.27
The results from scenario C exhibit the potential difficulty that some practitioners may have with knowing to whom they should report cases of unacceptable behaviour. The case highlights the particular difficulty that junior staff experience with pursuing a complaint even when it was initially discounted by another colleague. This difficulty likely relates to a feeling of powerlessness among junior staff, and is akin to the impotence sometimes expressed by other health professionals when confronted by incompetent practitioners in positions of authority.3
The difficulties of other professionals, coupled by the inability or unwillingness of some affected doctors to seek care,28,29 increases the demands upon practitioners to take action when they are aware of an incompetent colleague.3
This survey has several limitations. It describes the responses of practitioners to fictitious case vignettes. Although empirical evidence does support the validity and reliability of using vignettes as a reliable tool to describe the behaviour of doctors in real situations,30 the relationship between what practitioners say they would do in a hypothetical situation and what they actually do in real-life is not clear-cut or certain.31
Secondly, there is potential for selection bias in relation to which practitioners choose to participate in the study. Although the anonymous nature of the study was designed to enhance the response rate, it also prevented personal follow-up of non-responders.
Response rates varied across the three groups of doctors, and some response categories were associated with small numbers. The rate was lowest among house officers and highest among consultants. It is not possible to compare those who responded with those doctors who did not, and consequently the potential for selection bias cannot be determined. The relatively low participation rate among house staff suggests that there may be some difficulty with generalising the findings from this survey to house surgeons in general. In addition, the study did not collect personal data such as gender, age, and speciality; therefore we are unable to determine whether attitudes to mandatory reporting varied in relation to these demographic and professional characteristics.
Finally the study has not provided any details about why some practitioners may not wish to report dysfunctional doctors. Possible explanations include the belief that they would not be believed, that nothing would change, or that they would themselves be censured or harmed.3
To reliably address these issues, further research is needed using representative cohorts of practitioners and a wider array of questions.
Author information: Sumit Raniga, Medical Student, Christchurch School of Medicine and Health Sciences, University of Otago, Christchurch; Phil Hider, Senior Lecturer, Department of Public Health and General Practice, Christchurch School of Medicine and Health Sciences, University of Otago, Christchurch; David Spriggs, Clinical Director, General Medicine, Auckland Hospital, Auckland; Mike Ardagh, Professor, Emergency Department, Christchurch Hospital and Christchurch School of Medicine and Health Sciences, University of Otago, Christchurch
Acknowledegements: The cooperation of staff and management at the two hospitals included in the survey along with funding from the Medical Council of New Zealand for a summer studentship for Sumit Raniga are gratefully acknowledged. Helpful comments on a draft were provided by Prof John Campbell, Mr George Symmes, and Ms Sue Ineson. Sumit Raniga also thanks Aparna Seethepalli, John Molloy, Felicia Ling, Angela Bang, and Patricia Fogarty for all their help in collating the data.
Correspondence: Professor Michael Ardagh, Emergency Department, Christchurch Hospital, Private Bag 4710, Christchurch. Fax: (03) 364 0286; email: email@example.com
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