The study concluded that doctors often don't follow through on their own beliefs about protecting patients' privacy, avoiding conflicts of interest, or reporting incompetent or impaired colleagues.
The reasons for the disconnect are unclear, though researchers say many doctors may fear retribution or lawsuits if they expose bad behavior of colleagues. They also suggest that legal regulations governing doctors' ethics may not be strong enough.
"I think that our findings go well beyond personal ethics," says David Blumenthal, MD, director of the Institute for Health Policy at Massachusetts General Hospital in Boston and the study's senior author.
The survey shows widespread agreement with accepted professional norms among the 1,650 doctors it polled. More than nine in 10 said doctors should put patients' welfare above financial considerations and should minimize racial health disparities.
But while more than 90% of doctors supported reporting inept or incompetent colleagues, nearly half said they had encountered an impaired or incompetent fellow doctor in the last three years and didn't report the person.
At the same time, one-quarter of doctors surveyed said they would refer a patient to a medical facility with which they have a financial interest. In many cases these types of referrals violate anti-kickback laws.
Doctors and the groups representing them jealously guard their traditional role as a self-regulating profession. Most government regulation takes place at the state level with varying degrees of enforcement.
Heads of medical societies say they are revamping professional standards to include education on professional conduct and transparency with the public. A 1998 report from the Institute of Medicine detailing widespread but largely unreported medical errors helped spawn new quality improvement efforts that are just now taking root in many areas of medicine.
"We can't wait on regulations and laws to catch up here," says Jack Lewin, MD, CEO of the American College of Cardiology.
State medical boards are responsible for almost all regulation of doctors and the way they practice. But James Thompson, MD, CEO of the Federation of State Medical Boards, says many of those boards are too weak.
"It is simply not acceptable that bad physicians are not being reported to the appropriate state authorities," he says. "There are medical boards than don't even have their own teams of investigators."
Still, several experts including Thompson say that fear of punishment, either by courts or in terms of damaged reputation, may be preventing many doctors from becoming "whistleblowers," even if they believe it's the right thing to do.
What Do Patients Do?
Several experts say the study presents a dilemma for patients. While the results suggest doctors often don't live up to their stated ethics, patients tend to trust the intentions of their own caregivers.
Questioning one's own doctors about ethical issues can be difficult, says David Rothman, MD, president of the Institute on Medicine as a Profession, which sponsored the study.
"Do I dare ask my doctor ... 'because you're writing on a drug company pad, is that why I'm getting this prescription?'" Rothman says. Patients "would love to ask, but they dare not."
"I think one of our biggest challenges is getting patients interested in these issues," Lewin says.
Rothman says his group does not want to warn patients to take a "buyer beware" attitude to their relationship with their doctors.
"Any patient who did not bring at least part of that maxim into the (medical) office would probably be remiss," he says.
By Todd Zwillich
Reviewed by Louise Chang
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