Arthur Caplan, Ph.D., from the University of Pennsylvania Center for Bioethics, was online Tuesday, April 12, at 2:30 p.m. ET to examine medical boards, doctors and ethics -- issues raised in Washington Post staff writer Cheryl W. Thompson's three-part series, "Special Treatment: Disciplining Doctors."
The transcript follows.
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Do you think that there is a failure to properly protect the public from negligent or incompetent doctors? If so, do you believe that this plays a substantial part in the cost of medical liability insurance for the medical community at large?
Arthur Caplan, Ph.D.: There is a failure to protect the public. The system that we have simply does not work. There are too many wrist slaps and not enough pulling of licenses of clearly dangerous doctors. This absolutely contributes to the cost of malpractice insurance.
Ft. Lauderdale, Fla.:
Why is there so little apparent interest in solving this problem, both from the AMA, and from the Congress? We keep hearing from Conservative Republicans that malpractice lawsuits are the primary reason for high medical costs. Wouldn't the removal of "bad doctors" from practice significantly reduce the number of malpractice suits?
Arthur Caplan, Ph.D.: Removing bad doctors should be a precondition for malpractice reform. It is simply a bad idea to reduce your right to sue without toughening licensure standards for doctors. Congress is simply not protecting the public interest in this area when it focuses simply on malpractice reform without demanding higher standards to hold a medical license.
What role do you think the insurance industry has in this? I'm sure they must do some type of investigation on individual doctors when calculating their premiums or do they just use the state by state data?
Arthur Caplan, Ph.D.: Unfortunately, what happens is that doctors move from state to state and avoid detection. Those who have multiple problems with addiction, mental illness, senility, and other severe impairments fly under the radar screen. The system we have of state licensing does not protect us in a country where you can cross a state line within ours.
College Park, Md.:
Dr. Caplan, You might not be the right person to ask this question, but what can we as consumers do to protect ourselves against these selfish doctors and the apologist healthcare profession? These articles have really scared the "expletive" out of me. Thank you.
Arthur Caplan, Ph.D.: Sorry for the fright! But, you need to be sure that you ask to see a doctor's credentials, ask point blank if there is any history about their license that you should know, and most importantly ask for recommendations from other doctors. The most dangerous doctor is the one who operates alone without colleagues or without peer review.
I work in the insurance field. There are certain doctors names that cause concern re: quality of care. I have even gone to seminars attended by multiple people in my field where these names come up. I walk a fine line. I can't tell patients that I think they are going to a bad doctor since I have no details of discipline and information I do have involves confidentiality of other patients, but I feel like they are not getting the best care. In some cases unnecessary surgery. Remember everyone thinks their doctor is great until something goes wrong. Any suggestions?
Arthur Caplan, Ph.D.: The problem is that the information you have should be available to every patient and potential patient. Why should it be that you can get more information about a car you want to buy than you can about a surgeon who is going to remove your prostate? Congress should be demanding much more disclosure of physician-specific information. It should not just be held by third-party pairs and insurance companies. If we really are concerned about quality than we need to demand much more information about our doctors, hospitals and nursing homes.
San Diego, Calif.:
So then why are doctors and the AMA so steadfast against efforts to better police their industry and are supporting the assertion that settlements to the victims of the horrific of malpractice cases are the cause of insurance rate increases?
Arthur Caplan, Ph.D.: In part, it is true that malpractice settlements are out of control. They don't necessarily weed out the "bad doctors." But medicine has not yet bit the bullet. It is still protecting the guild. It really is time for doctors, the overwhelming majority of whom are excellent, to go after and get rid of their bad apples.
Lexington Park, Md.:
Are doctors in different specialties held to different standards? A drug-addicted psychiatrist poses less risk of killing someone than an addicted Cardiologist.
Arthur Caplan, Ph.D.: That's a good question. Specialists ought to be board certified. Remember, any doctor can actually perform any procedure than prescribe any approved drug for any purpose! This is tremendous power. It is often abused. Keep your eye out for board certified specialists, and ask your doctor if they continue to go to continuing education seminars. It would be easy to beef this system up since many doctors do not continue their educations once their formal education has ended.
The articles were terrifying! Suppose I ask my current doctor his opinion of another doctor (who in reality is horrible). Am I likely to get an honest opinion, or, with litigation being what it is, some vague comments which the doctor hopes I will interpret as a less than ringing endorsement?
Arthur Caplan, Ph.D.: You are likely to get an honest answer. Most doctors will tell you if they have reservations about another physician. However, the smaller the town and the smaller community, the harder it is for one doctor to speak ill of another. In small towns and rural communities you're likely to get vaguer answers -- these docs have to see each other every day and they're less likely to be open about their doubts.
Front Royal, Va.:
I found these articles really astonishing. I have a security clearance and if I did something that was of equal horror as to what many of these doctors did or to have committed a national security violation on a large scale, I would be fired immediately and my clearance would be revoked. I would have to find another field of work. So why is it that these doctors are still getting away with these horrendous things?
Arthur Caplan, Ph.D.: The system goes on because we don't demand more quality from it. We believe that malpractice will protect us, but that is an illusion. We need tougher licensing standards, tougher relicensing requirements, tougher continuing education standards, and most importantly, rules about addictions and incompetence that are just as tough as three strikes and you're out laws.
All the doctors in the articles seemed to have failed rehab. Are there many doctors who have succumbed to a addiction but managed to turn it around?
Arthur Caplan, Ph.D.: There are many success stories. Doctors are vulnerable to addiction because they're around addictive drugs. Specialties like anesthesiology are especially prone to problems given the easy access to addictive substances. There are some superb rehab programs for doctors. But, my view is if you fail your rehab more than twice that should be the end of your license. At least to treat patients directly. You ought to have a desk job or an administrative job or something outside of clinical care at that point. Sex offenders, I think, should have a zero tolerance policy in medicine, which they don't now.
Silver Spring, Md.:
I have a Durable Power of Attorney/Medical Directive filled out in case I am not in a position to make my own medical decisions. One of my specifications is that I receive NO blood transfusions. Are doctor's obligated to follows these papers -- despite their judgements? Or can they over-ride them in some states?
Arthur Caplan, Ph.D.: Living wills and durable power of attorney are binding. Legally, they must be followed, however, if you do not update them, there can be challenges made by your relatives and friends. Make sure your family and friends know you have these documents. Make sure you update them and re-sign them every two years.
Medical malpractice is a major issue at both the state and federal levels. It seems to be many doctors want to limit the ability to be sued, but do not want any further intrusion into their work records. Isn't it possible that systems be implemented that can understand both the risk of the type medical work done and the error rate of the medical work done so we can flag whenever their appears to be physicians that have higher than expected error rates? At what point should these physicians be removed from performing certain procedures? Wouldn't that then lower medical insurance when those creating most of the errors and lawsuits are removed from practice?
Arthur Caplan, Ph.D.: We don't have to argue about marginal cases or people with higher than average error rates. The Post series revealed just how many incompetent and dangerous doctors are out there. Let's focus on getting rid of them, then we can focus on those doctors who have above average error rates. Right now the system can't even get rid of the manifestly and indisputably incompetent and inept!!! I once proposed a simple test to get rid of the blatantly incompetent physician. To keep your license every doctor could be required to simply return a postcard answering ten or 12 basic questions. That simple test would do more to weed out mentally ill, drug addicted and senile physicians than the current system now in place!
Do you expect that the Post articles will be a catalyst for change?
Arthur Caplan, Ph.D.: I hope so. But, the broken system of medical licensing has been around for many, many years. We really need to write our legislators and demand that tougher standards to hold a medical license and keep it be a part of any effort to reform malpractice at the state of federal levels.
No question really except to say that I was responsible for filling out forms from other states for our former residents and interns (and fellows). By looking at their files, I would look and see if there were any disciplinary problems, etc. The attendings were very loathe to put anything negative in these files. I can only think of one time when there was something negative in the file and it was more a personnel issue between a doctor and a nurse about lost belongings.
If the attendings had trouble honestly assessing any potential problems with their interns, residents and fellows and RECORDING it for posterity, I am not surprised that they cannot police their own colleagues. I just remember that book by James Stewart on the physician who was possibly responsible for the most mass murders and he got by because no one would put anything down on paper for fear of suing and because they thought he deserved a second chance. (I still can't believe after he poisoned his ER squad for fun that he was allowed back into medical school for example)
Arthur Caplan, Ph.D.: You can't trust what people write in records because there's too much protection of one another. If we really want the truth we may need to create a no fault system like the airline systems use. When a plane crashes the FAA investigates but their finding cannot be used in court. That's a system that may work well for medicine too.
OK, I understand the concept of supporting each other and never stabbing someone in the back within your profession. (Or whatever term one wants to use such as the Blue Wall for Police)
BUT here's the part I don't understand -- The recent WP article details how doctors and hospitals dread turning in a fellow doctor as "incompetent" or dangerous. YET by doing so they aren't the simply adding to the cost of malpractice insurance? Is the professional 'brotherhood' more important than taking steps to keep premiums down and therefore help hold the line on health care costs.
Certainly I believe in tort reform to reduce frivolous lawsuits but aren't we at a breaking point here where society needs doctors and all medical professionals to join ranks and clean up the profession. As long as the sort of 'coverup' described in the WP article continues to allow bad doctors to keep practicing medicine,(In the worst sense of practicing here too1) we all are being hurt by the bad doctors and medical professionals in our country. What will it take to stop this problem?
Arthur Caplan, Ph.D.: I can only agree. That is a great note to end on. We have to demand that doctors put patients and the public health first, not the protection of the failed members of their profession. Doctors will never get malpractice relief unless they push to clean out their worst offenders. Nor should we allow malpractice reform without that promise.
Arthur Caplan, Ph.D.: Thanks very much for these very useful and intelligent questions. If you want to email me offline, please do at firstname.lastname@example.org.