THE PROBLEMS OF EGREGIOUS ETHICAL VIOLATIONS IN HEALTHCARE
Through a study funded by the NIH National Institutes on Aging, our team reviewed the literature and analyzed 280 cases of serious ethical violations in medicine.1 Serious ethical violations include:
Sexual abuse of patients by physicians
Criminal prescribing of opioids
Performing unnecessary surgeries
The majority of healthcare professionals are trustworthy and follow the rules of their profession and the law. However, a few use their professional power to access and prey on trusting patients. In fact, the rate of severe disciplinary actions against physicians is “similar to the rate of new diagnoses of breast cancer each year and much more common than new diagnoses of HIV — both of which are widely recognized as urgent challenges for medicine and public health.”2,3
Physicians and institutions are in a perfect position to help
It may be challenging to stop wrongdoing before it happens; however, physicians and institutional officials are often in a position to identify and report bad actors quickly and stop wrongdoing so it does not continue. Protecting the safety of patients requires that peers and institutions recognize wrongdoing early and that medical boards take decisive action.
Cases of egregious ethical violations frequently attract media attention and harm the reputation of the medical profession. Here are a few examples:
Dr. Manzella was an infectious disease physician, who obtained thousands of oxycodone pills by writing fraudulent prescriptions and working with a con man who sold them on the black market. Manzella worked in a private practice with his brothers who did not know about the scam.4
THE 5 R’s
This guide provides direction for physicians and institutional leaders to prevent and respond to ethical wrongdoing by following five specific steps—the 5 R’s
RECRUIT TRAINEES, PHYSICIANS, AND STAFF WHO EMBRACE THE POSITIVE CORE VALUES OF MEDICINE
When individuals with integrity join an organization, it contributes to a culture where unethical behavior is both rare and not tolerated7. When you are not clear about your options, your diagnosis, or how well an expensive test or treatment will work. Don’t worry about offending your doctor — second opinions are part of standard medical practice. Your doctor will want you to have the best information to make your decisions.
Throughout the recruitment process, clearly articulate institutional commitment to the positive core values of medicine8
When seeking letters of recommendation or references, pay special attention to matters of character
When hiring, use the National Practitioner Data Bank and related resources to identify individual histories of ethical violations9*
Be honest about performance and character when serving as a reference for a former employee, or refuse to serve as a reference
*Unfortunately, the most commonly used categorizations of violations are “not specified” and “other.” Later we address the need for improved reporting and tracking processes.
RECOGNIZE PROBLEM BEHAVIORS
Sometimes peers or colleagues are uncertain when behaviors cross a line. In other cases, wrongdoing is permitted to continue because there is very little oversight. Recognizing problem behaviors and creating an environment where recognition of problem behaviors can occur is imperative to ensuring the expectations of the practice, institution, and healthcare profession are being met.
- Establish, teach, and model clear guidelines and policies on medical practice and sexual boundary issues
- Train physicians and staff to recognize violations of guidelines, policies, and laws
- Increase the transparency of physician practices through the routine use of chaperones, prescription drug monitoring programs, peer audits, 360° feedback surveys,10 and increased presence of staff and trainees11
- Advocate for system reform for improved data collection protocols to track serious violations effectively, making it easier to recognize people with a history of serious violations
Patterns of known unethical behavior may go undetected for months or even years. This often happens when witnesses feel unsafe reporting, are unsure to whom they should report, or when entities processing and tracking reports fail to keep detailed and useful records.
- For medical students, residents, and fellows, train faculty to report to the dean or similar office to track students’ violations for the entire duration of their time in school
- When reporting physician wrongdoing, avoid the use of vague classifications (e.g. not applicable, other). Rather, describe the specific behavior
- Establish clear and safe policies and procedures for employees to report suspected or known wrongdoing
- Take all reports seriously, and thank individuals who do report
- Train employees to offer guidance to patients on how to report to the State Medical Board or the police12
- Visit www.PreventingSexAbuse.org to learn more about reporting options
- Know what you are required to report, and educate employees to know what they are required to report.12 In many cases, there are federal or state laws that mandate reporting for the types of wrongdoing listed below. There are often reporting mandates from organizations, funders, institutions, and the Federation of State Medical Boards.
Events that physicians and institutions may be mandated to report:
- Sexual misconduct or sexual abuse
- Physical abuse or neglect of a patient
- Prescribing drugs in excess or without legitimate reason
- Conviction of a felony
- Dishonesty during the license application process or failing to meet continuing medical education requirements
- Inadequate record keeping
- Failing to meet the accepted standard of care in a state
Obligations to report may also go beyond the law.
Physicians get into trouble for a variety of behaviors ranging from minor mistakes to major indiscretions or criminal behavior. For more minor infractions, rehabilitation education is an important tool that institutions should have. Rehabilitation programs help good doctors gain professional skills, learn how to manage stress and anger, and become better communicators.
- Identify those who need remediation early. Keep in mind that sometimes more minor violations precede or accompany more serious violations
- When appropriate, intervene early with evidenced-based programs such as:
- Reassess skills, oversight, and practice requirements
REMOVE THE MOST EGREGIOUS WRONGDOERS
- When necessary to protect patients, do what it takes to efficiently remove a medical student or physician from the medical profession – not just your institution.* This may involve:
- Reporting physicians to appropriate investigating bodies
- Cooperating with investigations
- Terminating enrollment or employment
- Report findings or actions to the National Practitioner’s Data Bank or other appropriate organizations
Investigating Egregious Wrongdoing in Medical Practice
The goal of this project was to examine individual and environmental factors that predict serious breaches of medical ethics with the aim of developing prevention programs. The research team analyzed 280 cases in three areas of clinical wrongdoing: improper prescribing of controlled substances, sexual abuse of patients, and fraudulent, unnecessary invasive procedures. While these behaviors are relatively rare among physicians, they are very damaging to patients and harm public trust in medicine. A working group of experts convened in St. Louis to discuss the data and develop recommendations for action related to education, remediation, policy, and oversight.
WANT TO LEARN MORE?
DuBois, J. M., Anderson, E. E., Chibnall, J. T., Diakov, L., Doukas, D. J., Holmboe, E. S., . . . Whelan, A. J. (2018). Preventing egregious ethical violations in medical practice: Evidence-informed recommendations from a multidisciplinary working group. Journal of Medical Regulation, 104(4), 23-31.
Dubois J.M., Bante, H., Hadley, W.B. (2011) Ethics in psychiatric research: A review of 25 years of NIH-funded empirical research projects. AJOB primary research, 2(4), 5-17.
DuBois J.M., Chibnall, J.T., Anderson, E.E., Eggers, M., Baldwin, K.A., Vasher, M. (2016). A mixed-method analysis of reports on 100 cases of improper prescribing of controlled substances. Journal of Drug Issues, 46(4), 457-72.
DuBois, J. M., Chibnall, J. T., Anderson, E. E., Walsh, H. A., Eggers, M., Baldwin, K. A., & Dineen, K. K. (2017). Exploring unnecessary invasive procedures in the United States: A retrospective mixed-methods analysis of cases from 2008-2016. Patient Safety in Surgery, 11(1), 30.
DuBois, J. M., Walsh, H. A., Chibnall, J. T., Anderson, E. E., Eggers, M. R., Fowose, M., Ziobrowski, H. (2017). Sexual violation of patients by physicians: A mixed-methods, exploratory analysis of 101 cases. Sex Abuse,31(5), 503-23
1.DuBois, J.M., Anderson, E.E., Chibnall, J.T., Mozersky, J., Walsh, H.A. (2019). Serious ethical violations in medicine: A statistical and ethical analysis of 280 cases in the United States from 2008–2016. The American Journal of Bioethics, 19(1), 16-34.
2.DuBois, J. M., Anderson, E. E., Chibnall, J. T., Diakov, L., Doukas, D. J., Holmboe, E. S., . . . Whelan, A. J. (2018). Preventing egregious ethical violations in medical practice: Evidence-informed recommendations from a multidisciplinary working group. Journal of Medical Regulation, 104(4), 23-31. doi:10.30770/2572-1852-104.4.23
3.National Center for Health Statistics. (2017). Health, United States. In Health, United States, 2016: With Chartbook on Long-term Trends in Health. Hyattsville (MD): National Center for Health Statistics (US).
4.Hall, P. (2013). Salisbury doctor charged in prescription drug ring. The Morning Call. Retrieved from https://www.mcall.com/news/local/mc-xpm-2013-08-01-mc-jim-thorpe-doctor-manzella-charged-pill-mill-20130801-story.html
5.In the Matter of the First Amended Accusation of David Hung Do, M.D. (2011). Physician’s & Surgeon’s Certificate No. A 92915 Decision, Medical Board of California Department of Consumer Affairs State of California.
6.Pickert, K. (2013). Medicare fraud horror: Cancer doctor indicted for billing unnecessary chemo. TIME. Retrieved from http://nation.time.com/2013/08/15/medicare-fraud-horror-cancer-doctor-indicted-for-billing-unnecessary-chemo/
7.Schneider, B. (1987). The people make the place. Personnel Psychology. 40(3), 437-53.
8.Roberson Q.M., Collins, C.J., Oreg, S. (2005). The effects of recruitment message specificity on applicant attraction to organizations. Journal of Business Psychology. 19(3), 319-39.
9.Harvan, A.C. (2018). The ABCs of the National Practitioner Data Bank: What physicians should know. Pennsylvania Medical Society. Retrieved from https://www.pamedsoc.org/detail/article/national-practitioner-data-bank-part1.
10.Donnon T., Al Ansari, A., Al Alawi, S., Violato, C. (2014). The reliability, validity, and feasibility of multisource feedback physician assessment: A systematic review. Academic Medicine, 89(3), 511-6.
11.DuBois, J.M., Chibnall, J.T., Anderson, E.E., Eggers, M., Baldwin, K.A., Vasher, M. (2016). A mixed-method analysis of reports on 100 cases of improper prescribing of controlled substances. Journal of Drug Issues, 46(4), 457-72.
12.Federation of State Medical Boards. (2016). Position statement on duty to report. Washington DC: Federation of State Medical Boards.
13.Connor, T. (2018). Larry Nassar gets another 40 to 125 years in sex abuse case. NBC News. Retrieved from: https://www.nbcnews.com/news/us-news/larry-nassar-gets-another-40-125-years-sex-abuse-case-n844676.
All contributors are affiliated with the Bioethics Research Center at Washington University School of Medicine
Meredith Parsons, BS, CHES
Heidi Walsh, MPH, CHES
Jessica Mozersky, PhD
Tristan McIntosh, PhD
Erin Solomon, PhD
Kari Baldwin, MSW, CRC
James DuBois, DSc, PhD – Principal Investigator
Meredith Parsons, BS, CHES
Patricia Curran, BFA