Practice of Medicine
Don’t Make Your Patient a Victim: When Doctors Criticize Other Doctors
December 29, 2016
"Jousting" is the unfortunate practice of one health care professional making derogatory comments about another provider’s care, either to the patient, or in the chart, and without having reviewed all the pertinent records, or discussing his concerns with the previous physician. We have often seen jousting as the cause of medical litigation, but until recently, jousting had never been studied. A 2013 article in the Journal of General Internal Medicine[i] shed light on this hitherto known but underappreciated practice.
Researchers from Rochester, Purdue, and Michigan wanted to know how physicians talked about other physicians to seriously ill patients. They evaluated this by enlisting standardized patients (SPs) to portray middle-aged men with advanced lung cancer. The medical record was constructed by a medical oncologist and reflected standard of practice care.
The SPs visited family medicine and oncology physicians and the visits were secretly recorded. The SPs presented for a first visit without the physicians’ knowledge of the study. The SPs were not to ask opinions about their previous care and previous physicians. The transcripts of these visits were analyzed and divided into neutral, supportive, or critical. Of the 34 encounters, 41 percent contained comments about prior care. Within a total of 42 comments, 12 were supportive, 28 were critical, and two were neutral.
One of the interactions went like this:
“So he radiated your ribs not your…,” said Dr. 25.
“Yeah,” said the SP.
“That guy’s an idiot,” said Dr. 25.
“Doctors will throw each other under the bus,” said Susan H. McDaniel, M.D., lead author of the study from the University of Rochester Medical Center. “I don’t think they even realize the extent to which they do that or how it can affect patients.”
Jousting comes in many forms. When one physician criticizes another, both may be at increased risk for litigation. When a patient hears criticism, he or she may feel the care they received was inappropriate. The words they hear may lead them to seek legal counsel regarding litigation. A glance away, a look of incredulity, or an offhand comment may also be enough to trigger the feeling that care was inadequate.
We always try to do our best for our patients. Medicine is complex and often we are treating patients early in the course of their illness or relying on gut instincts in the care of the patient. Autopsy studies suggest that we are wrong at least 10 percent of the time in our diagnosis and treatment decisions. It is much easier to make the right call when looking back at a case after tests are all in and the illness has evolved. Hindsight is indeed 20/20. Often those who criticize don’t have a clear understanding of what has happened and are jumping to a conclusion with incomplete facts or just the patient’s side of the story.
Jousting can also occur outside of in-person interactions. A chart entry may also be damaging. “Dr. A did not return his phone calls as is usually the case,” could be an example of a note in a chart that casts a bad light on the physician. Even if the care is good, that physician may have a difficult defense related to that note.
“There is probably something reassuring in saying, ‘Boy, your doctor didn’t do a good job and now I’m going to take care of you’,” noted Dr. McDaniel. “But those kinds of comments are bad for the patient…In the moment, criticizing another physician to a patient might have felt like an effective way to fortify their own credentials and build up the patient’s trust.” Perhaps the only way we can put ourselves in suffering's way or perform complex surgeries is to feel we can do a better job than other providers.
Whatever the reason or form jousting takes, The American College of Physicians Ethics Manual states “It is unethical for a physician to disparage the professional competence, knowledge, qualifications, or services of another physician to a patient or third party or to state or imply that a patient has been poorly managed or mistreated by a colleague, without substantial evidence.”[ii]
Teams and teamwork are at the core of health care delivery these days. No one person can deliver all the parts of a patient’s care. Therefore, we need to have clear communication between specialists, generalists, and subsequent physicians. Jousting has a profound effect on providers and on the emotional and physical well-being of the patient, and reflects an erosion of collegiality and professionalism.
Finally, after investigation, a physician may sometimes discern care or treatment that is clearly inappropriate or substandard. In this case, it is appropriate to discuss the situation with patients, with care and concern for what is best for them. While is it inappropriate to make negative comments about other physicians, a patient deserves an honest response with the most accurate information available. Trying to ascertain the facts, observations and thought processes used by another physician is challenging. It is important to relay this to the patient in a neutral way. As we have outlined, there are often other drivers to making negative statements. In the JGIM study above (where the records showed guideline-concordant care), critical remarks were still seen in one-third of the visits. Physicians must be aware of their own reactions and other reasons that can lead to negative comments.
None of this discussion should prevent health care providers from reporting care that they believe to be inappropriate or in significant need of improvement through the appropriate process. Ideally, such reports should involve the discussion with and appreciation of the perspective of the provider in question. Professional review proceedings, licensing board proceedings, or other entities that perform comprehensive investigations based on all the necessary information, are strongly encouraged when health care providers are unable to communicate and/or come to a performance improvement plan, or have determined a significant issue exists that adversely affects patient care. "Jousting" has none of these elements.
In closing, John Shaw Billings, M.D. (creator of the Index Medicus) stated in 1878 that “There may have been a time when the physicians of some favoured country were entirely satisfied with each other’s professional skills; but the records of that period have been lost.” Apparently little has changed since then.
[i] J Gen Intern Med 28(11):1405–9 May 2013
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