A significant minority of physicians responding to a national survey disagreed with or admitted not upholding accepted standards of professionalism for open and honest communication with patients. In the February issue of Health Affairs, investigators from the Mongan Institute for Health Policy at Massachusetts General Hospital (MGH) report that, among other findings, one fifth of respondents indicated they had not fully disclosed a medical error out of concern for malpractice lawsuits and about one tenth admitted telling a patient something that was not true during the preceding year.
"While most of those responding to our survey gave answers consistent with the norms of professionalism, in a few instances we found significant deviations," says Eric G. Campbell, PhD, director of research at the Mongan Institute and principal investigator of the study. "Our concern lies not with a specific finding but with the whole body of findings, which call into question one of the fundamental aspects of the doctor/patient relationship."
The authors cite a 2001 report from the Institute of Medicine that listed patient centeredness – defined as "care that respects patients' preferences, needs and values" – among six essential features of high-quality health systems. They also note that the Charter on Medical Professionalism, written in 2002 and endorsed by more than 100 professional groups, lists patient welfare as a first principle, patient autonomy as second and states that physician honesty is essential to informed decision making. Since the extent to which these principles are actually followed by U.S. physicians was not known, the investigators included questions on physician/patient communications in a 2009 survey addressing broad issues of medical professionalism.
Five questions on the survey specifically addressed attitudes related to communication – including whether physicians should fully inform patients of the risks and benefits of their treatments, disclose all significant medical errors to patients and always keep patient information confidential – and four addressed what respondents had actually done in the preceding year. The survey was sent to 3,500 U.S. physicians – 500 each in internal medicine, family practice, pediatrics, cardiology, general surgery, psychiatry and anesthesia – and almost 1,900 surveys were completed and returned.
The overhelming majority of respondents agreed that physicians should completely inform patients about risks and benefits, never disclose confidential information and never tell a patient something untrue. While 66 percent agreed that all significant medical errors should be disclosed to affected patients, one third did not completely agree. Also, about one third did not agree that financial relationships with drug and device companies should always be disclosed. When asked about their own behavior in the preceding year, almost 20 percent admitted not fully disclosing a medical error for fear of being sued, 28 percent admitted revealing a patient's health information to an unauthorized person, and 11 percent responded that they had told a patient or the parent of a child something that was not true.
When demographic information was analyzed, women and members of minority groups traditionally under-represented in medicine were more likely than white males to indicate upholding Charter principles – something the authors note could reflect greater consciousness of the need to comply with professional standards among those groups. They also noted that admissions about not always telling the truth – which included describing a patient's prognosis in a more positive manner than was accurate – could reflect the complexities of modern medical practice and physicians' interpretation of what individual patients actually want or need to know.
"We need to encourage patients and their families to ask questions and make clear to their physicians the extent to which they desire full and open communications," says lead author Lisa Iezzoni, MD, MSc, director of the Mongan Institute at MGH and a professor of Medicine at Harvard Medical School (HMS). "Patients should feel free to ask about relationships their physicians might have with pharmaceutical or device companies, especially when new medications or procedures are being recommended; but most often the issues will involve the information patients want about their prognosis and other aspects of their health condition."
Campbell, an associate professor of Medicine at HMS, notes that survey responses may actually underestimate how frequently physicians fail to uphold accepted standards and adds that future studies should examine factors that underlie the attitudes and behaviors reported in this survey. Co-authors of the study – supported by a grant from the Institute on Medicine as a Profession – are Sowmya Rao, PhD, Catherine DesRoches, DrPh, and Christine Vogeli, PhD, all of the Mongan Institute for Health Policy at MGH when this paper was written.
Massachusetts General Hospital (www.massgeneral.org), founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH conducts the largest hospital-based research program in the United States, with an annual research budget of more than $750 million and major research centers in AIDS, cardiovascular research, cancer, computational and integrative biology, cutaneous biology, human genetics, medical imaging, neurodegenerative disorders, regenerative medicine, reproductive biology, systems biology, transplantation biology and photomedicine.
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