Why do we keep letting dangerous doctors put patients at risk?

This issue of our newsletter is personal for me. More than 40 years ago, when I was a young medical reporter at the Miami Herald, I first encountered our nation’s broken system of disciplining dangerous doctors and protecting patients. 

It’s still broken, I’m sorry to say.

And it’s broken in the same ways and for a lot of the same reasons that existed in the 1970s when a team of reporters that I was part of published an award-winning series of articles called “dangerous doctors.”

Our regulatory bodies – especially the boards in every state that have the power to keep or revoke a doctor’s license to practice medicine — are still under-funded, under-motivated, under in a lot of ways that expose patients to unnecessary risk of serious harm.

The vast majority of doctors are dedicated, competent, careful human beings. But then there are the others…

For the sake of our safety — especially when we are most vulnerable while seriously ill or injured and in doctors’ care — it is vital to understand the key reasons — at least five of them — as to how and why physicians put patients at high risk and harm them.

Popular media, with soap operatic portrayals of them, strives to show that doctors have many ordinary shortcomings. Still, a lot of us can’t set aside a positive bias. We admire doctors, notably now because of the valiant care many doctors have provided during the coronavirus pandemic. Public opinion polls show that doctors consistently rank high for the trust we put in them and the quality of their work.

Alas, doctors are human, and research shows they are all too fallible. In pre-pandemic times, experts found that medical errors claimed the lives of roughly 685 Americans per day — more people than died of respiratory disease, accidents, stroke, and Alzheimer’s. That estimate came from researchers led by a professor of surgery at Johns Hopkins. Medical blunders have only worsened as the pandemic overwhelmed the U.S. health care system, reported Becker’s Hospital Review, an industry news outlet:

“Health care workers are burned out and exhausted from juggling pandemic-related stressors and additional burdens linked to workforce shortages for more than two years. These issues pose serious consequences for employees and patients, as numerous studies link clinician burnout and stress to an increased likelihood of medical errors. The full picture of how Covid-19 has affected patient safety is still unclear, but emerging data on health care-associated infections and other forms of patient harm suggest significant lapses have occurred amid the pandemic.

“The number of serious patient safety incidents reported to The Joint Commission jumped in 2021, reaching the highest annual level seen since the accrediting body started publicly reporting them in 2007. The organization received 1,197 reports of sentinel events last year [incidents that result in death, permanent harm, or severe temporary harm], up from 809 in 2020.”

As for doctors’ role in determining the fundamental causes of what may be wrong with us, the Society to Improve Diagnosis in Medicine provides disconcerting data. These researchers, health care providers, advocates, and others who seek to improve practices in the field to benefit patient safety, report this of misdiagnoses:

Every nine minutes, someone in a U.S. hospital dies due to a medical diagnosis that was wrong or delayed. Roughly one in 10 patients with a serious disease is initially misdiagnosed. Diagnostic errors affect an estimated 12 million Americans each year and likely cause more harm to patients than all other medical errors combined. Misdiagnoses boost medical costs through unnecessary tests, malpractice claims, and costs of treating patients who were sicker than diagnosed or didn’t have the diagnosed condition. 

In a perfect world, doctors would be among the first to report peers for mistakes, impairment, or incompetence. It doesn’t occur as it should even though ethical duties require such.

Researchers have found that doctors worry, incorrectly and excessively, about malpractice lawsuits and fear getting mired in sorting out others’ messes. They fret that they will subject themselves to colleagues’ harsh reactions if they break an unspoken bond of peer silence. A handful of cases that have gotten widespread media coverage show that doctors and hospitals will stay silent about negligent, abusive, and poor-performing doctors hoping, instead, that with professional nudging the bad actors will just move on.

Besides providing peer oversight, doctors also are supposed to be scrutinized by hospitals granting them practice privileges. But hospitals can be both too lax in investigating doctors and, at the same time, bogged down in laborious processes that administrators hope will shield themselves from the possibility of lawsuits by patients or doctors over “negative credentialing,” news reports on ghastly serial malpractice cases have shown.

Doctors and hospitals, by the way, may point to institutional “morbidity and mortality conferences,” formal sessions in which doctors gather and dissect why treatments and procedures failed, as an important way to improve medical care and safeguard patients. While hundreds of hospitals, and especially academic medical centers, may run the sessions, many stopped them during the pandemic, and it is unclear when or if they will resume.

Critics call it a relic of the past. But this country leaves it to each of the 50 states to determine their own requirements for its doctors to be licensed to practice medicine. The boards that also are supposed to take public complaints, investigate them, and punish doctors for wrongdoing happen to be made up mostly of, yup, doctors.

CBS News spent a year investigating medical licensing authorities nationwide, reporting that they claim their main focus is patient safety. But they act otherwise — chiefly to protect doctors and to go easy on punishing miscreants. Consumer Reports found this to be true in its investigations, and the Los Angeles Times reached similar infuriating conclusions in its deep dig on California’s medical board.

The doctors who get off light and keep their licenses do so despite the serious harm they inflict on patients, the news reports show. Patients have endured bungled surgeries, wires and other materials left in their bodies, toxic combinations of drugs prescribed for them, and sexual misconduct.

Few doctors show up with formal sexual abuse complaints by patients in a national database that is supposed to catalog physician wrongdoing, the nonprofit advocacy group Public Citizen has found. The group further found that doctors against whom there are such complaints too often (in 38% of cases) kept licenses and continued to practice. Scandal after scandal involving universities and sexual abuse by doctors of female and male students — athletes and those using school health services — have shown how medical boards suspended or revoked M.D. licenses far too late, after dozens and even hundreds of young people were victimized.

Critics have ripped licensing boards nationwide for allowing themselves to be politicized during the pandemic, failing to rein in doctors who have spread extreme disinformation and anti-science hokum. Extremist doctors largely appear to have skated by medical board oversight while promoting, without evidence or even in opposition to research and established standards of care, prescription drugs and other treatments debunked for Covid-19.
 

When doctors get in trouble for repeated malpractice on patients, too many of them just mosey down the road and practice elsewhere. That’s because the professional licensing system is a state-by-state patchwork, with a lax and unworkable national reporting system.

The Milwaukee Journal-Sentinel and MedPage Today dug into medical board records across the country to find at least 500 hop-scotching and problematic practitioners. They included a Colorado doctor whose care of a multiple sclerosis patient caused four other MDs to complain to the state medical board when the patient died in 2011. The board and the doctor agreed he was “permanently inactivating” his license in 2014, meaning he can’t ever get it back. But the doctor also practiced in Florida, where he worked with no restrictions, despite malpractice lawsuits from seven other patients in two states, all accusing him of MS misdiagnoses. Reporters also found a New York plastic surgeon who had sex with a patient and had his license suspended for three years. He was permanently ordered to have a chaperone present whenever treating any female patients in the Empire State. But he operated free of medical restrictions in Wisconsin. There he was appointed to an endowed chair at the University of Wisconsin-Madison, funded in part by billionaire Diane Hendricks, a patient and major political contributor to Gov. Scott Walker.

How can doctors so easily skip the consequences of their wrongdoing just by moving? Critics, including the consumer rights group Public Citizen, blame the National Practitioner Data Bank, a creaky 30-year-old system. It is supposed to help inform hospitals and state boards about problem doctors, the investigation found.

But as reporters have found, “it has never been available to the public, provides only portions of troubled medical backgrounds, and even state medical boards rarely turn to it.” Further, as Public Citizen and others have found, the database likely falls far short in capturing grievous wrongs committed by doctors due to underreporting of key information by hospitals and others. Half of all hospitals have not made any reports at all to the database in two decades, Public Citizen has reported. Part of this problem is rooted in big disciplinary disparities among state medical boards, with the consumer group finding many low rates while a few act with rigor.

By the way, risky doctors’ moves may not involve much geography at all. In one infamous case, an orthopedic surgeon whose work was so egregious that prosecutors finally charged him criminally eluded consequences of his misconduct for a while by moving around hospitals in a metro area. In another much-publicized case, also involving a problem orthopedist, he skirted oversight by moving only a few miles away — across the border to a neighboring state. Stanford researchers also found that doctors with multiple settlements in malpractice lawsuits too often left big practices for smaller ones, perhaps with two or three others. That poses problems because that means the problem doctors likely had less collegial oversight and support — and greater responsibilities.
 

Doctors deserve a ton of credit for putting in years of hard work to earn medical degrees and then to qualify for licenses in the state(s) where they practice. It also is true, though, that some of them “drift,” providing or supervising medical services in which they have scant training.

This challenging situation has its roots in medical history and current economics. In days of yore, small-town general practitioners needed to provide a vast array of care — from delivering babies to performing surgeries and managing complex, chronic conditions. So the law recognized that a licensed M.D. could practice just about any type of care from head to toe and in between.  Over time, though, doctors specialized and set up boards to certify members who underwent extended periods of training and supervised practice in various fields. Hospitals respected physician groups’ higher standards and insisted that doctors be board certified to provide specific treatments within their walls. Doctors, though, have drifted from the high bar, partly, perhaps, for patient convenience and because it can be profitable for them to do so.

Because many states allow it, doctors may perform procedures for which they may not be “board certified.” They may argue, instead, that they have taken short courses, in person, or online, or gone to conferences to acquire new expertise. They also may medically supervise others in performing certain procedures allowable under the oversight of anyone who is a licensed M.D. In some states, an obstetrician-gynecologist or a psychiatrist might provide medical oversight for facilities offering cosmetic treatments.

Hospitals also have become so pricey that practitioners have moved to less costly sites. USA Today and the Kaiser Health News service have raised significant questions about the safety and quality of care at free-standing surgical centers, where the drive for profits can leave patients vulnerable to harm, including problems with anesthesia and the facilities’ inability to assist patients when emergencies happen. (See the nightmare with comedienne Joan Rivers.) 

The Leapfrog Group, a national watchdog organization of employers and other purchasers focused on health care safety and quality, has begun to rate surgical centers for safety and quality, just as it has hospitals. The group has reported that 60% of surgical procedures occur on an outpatient basis now. Leapfrog has raised concerns that its surveys show “gaps in the education, training and national certifications of clinicians” working in surgical centers and hospital outpatient facilities, notably in whether medical staff have the advanced expertise to treat surgical patients who need emergency rescue. Maryland and the District of Columbia cracked down on med spas after infections — including a death — occurred among patients.