Doctors and the Deadly Anti-Snitch Reflex

Everybody, or almost everybody, hates to report friends and colleagues for misconduct. This is the anti-snitch reflex, a strongly programmed response from childhood. Telling authorities about the misconduct of others sets off internal alarms that have been installed by parents and peer groups, ensuring that we feel terrible if we “tattletale.” This is betrayal, a violation of loyalty, and most of all, a breach of the Golden Rule: we’d never want anyone to snitch on us.

For professionals, however, this reflex is false, mistaken and even deadly. The duty to report dishonest public employees, crooked cops, unethical lawyers, conflicted accountants, self-dealing business executives, fraudulent researchers and others in the workplace—even if they are colleagues and friends—trumps childhood codes, personal loyalty and general discomfort. There is nothing noble or admirable about allowing innocent people to entrust their life and livelihood with untrustworthy professionals. Nevertheless, a disturbing large proportion of all professionals can’t bring themselves to do the right thing when it comes to the core ethical duty of stopping workplace dishonesty, incompetence or corruption when it involves a colleague.

A recent survey of doctors is not comforting, but it confirms the problem. Published online  in the Journal of the American Medical Association,  the study used data from a 2009 national survey of close to 3,000 physicians practicing in anesthesiology, cardiology, family practice, general surgery, internal medicine, pediatrics and psychiatry. They answered queries about their duty to report other physicians who were incompetent or impaired by drugs or alcohol, their comfort level in doing so, and their experiences encountering the issue.

About 70% of physicians said they would report impaired physicians, and 64% said they would blow the whistle on incompetent ones. More than a third, 36%, said they did not have a professional commitment to “snitch.”

Pediatricians and family practice doctors were the least likely to say they felt prepared to deal with impaired or incompetent colleagues; anesthesiologists and psychiatrists apparently felt most prepared. The survey results showed that 17% of respondents had encountered an impaired or incompetent physician colleague in their hospital, group or within in the previous three years. Of these physicians, 67% said they had reported colleague, which is only slightly better than the 64% predicted by the survey’s responses to hypothetical situations.

The respondents who chose not to report the incompetent or impaired doctors in their midst tended to explain their non-action by citing their belief that someone else was going to report and the belief that a report would be futile. Prof. Catherine DesRoches of Harvard Medical School, who was the lead author of the study, concluded from this that the problem was the reporting system itself. “By targeting these two main issues — the belief that someone is taking care of it or that nothing will come of the report — we can increase the numbers of physicians who are both willing to report and feel prepared enough to do so,” she told the Los Angeles Times.

Wrong. Prof. DesRoches apparently doesn’t recognize rationalizations when she sees them. These are classic ones—“Somebody else will do it, so I don’t have to,” which falsely justifies ducking personal responsibility, and“It’s futile, so why bother?” which allows the shifting of blame to others, or “the system.”. The reason a third of doctors don’t report is that they have been taught since childhood that it is wrong to be a snitch, and such a deep and long-held belief can’t be dislodged by a training session or a pamphlet.  Prof. DesRoches says she wants to see more education on the responsibility of physicians to report impaired or incompetent colleagues and the development of systems that both ensure confidentiality and notify the reporter when the issue has been addressed. This can’t hurt. Still, these measures won’t deal with the underlying ethical problem, which is a miswired ethics alarm. Most of those 36% of doctors know they have a duty to report. They just don’t want to do it, because deep down, they think being a snitch is wrong, and they don’t want to be one.

4 thoughts on “Doctors and the Deadly Anti-Snitch Reflex

  1. When I read about this study a few weeks ago I was stunned that so many physicians wouldn’t report colleagues. The story I read included comment from a doctor who had been reported by a colleague years ago for alcohol abuse. The doctor said being reported was the best thing that could have happened to him, because he got the help he needed and now has a successful practice. It’s a shame there are educated professionals out there that just don’t want to get involved, even when it could mean a patient could get hurt…or worse.

  2. I think there is more to this than meets the eye. Don’t forget the “God” complex. If I report you as “imperfect” and you are my colleague, and therefore like me, or “alike unto me”, then why will I not be next? You have to remember that those who enter this field often have a need to matter, as confirmed by others, to be in authority, as confirmed by others. After all, do you want a slacker for a doctor? In other words, they have an underlying personal insecurity (don’t we all in some way or another?) and that’s their way to deal with it. Indeed, this need must be fairly deep in order to endure all that it takes to become a trained physician (at least as it was 30 years ago, with some similarities today). So if you’ve done it, and you know your colleague has done it, are you going to destroy what it has taken you both 25 years of schooling to achieve?

  3. You must realize that these numbers are disgraceful. It works out to 11% of respondents claim they reported coworkers for malpractice. Over half of the people I have seen go into the hospital in the last 5 years has been the victim of malpractice. By malpractice, I mean delivering all remaining doses of a morphine pump to a patient at once (accidentally…oopsie), taking a heart patient off of all 17 of her medications and making her take a new medicine without letting her call her regular cardiologist (and almost overdosing her on nitrocream), refusing to see a kidney patient who can’t urinate for 3 days, letting a 10 year old seize for 8 hours because you don’t know what to do and don’t want to wake up the neurologist for a kid with a poor mother, sending a pregnant woman with a distended uterus home with some 4×4’s and telling her to see her OBGYN the next week, etc. Any physician who is working in a hospital setting probably sees malpractice on a weekly basis at least, but only 10% say they have reported it (I do realize that not all physicians work in a hospital setting).

    We need to start regulating physicians at the state level. Self-regulation doesn’t work. If hair-stylists need to be regulated, licensed, and inspected by the state, I think physicians should be too.

  4. The instances Michael reports are truly disgraceful, and I don’t know this place, although I assume some big city hospital. As a radiologist, I see only some of such mistakes through their imaging. The fact that I don’t experience such a high proportion of medical errors may reflect this.

    As former Quality Assurance Director for a Department of Medicine in a big city hospital some years ago, such cases were brought to my attention, and indeed some cases were thorny, such as when some specialists threatened to take their business elsewhere if sanctions or limitations were imposed, or they were prevented from doing procedures for which they believed they were qualified, but for which others were well-trained for. Keep in mind, also, that a complaint, a sanction or other disciplinary action can be career-ending. Indeed sometimes perhaps it should be, but proctoring, re-education, mandatory consultations, and, of course, substance abuse counseling can be helpful also. I have been on the receiving end of this, and sometimes the motivations for reporting were related to political or interpersonal issues.

    Of course, the expectation that every medical encounter be conducted perfectly, with perfect outcome creates a very high standard, impossible to meet all of the time. Having outside regulatory agencies isn’t the answer either, because then bureaucracies are created that MUST find error in order to justify their existence. Nevertheless, the system could be improved.

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