Book Review

Problem Doctors: A conspiracy of silence

N Engl J Med 1997; 337:1093October 9, 1997

Article

Problem Doctors: A conspiracy of silence
Edited by Peter Lens and Gerrit van der Wal. 274 pp. Burke, Va., IOS Press, 1997. $76. ISBN: 90-5199-287-4

Several studies have suggested that 5 percent of practicing physicians could be considered problem doctors. Although there is no agreed-on definition of “problem doctors,” it is a term that has been used to encompass a wide range of behavior, including physical and mental impairment, substance abuse, inappropriate sexual contact, and professional incompetence. Most of the literature has addressed efforts to rehabilitate impaired physicians, but little has been written about the underlying causes, methods of identification, and prevention.

The editors of Problem Doctors have selected an excellent group of contributors who are working on the issues of problem doctors. The book has three discrete sections, addressing themes and issues, international experience, and prevention, treatment, and solutions. In the first section, an elegant essay by Marilyn Rosenthal addresses professional autonomy and physician self-regulation. She describes the uncertainty and fallibility physicians must live with on a daily basis. This can cause reluctance to criticize colleagues and a “conspiracy of tolerance.” Informal methods of changing the behavior of physicians before instituting formal proceedings are also discussed.

The lack of definitions and uniform criteria for measuring outcomes makes it difficult to compare studies done in different countries, but it appears that 3 to 4 percent of all hospital admissions result in some measurable adverse effect. Needless to say, this may not be due to negligence or problem doctors, but since we have difficulty communicating about these issues, they often get confused. Reports from other countries clearly demonstrate that problem doctors are prevalent throughout the Western world, and each country has been working to develop a system to address the issue. Most efforts have been recent, however, and little is known about their effectiveness. The program being developed by the General Medicine Council in the United Kingdom looks promising, because it includes standardized approaches to assessing physician performance and techniques for remediation.

The last section discusses the selection of students, training, and the identification of potential problem students. Many students are not prepared for the arduous tasks of undergraduate and graduate education and have difficulty with the combination of a heavy workload, clinical uncertainties, and the likelihood of adverse outcomes. This pressure can lead to inappropriate behavior unless students receive support and develop good coping skills.

If physicians want to maintain their professional autonomy, they must become more involved in the self-regulation process. Most problem doctors have difficulty with competence, conduct, or communication, and their peers must be willing to intervene when they suspect a problem. The initial response when problem doctors are confronted is often denial; this can compound the problem, so persistence may be necessary. These issues must be discussed in the undergraduate curriculum, in graduate medical education, and in continuing education programs.

This book clearly documents the extent of the problem and the inadequate job the medical profession has done in regulating itself. Its real value is in its assessment of the roots of the problem and potential approaches to addressing it. However, several of the chapters describing the international experience are repetitive and add little new information.

With the increasing interest in credentialing in the United States, this book should be of value to those involved in the process. I would also recommend it to readers engaged in medical education, quality assessment, and health care administration.

Jeoffrey K. Stross, M.D.
University of Michigan Medical School, Ann Arbor, MI 48109-0368