Many doctors don't blow whistle on colleagues

Your doctor could be drunk, addicted to drugs or outright incompetent, but other physicians may not blow the whistle.

A new survey finds that many American physicians fail to report troubled colleagues to authorities, believing that someone else will take care of it, that nothing will happen if they act or that they could be targeted for retribution.

A surprising 17% of the doctors surveyed had direct, personal knowledge of an impaired or incompetent physician in their workplaces, said the study's lead author, Catherine DesRoches of Harvard Medical School.

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One-third of those doctors had not reported the matter to authorities such as hospital officials or state medical boards. The findings, appearing in Wednesday's Journal of the American Medical Association, are based on a 2009 survey of 1,891 practicing U.S. doctors.

Reporting a problem doctor can trigger important changes. Twenty-one years ago, a colleague smelled alcohol on a young physician's breath and anonymously reported him to the head of the residency program. A now-sober Dr. A. Clark Gaither is grateful.

"I wish I knew who reported me," Gaither said. "I'd like to give them a big ol' hug and thank them for saving my life."

Programs exist for retraining doctors with weak skills and getting addicted ones into treatment. But the survey results suggest doctors are not confident in the system, DesRoches said.

The American Medical Association and other professional groups say doctors have an ethical obligation to make such reports. And many states require doctors to tell authorities about colleagues who endanger patients because of alcoholism, drug abuse or mental illness.

Despite that, many doctors do not know what to do or where to start, DesRoches said.

In an accompanying editorial, one ethics expert called the findings "jarring."

"I don't think there's any excuse for less than 100% of physicians holding true to these ideals," said Dr. Matthew Wynia, director of the AMA Institute for Ethics.

He called for better protections for whistle-blowers and more education for doctors on how to report a colleague.

The survey did not specify the type or severity of the impairment or incompetence, asking: "In the last three years, have you had direct, personal knowledge of a physician who was impaired or incompetent to practice medicine in your hospital, group, or practice?"

Most states have programs that not only get doctors into treatment but also advise their colleagues how to intervene. Most will keep reports anonymous. Some use the threat of medical board sanction to persuade doctors to go to rehab.

For Gaither, the first confrontation with concerned colleagues was in medical school. He reassured his fellow students he was fine. Even the second confrontation, from the program head who had heard the report of Gaither's alcohol-scented breath, did not take. Gaither signed a contract promising to stay sober, go to Alcoholics Anonymous meetings and submit to testing.

"I went home and drank that night," he said. "I was thinking with an addicted brain, and I was an alcoholic."

Finally, a third confrontation and the temporary loss of his training license forced Gaither into what he calls "a state of surrender." With help from the North Carolina Physicians Health Program, he got into a residential rehab program.

His last drink was Jan. 21, 1990. Gaither, now 55, finished his residency and became a family doctor. He practices in Goldsboro, N.C., where he started a free mobile clinic for the uninsured.

In 2002, the North Carolina Academy of Family Physicians named him Physician of the Year. He thanked AA and all the colleagues who confronted him and supported him in his acceptance speech.

He now urges others to report what they know. "It is our duty," he said.

Dr. Warren Pendergast runs the North Carolina program, which cooperates with the state medical society and state disciplinary board. About 200 doctors a year are referred for alcoholism, drug addiction, anger-management problems and depression.

Ninety% of addicted doctors who've been through the program remain clean and sober five years after treatment, Pendergast said.

"They're motivated. They have a lot to lose," he said. Their reputations and careers depend on their participation in treatment. Colleagues of troubled doctors "can feel comfortable getting peers help rather than sticking their head in the sand," he said.

Gaither, who speaks publicly about the program, said doctors worry that their troubled colleagues will lose their licenses and livelihoods if reported.

"I ask them, 'Would it be better if they lost their money, their marriage, their home, their cars, their license and then their life?'" he said. "Does that sound better than getting them the help that they need?"

Why doctors threaten to ditch Medicare patients

Medicare has become a scary word to the doctors at the largest private group practice in Kansas City, Mo.

It's so scary that most physicians at Kansas City Internal Medicine, with 65% of its nearly 70,000 active patients age 65 or older, have stopped accepting walk-in Medicare enrollees, said Dr. David Wilt, an internist at the group.

Wilt and his colleagues say they are shunning the area's growing senior population because they believe Medicare doesn't reimburse physicians enough to cover the cost of care.

"And if Medicare further cuts its reimbursement rates, then we'll be functioning at a loss," said Wilt.

Wilt -- and doctors with lots of senior patients -- are especially troubled by a 21% cut in Medicare payments to physicians scheduled to take place in 2010. Last week, the Senate voted against stopping that cut, and more annual cuts over the next decade, from taking place.

"If the [21%] cut happens, that cut in our payments will exceed our profits. The only option to us to stay in business will be to fire employees," Wilt said.

Physicians say a boycott against Medicare has already begun because they are tired of dealing with the yearly threat of a payment cut.

Dr. John Hagan, a Kansas City-area ophthalmologist, offers a unique perspective. "I can speak to both sides of this," he said.

As many as 75% of patients at his group practice are Medicare beneficiaries who are treated for problems such as glaucoma or undergo cataract surgery. And if payment rates are cut 21%, after already being reduced to about half the going $1,200 rate for cataract surgery and care in Missouri, Hagan said he won't be able to see more Medicare patients because he won't be able to cover his expenses.

But Hagan himself became Medicare-eligible this month -- and he's nervous. "If I accept Medicare for myself and my wife, I'm fearful I won't be able to stay with my cardiologist and my wife won't be able to stay with her physicians," he said.

Hagan has elected not to enroll in Medicare. Instead, he's paying extra out of pocket for his company's insurance coverage.

"At some point I won't want to work," said Hagan. "At that time, I will be on Medicare, and I am scared to death."

Perception versus reality?

The federal government's Center for Medicare and Medicaid Services (CMS) said it is aware of anecdotal reports of doctors not taking Medicare beneficiaries.

However, the agency maintains that its own data, and other industry reports, show only a small percentage of beneficiaries unable to get physician access.

CMS said 96.5% of all practicing physicians, nearly 600,000 doctors, currently participate in Medicare.

"Geographically, the level within every state is less than 5% of Medicare beneficiaries who have difficulties accessing a doctor," said Renee Mentnech, director of CMS' Research and Evaluation Group.

Mentnech also pointed to an August report from the Government Accountability Office (GAO), an independent branch of the Congress, that showed less than 3% of Medicare beneficiaries reported major difficulties accessing physician services in 2007 and 2008.

But these numbers do little to comfort seniors such as Earl Bean, 67. He recently told CNNMoney.com that he couldn't easily find a new primary care physician who accepted Medicare after his former doctor retired and Bean himself had to move to a new city.

"I had a company supplemental policy with drug coverage. It didn't matter," said Bean. "They wanted nothing to do with me."

Dr. Mark Laitos, a family physician based in Longmont, Colo., said Medicare-dependent seniors in his area are still able to find primary care physicians "but it takes some effort."

"They have to make a bunch of phone calls, get on waiting lists or go over to the next town," said Laitos.

He stopped seeing new Medicare seniors six years ago because of reimbursement issues. Laitos said Medicare on average reimburses him 80 cents on the dollar. "If I charge a patient under 65 one dollar for a service, for a Medicare patient I can only charge 80 cents," he said.

"As patients in my practice are getting older, the day they become Medicare-eligible, my reimbursement drops," he said.

Still, he's not ditching his long-standing patients who've aged into Medicare. "If I ran the practice like a business, I would," Laitos said. "This is a small town. It's hard to drop all Medicare patients."

"Doctors face this bizarre dance every year. Most are frustrated and resent this threat to cut our rates when our costs are increasing every year," he said.

Federal law requires that Medicare physicians' payment rates be adjusted annually based on a sustainable-growth rate that's tied to the health of the economy.

Physicians face a rate cut every year, although Congress has at the last minute blocked those cuts from happening in seven of the last 8 years.

Dr. Keith Jantz, an internist at Kansas City Internal Medicine, fears that if the 21% cut goes through next year, "physicians around the country would stop seeing any Medicare patients."

"It's happening in places like Las Vegas and in Anchorage, Alaska, and this could be a harbinger of what's to come unless Medicare maintains decent [payment] rates," Jantz said.

The AARP, the nation's largest senior-citizen advocacy group, not only wants the Senate to rescind this year's cut, it wants long-term action. "Short-term patches to preserve physician pay make the access problem [for seniors] worse by undermining doctors' confidence in the Medicare program," the group said in a statement

The American Medical Association (AMA), which represents doctors, is pushing for a permanent repeal of the reimbursement formula.

"We believe that as part of comprehensive health reform, physicians have to be incented to keep people healthy and out of the hospital," said James Rohack, president of the AMA. "Under this formula, they are penalized for doing it."