Professional self-regulation: learning from the disciplinary process

Robert J. Byrick 0 0 R. J. Byrick, MD (&) Department of Anesthesia , St. Michael's Hospital, University of Toronto , 30 Bond Street, Toronto , ON M5B 1W8, Canada Medical regulatory colleges have a mandate to protect and promote the health and safety of the public by regulating the practice of medicine by physicians. In Canada, provincial colleges of physicians and surgeons fulfill this mandate through activities related to a) the registration of physicians to practice, b) the regulation of how physicians practice (either proactive or reactive regulatory activities), and c) remediation of physicians where specific deficiencies are identified and where remediation is appropriate. Throughout most of the 150-year history of selfregulation of the medical profession in Canada, this role has been performed primarily by reactive regulation, i.e., disciplining physicians who have been found to be practicing in a manner that members of the profession would consider to be dishonourable, disgraceful, or unprofessional. As important as remediation may be, the disciplinary process remains a key means of maintaining the public trust in the profession. This is reactive regulation, as it results from a specific complaint, inquiry, or report to the college about a physician's behaviour or performance. It is important to emphasize that most colleges have remediation programs that manage clinical practice deficiencies identified during the The author is a member of Council of the College of Physicians and Surgeons of Ontario and has no other competing interests to declare. L'auteur est membre du Conseil de l'Ordre des medecins et chirurgiens de l'Ontario et n'a pas d'autre conflit d'interet a` declarer. - complaint process. Disciplinary procedures are invoked only when major unprofessional practices are found. By law, the colleges disciplinary proceedings and outcomes are transparent to the public. Disciplinary findings result from a formal adversarial legal process after an extensive investigation of the merits of the allegations. Formal charges are filed, and the physician involved is allowed to mount a thorough defense to the allegations. Although individual disciplinary findings are published by each provincial regulatory body, the report presented by Alam et al. in this issue of the Journal1 is the first systematic evaluation of disciplinary findings against anesthesiologists in Canada. The report follows the publication of their data on all disciplined physicians in Canada from 2000-2009.2 The authors conclude that publication of the causes of disciplinary actions may result in interventions aimed at educating physicians around standard of care and prevent such problems. Whether education can prevent such serious lapses of professionalism remains speculative at best, but their data give us the first specialty-specific, national perspective on this important issue. Their first contribution is to compare the scope of the problem for anesthesiologists with that for all physicians in Canada. They emphasize that there were 721 disciplinary findings against physicians of all specialties in Canada from 2000-2011, whereas only 11 findings were against anesthesiologists. This frequency represents disproportionately fewer anesthesiologists than many other specialties. This result differs from the report from Californias State Medical Board where anesthesiologists were overrepresented among disciplined physicians.3 Complaints that reach the Discipline Committee represent only 2-3% of the total number of patient complaints about physicians. This number probably underestimates the incidence of physicians who would be found to be unprofessional, as some surrender their license voluntarily when allegations of unprofessional conduct are made. Their resignation limits the investigative process at that point. We also do not know the denominator for the number of complaints to regulators about anesthesiologists in Canada during this time frame. Although there were only eleven disciplinary findings, there were certainly many more reports of concern about anesthesiologists to regulatory colleges. Most (97-98%) patient complaints, coroners reports, and hospital inquiries result in dispositions that are not referrals to the Discipline Committee. One limitation of using this public database of disciplinary findings is that various regulatory colleges may have different thresholds for referral to discipline, creating a selection bias. There is no doubt that disciplinary findings represent the tip of the iceberg albeit an important tip when it comes to patient complaints and the publics concerns and perceptions of our care. The authors1 describe general features of the cases that result in disciplinary findings for our specialty. There were some similarities between these data for anesthesiologists and their data for the profession as a whole.2 For example, all disciplined anesthesiologists were male. The most common causes for discipline were standard of care issues, inappropriate prescribing, and fraudulent behaviour. These are significant and important areas of professional practice that should be included in designing educational programs for practicing anesthesiologists. We are not given the details for these specific cases; however, they correctly emphasize that the nature and scope of clinical practice influences the frequency of disciplinary findings. For example, anesthesiologists practicing in chronic pain medicine need to have a heightened concern about inappropriately prescribing opiates. The authors reported that only one anesthesiologist was disciplined for self-use of drugs and alcohol.1 This is undoubtedly a significant underestimation of the incidence, and there is no room for complacency regarding the issue of substance abuse in our specialty. The authors correctly emphasize that substance abuse problems and the rehabilitation process is usually managed confidentially by the provincial physician health program with the approval of the regulatory college, not through the disciplinary process. For anesthesiologists, this problem remains an important issue and emphasizes that data on disciplinary findings have limitations with respect to generalized usefulness to prioritize educational programs. It is clear that disciplinary findings do not represent a balanced picture of the complaints received from patients or concerns relating to standard of care. Bismark et al.4 recently reported a study of patient complaints to regulators in Australia. The reporting of all complaints to the regulator would give a more balanced assessment of patient concerns than disciplinary findings. In the United Kingdom, Campbell et al.5 recently analyzed all complaint cases referred to the General Medical Council (GMC) concerning anesthesiologists in 2009. Their data showed that anesthesiologists had a lower rate of referral compared with doctors in general (P \ 0.0001). There are differences between co (...truncated)