Recent articles in the Harvard Courant have suggested that some schools are more likely to graduate physicians who run into disciplinary problems. This study involved years of physician practice, in most cases years more than medical training itself.
It is certainly possible that physician discipline results from
Characteristics of the candidate or environment that the physician was raised in
Medical training during medical school
Medical training during residency
Influence of factors beyond residency such as practice location, patients, family influences, etc.
Pre-Professional Environment - Being raised in an underserved environments might have some as yet poorly understood effect. Perhaps some who escape such environments fear a return, overcompensate, or have learned skills that helped them escape poverty, only to find that such skills make them more prone to problems later on.
Medical School Admissions - I doubt that medical school admissions teams plan to be lax regarding admitting students with past criminal records or those likely to need discipline. The major problem here might be that medical schools do not devote enough time and effort to admissions, nor do they reward faculty and staff for participating in such areas. Certainly there may be some who were behind in science or other areas and have struggled to make up the difference.
Medical School Too Focused on Exams, not enough Focus on People - Medical school graduation is tied to state licensure, state boards, and national board exams. The teaching in most cases is dominated by being constantly tailored to such exams. It is entirely possible that emphasis only in these areas might preclude important training in other areas that might help physicians avoid the need for disciplinary actions. The pressures to pass may be distorting true education and integration of knowledge.
Residency Training Effects - In the article, Four that Flunk, the authors quote experts as noting that residency training is more important. However they must have decided not to attempt evaluation of this important area.
Post Graduation Environments - The influence of patient care situations, practice environments, and family pressures would seem to have a major impact on disciplinary actions.
Practicing in underserved locations - It is also known that the medical care in areas with a better supply of physicians is better in terms of early detection of cancer. This means that in underserved areas, patients are more likely to have cancer diagnosed at a later stage. This is a major cause of malpractice lawsuits and potential disciplinary actions. Campbell RJ, Ramirez AM, Perez K, Roetzheim RG., Roetzheim RG, Gonzalez EC, Ramirez A, Campbell R, van Durme DJ., Ferrante JM, Gonzalez EC, Pal N, Roetzheim RG., Prenatal access is also related to outcomes Larimore WL, Davis A.
Impacts of family environment - Age 40 - 44 is the peak age when physicians face malpractice suits. Is there something about raising kids, dealing with aging parents, changes in marriage, or other factors? Since such physicians are experienced and mature, they should be less liable to medical knowledge errors. Clearly the environment of the physician and the practice impacts disciplinary actions.
Artifacts of Minority itself - The authors of Four that Flunk have already noted that physicians who are different in race or culture might be more likely to be singled out.
My contribution below is a descriptive analysis of some of the factors that might make physicians who practice in underserved locations and with underserved populations, more likely to face disciplinary actions. The following table includes some of the common errors made by physicians and how underserved primary care physicians might be more likely to have difficulty.
| Urban, specialty | Underserved, primary care | ||
| Environmental Influences a Baseline |
Patients with access to health, specialists, treatments, transportation
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Patients with low income, less transportation, patients often want you to do more with less. | |
| Physician Problems | |||
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Errors of knowledge |
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Inadequate database and not knowing limits |
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Constant new challenges to knowledge, broad range of patients and pathology.
Inadequate data collection due to culture, translation, assumption, and other errors.
Pressures of lots of patients with little time in some locations can tend to date physician knowledge. Isolation in some underserved practices may decrease contacts and sources of update |
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Carelessness |
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Not taking or errors in communication the time |
More personnel to work with, less direct contact with patients, less communications practice |
Demand of other patients or other activities, family and community |
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Physician impairment Drugs Alcohol
Sex/relationships
Family/spouse
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Lots of financial affairs to manage, more spare time |
Those acting as directors, and those running their own practice or managing, face the constant pressures of underserved patients. Tradeoffs are made between equipment, personnel, services, availability, etc.
Often underserved practices have patients who are friends or neighbors or even employees. There is sharing of very private information.
Working closely with patients in primary care can challenge physicians without good boundaries. This can be a goodly number since primary care practitioners tend to be amiable personality types that do not like to conflict with patients. Other factors leading to frustration include lack of understanding in the nation and community regarding need for care or impact of regulations, bureaucracy, etc.
Tendency toward separate lives is a difficult process to deal with, especially if physicians tend toward workaholism or do not overcome their delay in maturation that is a common part of being a physician (selections vs socialization) |
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Errors of judgment |
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Not knowing limits of own knowledge. Balancing desire to serve with needs of patients
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Access to a full range of specialists and colleagues |
Less access to care from specialists and fewer if any colleagues or those who are in different offices or also busy.
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Working too hard, too many patients, too much complexity |
A possibility |
Daily demands and night calls can be reasonable, or overwhelming |
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Trusting those you work with above or below and being taken advantage of |
Usually capable management overseeing personnel |
Smaller offices with fewer people and sometimes not the full range of skills or talents to do health care work. Often the most underserved practices have to "grow their own" or recruit from isolated communities or neighborhoods. Also less ability to pay for both numbers and quality of workers |
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Gross fraud and billing errors due to greed, personality disorder
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All physicians can be subject to these areas - resentment toward personal situation, tuition debt, treatment or perceived treatment by others, underserved physicians tend to have less pay and can face more obstacles in paying off debt. Physicians who develop and harbor resentment in doing what society needs and yet not being rewarding appropriately, can have subtle forms of judgment impairment. |
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The table below notes how medical training might impact errors as well as societal influences, research information, and what we could do to improve physicians.
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Errors of knowledge
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How medical training impacts errors |
How society impacts errors |
What does the research show? |
What could be done? |
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Inadequate database and not knowing limits |
Massive increases in breadth of medicine and loss of broad general focus of training means primary care grads are less well prepared (accel)
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Reductions in care for indigent, loss of transportation and day care
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Physicians caring for the underserved may have higher rates of disciplinary actions
Underserved practices have inherent risks in medical problems likely to cause malpractice suits (see above).
Rural experiences stand out as great learning experiences, probably due to more of a focus on learning and doing and continuity at non-academic sites rather than a rural characteristic (paulman, Gjerde, Why preceptorship) |
Return of generalist perspective (Generalism, Generalists, Specialists, and Medical Education not generalists or general practitioners) to medical training. Generalist approach has a predominate emphasis on knowing limits and focus on dealing with uncertainty, accepting responsibility for evaluation, and organized approach and evaluation rather than quick screen and pass the buck to others.
Special protections for learners under proper supervision
Special billing provisions for learners working with practitioners
Better day care, transportation, distribution of education and health resources |
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Errors of Carelessness
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How medical training impacts errors |
How society impacts errors |
What does the research show? |
What could be done? |
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Not taking or errors in communication the time |
Communication skills are not a priority for selection of candidates and during training |
Focus on intellectual |
Physicians scoring high on Family Practice Certification tests are more likely to be involved in a malpractice suit (Florida study) |
Do not accept physicians with inadequate communications skills.
Develop alternate payment mechanisms for medical school tuition and debt. This could improve the selection of students more suited for caring for others but at a bit more risk for failure. It would also allow for dismissal of those without good communication skills or ethics to be sent away without the burden of tuition.
Make a career in medicine more of a calling and actually pursue those with people skills and leadership and service orientation to recruit them into medical school |
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Physician impairment
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How medical training impacts errors |
How society impacts errors |
What does the research show? |
What could be done? |
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Drugs Alcohol
Sex/relationships
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Focus is on short term goals, next test, next rotation.
Advisement is often lacking or can lead to additional time demands and potentially more stress.
Little actual contact with the full range of what being a physician is about. Usual picture is just a few hours a week where the attendings are “on display” during rounds. Actual faculty contact is declining steadily. Getting involved in various projects takes time and effort for a small amount of success.
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Larger class sizes due to accreditation, centralization of higher ed and medical school resources
Kids growing up that have run into difficulties are often rejected from future careers, even when they have overcome previous obstacles. Kids who have never been severely challenged in personal or situational ways are readily admitted, even when we have no idea how they will react to the significant challenges they will face. |
Physicians from larger class size medical schools are more likely to have disciplinary actions (Bowman)
More supervision means more observation and better ability to document and correct or dismiss.
Preceptorships not only have discovered students with problems, but also preceptors. The nature of smaller group or 1 on 1 teaching does not allow serious problems to be hidden.
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Medical schools could graduate 2 or 3 classes each year that would be 1/2 or 1/3 the size. This was successful during WWII. This would help shift the focus from passing exams to developing competency. What Should the Next Generation of Medical Schools Look Like
Peer efforts to help monitor student behavior during the course of medical training.
More extensive background checks.
Pursue for admission those who have overcome obstacles of all kinds because they have demonstrated maturity.
Ask more questions about students and their upbringing to see if their lives have been tested. A career in medicine will indeed test all physicians at some point. Choosing those who have never had to overcome much or who have not experienced work with people or doing work that involves sacrifice makes little sense. |
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Family/spouse
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How medical training impacts errors |
How society impacts errors |
What does the research show? |
What could be done? |
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Few role models in faculty or friends that demonstrate balance of medical life, personal life, etc.
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Issues of who will raise the children are a constantly increasing concern, particularly for those without significant resources who are trying to make it out of poverty or difficult situations. |
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Retreat experiences yearly to explore personal development, especially prior to M-3 year which can set many lives out of balance as medicine takes over their lives.
More exposures to physicians during all parts of their lives, not just during rounds |
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Not knowing limits of own knowledge |
How medical training impacts errors |
How society impacts errors |
What does the research show? |
What could be done? |
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Constant theme throughout training of rating most poorly behaviors resulting from not knowing limits.
Active work at all levels to push students and residents to expand their limits through patient contact and decision-making.
Model should be active adult learning and not passive convenient hours learning. |
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Working too hard, too many patients, too much complexity |
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Neglect of the underserved continues |
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Learning process should include periods of high patient demand under |
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Trusting those you work with above or below and being taken advantage of Gross fraud and billing errors due to greed, personality disorder
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This will only increase as medicine becomes more of a business and more and more lampreys attach themselves to it to suck life from it. |
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Millennium Conference on the Clinical Education of Medical Students
Millennium Conference and Rural Medical Education
Underserved - Overview and Models
Graduates Answer Hartford Courant
Controversy in Medical Education