We’ve all heard about the blue wall of silence that describes a belief that law enforcement personnel will refrain from reporting misconduct of their colleagues to the proper authorities. Physicians had similarly been accused of hiding behind a white coat wall of silence, as I have written previously.

This describes the belief that physicians do not reliably turn in colleagues who are incompetent and impaired. Personally, I have never knowingly participated in the care of a patient with an impaired colleague. Competency is a murkier issue and is, of course, variable in the medical profession. In addition, it’s not easy to define or to measure. It is this very fact that has made me so hostile to the pay-for-performance schemes that claim to be a quality metric but is truly used as a cost-cutting tool.

I am aware of physicians in my community who do not have a strong reputation of medical skill. Yet, many of these physicians are beloved by their patients. Clearly, they are delivering something of great value that may not be included in our traditional definition of medical competence. In addition, if physicians of lower medical skill levels, consult specialists more liberally to assist in the care of their patients, then the patients receive good medical care, albeit at a higher cost.

What obligations to physicians have to come clean to patients about other doctors and health care facilities? Weigh in on the following.
A patient asks you if her primary care doctor is any good. The primary care physician is a strong referrer to the practice, but is not highly regarded among colleagues. How would you respond if you were the doctor?

• A private practice surgeon operates at only one hospital. His patient asks if another hospital would be a better choice. The doctor is aware that the post-operative infection rate in his hospital is 5 percent higher than in area hospitals. How would you respond if you were the surgeon?
• A hospitalized patient is medically ready to be sent home. Every additional day in the hospital consumes time and resources. More importantly, it exposes the patient to risks of hospital life, including infections and other complications. The admitting doctor intends to discharge the patient home at the end of the week. If you are a physician consultant on the case, what would you do?

Of course, I know what the correct answers should be. But, my profession, and probably yours, are not as pure as we would like them to be. While integrity may be absolute and impeccable, alas, we are not.

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower.

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