Review a quantitative article Identify in narrative format the following: What is the purpose of the study, what is the question? What does the literature review suggest?

Professional values and reported behaviours of doctors in the USA and UK: quantitative survey

Martin Roland, 1 Sowmya R Rao,

2 Bonnie Sibbald,

3 Mark Hann,

3

Stephen Harrison, 3 Alex Walter,

3 Bruce Guthrie,

4 Catherine Desroches,

5

Timothy G Ferris, 5 Eric G Campbell

5

ABSTRACT Background: The authors aimed to determine US and UK doctors’ professional values and reported

behaviours, and the extent to which these vary with the

context of care.

Method: 1891 US and 1078 UK doctors completed the survey (64.4% and 40.3% response rate respectively).

Multivariate logistic regression was used to compare

responses to identical questions in the two surveys.

Results: UK doctors were more likely to have developed practice guidelines (82.8% UK vs 49.6% US, p<0.001)

and to have taken part in a formal medical error-

reduction programme (70.9% UK vs 55.7% US,

p<0.001). US doctors were more likely to agree about

the need for periodic recertification (completely agree

23.4% UK vs 53.9% US, p<0.001). Nearly a fifth of

doctors had direct experience of an impaired or

incompetent colleague in the previous 3 years. Where

the doctor had not reported the colleague to relevant

authorities, reasons included thinking that someone

else was taking care of the problem, believing that

nothing would happen as a result, or fear of

retribution. UK doctors were more likely than

US doctors to agree that significant medical

errors should always be disclosed to patients.

More US doctors reported that they had not

disclosed an error to a patient because they were

afraid of being sued.

Discussion: The context of care may influence both how professional values are expressed and the extent

to which behaviours are in line with stated values.

Doctors have an important responsibility to develop

their healthcare systems in ways which will support

good professional behaviour.

INTRODUCTION

The place of doctors in society is changing, and previously accepted claims that doctors have rights to self regulation and autonomy are now routinely questioned. There are

many reasons for this, including the ability of patients to access detailed and accurate information about their own health and illnesses, demonstration of widespread varia- tions in quality of care, well-publicised medical scandals and the rise of mana- gerialism.1 2 In response to these changes, there have been initiatives in several coun- tries to redefine what it means to be a medical professional,3 in some cases advocating a new type of relationship between doctors and their patientsda ‘new professionalism.’4 5 These initiatives have produced a number of key documents including a US/European Charter on Medical Professionalism (‘the Charter’),6 7

‘Doctors in Society’ produced by the Royal College of Physicians of London8 and state- ments by the UK General Medical Council including ‘Good Medical Practice.’9

These statements on professionalism affirm the primacy of patient welfare, avoiding discrimination against patients, and acting with honesty and integrity. They define professional behaviour in terms of avoiding conflicts of interest, providing a high stan- dard of care and engaging in quality improvement activities. All of the documents contain statements about doctors’ responsi- bilities for just distribution of limited medical resources, ensuring fair access to care, and promoting the autonomy of patients. The statements also depart from previous descriptions of professionalism. For example, recent statements emphasise doctors’ responsibilities for addressing poor perfor- mance by other doctors, with explicit guid- ance in UK documents that doctors should address unacceptable practice by colleagues.9

In addition, self-regulation and professional

< An additional appendix is published online only. To view this file please visit the journal online (http:// qualitysafety.bmj.com). 1Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Cambridge, UK 2Massachusetts General Hospital, Biostatistics Center and Mongan Institute for Health Policy, Boston, Massachusetts, USA 3National Primary Care Research and Development Centre, University of Manchester, Manchester, UK 4Centre for Primary Care and PopulationResearch,University of Dundee, The Mackenzie Building, Dundee, UK 5Harvard Medical School, Massachusetts General Hospital, Mongan Institute for Health Policy, Boston, Massachusetts, USA

Correspondence to Professor Martin Roland, Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Robinson Way, Cambridge CB2 0SR, UK; [email protected]

Accepted 20 December 2010 Published Online First 7 March 2011

This paper is freely available online under the BMJ Journals unlocked scheme, see http://qualitysafety.bmj. com/site/about/unlocked.xhtml

BMJ Qual Saf 2011;20:515e521. doi:10.1136/bmjqs.2010.048173 515

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autonomy, once seen as defining features of a profes- sion, are largely absent from recent documents. The British Medical Association, commenting on recent changes in public attitudes to doctors, associates a loss of professional autonomy with a loss of morale among doctors.10 However, another study found that doctors generally supported shifts away from paternalism11

towards a new type of relationship which Hilton describes as moving from ‘priest to mountain guide.’12

Although statements of professionalism from different countries have much in common, doctors’ values and behaviours may be shaped by the context in which they live and work. In this study, we investigated the extent to which current statements of values are supported by doctors working in the different healthcare systems of the UK and USA. These differences include the UK having a nationalised health service with national programmes of standard setting and quality improvement, national bodies to define cost-effectiveness criteria for prescribing drugs, and a payment system under which doctors’ income is relatively independent of volume of services provided to patients. We explored the extent to which doctors’ reported behaviours were consistent with their stated values and whether differences in reported values and behaviours might be related to differences in the context in which doctors practised.

METHOD

A survey of professional values previously carried out in the USA in 2003/200413 was revised and refielded in 2009 alongside a UK survey based on four source docu- ments on professionalism.7e9 14 The questionnaires were designed to permit comparison between the responses

of US and UK doctors. We drew random samples of US doctors certified to practise in three primary care specialties (internal medicine, family practice and paediatrics) and four non-primary care specialties (cardiology, general surgery, psychiatry and anaesthesia). In the UK, we drew stratified random samples of trained general practitioners (GPs) and cardiologists, general surgeons and psychiatrists working in England and Scotland. The response rate was 64.4% in the USA and 40.3% in the UK. We included weights in the analysis to account for both sampling design and non-response. Analyses reported in this paper were restricted to survey items that were common to both of the US and UK surveys. Multivariate logistic regression models were used to determine the effect of survey country on the different outcomes (values and behaviours) controlling for a range of doctor characteristics. From these models, we obtained adjusted percentages and standard errors which indicate the percentage of respondents in a given category who reported values and behaviours that were in line with the normative statements of professional values. The online appendix contains further details of the development and delivery of the questionnaire and statistical methods used.

RESULTS

Table 1 summarises doctors’ characteristics. We adjusted for these in subsequent multivariate analyses which are shown in table 2 (reported values) and table 3 (reported behaviours). The great majority of doctors supported the normative

values expressed in the documents on which the two surveys were based. Likewise, the majority of behaviours

Table 1 Comparison between US and UK respondents

Variable Category Percentage USA (n[1289*) SE

Percentage UK (n[1078y) SE p Value

Gender Female 30.4 1.51 38.1 2.64 0.0111 Male 69.7 1.51 61.9 2.64

Years in practice <10 12.5 1.09 8.8 1.66 0.008 10e19 27.4 1.48 25.2 2.33 20e29 30.1 1.47 42.1 2.69 $30 30.0 1.44 23.9 2.31

Specialty General/family practice 68.1 0.17 84.1 0.00 <0.0001 Cardiology 8.7 0.04 1.8 0.00 Psychiatry 13.6 0.07 9.8 0.00 General Surgery 9.7 0.05 4.3 0.00

Country of graduation

Graduated from medical school in the country of survey (USA/Canada/UK)

71.0 1.49 81.4 2.08 <0.001

Full-time working $40 h/week 73.8 1.42 57.0 2.67 <0.001

*Analysis restricted to doctors working in primary care, cardiology, general surgery and psychiatry to allow comparison with the UK sample.

yMultiple regression analysis was based on 1148 responses, including an additional 70 doctors from an identical survey administered to doctors in training who had in fact become fully qualified by the time of the survey.

516 BMJ Qual Saf 2011;20:515e521. doi:10.1136/bmjqs.2010.048173

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which might be regarded as running counter to profes- sional values were reported infrequently. Where such behaviours were reported, doctors were more likely to say that they happened ‘sometimes’ rather than ‘often.’ Almost all doctors reported that they had changed their

practice in the previous 3 years as a result of familiarising themselves with a practice guideline (95.5% UK, 93.1% USA, p¼0.14), though UK doctors were much more likely to have participated in the development of practice guidelines (82.8% UK vs 49.6% US, p<0.001).

Doctors were less positive in their support for quality improvement activities. UK doctors were more likely to agree that they should participate in peer review of care provided by their colleagues (completely agree: 68.4% UK vs 54.9% US, p<0.001) but only just over half had taken part in reviewing another doctor’s records for the purpose of quality improvement (54.5% UK vs 55.0% US, p¼0.88). UK doctors were much more likely to report that they had taken part in a formal medical error reduction programme (70.9% UK vs 55.7% US, p<0.001), but US doctors were

Table 2 Comparison of US and UK doctors’ responses to value statements

Value statement Country of survey

Adjusted percentages (strongly agreeing with statement) SE p Value

Making the patient your first concern, avoiding conflicts of interest

Doctors should put patients’ welfare above the doctor’s own financial interests

USA 78.7 1.37 0.1932 UK 82.3 2.23

Doctors should disclose their financial relationships with drug/medical device companies to their patients

USA 65.4 1.58 0.0465 UK 58.9 2.76

Providing good care, commitment to improving care, keeping up to date

Doctors should participate in peer review of the quality of care provided by colleaguesdfor example, by reviewing their records

USA 54.9 1.67 <0.0001 UK 68.4 2.61

Doctors should undergo periodic recertification examinations throughout their career.

USA 53.9 1.66 <0.0001 UK 23.4 2.44

Taking action (including relevant reporting) to deal with colleagues’ poor performance

Doctors should report all instances of significantly impaired or incompetent colleagues to relevant authorities

USA 63.1 1.61 0.2601 UK 59.3 2.82

Maintaining confidentiality of information about patients and their conditions

Doctors should never disclose confidential patient health information to an unauthorised individual

USA 91.1 0.97 0.0026 UK 96.3 0.99

Being truthful to patients and to colleagues, including when things go wrong

Doctors should disclose all significant medical errors to patients who have been affected

USA 63.5 1.64 0.0384 UK 70.2 2.57

Doctors should fully inform all patients of the benefits and risks of a procedure or course of treatment

USA 88.4 1.07 <0.0001 UK 73.8 2.44

Doctors should never tell a patient something that is not true (assuming the patient is competent)

USA 83.2 1.24 0.387 UK 85.3 1.94

Avoiding inappropriate relationships with patients Joint business ventures with patients are ‘never appropriate’

USA 46.7 1.62 <0.0001 UK 60.0 2.69

Sexual relationships with patients are ‘never appropriate’

USA 92.1 0.92 0.8174 UK 91.7 1.53

Accepting modest gifts from patients or patients’ families is ‘never appropriate’

USA 11.5 1.06 0.0426 UK 7.2 1.6

Avoiding discriminationdfor example, on grounds of race and creed

Doctors should minimise disparities in care due to patient race, gender or income

USA 84.2 1.21 0.0569 UK 88.7 1.82

Values adjusted for country differences in gender, years since qualification, specialty, country of graduation and part-time working

Home graduate: graduate from a medical school in the country of survey (USA/Canada or UK).

Working full time: $40 h/week.

BMJ Qual Saf 2011;20:515e521. doi:10.1136/bmjqs.2010.048173 517

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Table 3 Comparison of US and UK doctors’ reported behaviours

Behaviour (all in past year except where indicated) Country

Adjusted percentage replying ‘Yes’ SE p Value

Making the patient your first concern, avoiding conflicts of interest Have you received any gifts/samples from drug, device or other medically related companies (past year)? Percentage replying ‘Yes.’

USA 83.3 1.27 0.0002 UK 73.2 2.52

Providing good care, commitment to improving care, keeping up to date Have you changed your practice after familiarising yourself with a practice guideline relevant to your field (past 3 years)? Percentage replying ‘Yes.’

USA 93.1 0.83 0.1436 UK 95.5 1.18

Have you participated in a formal medical error reduction initiative in your office, clinic, hospital or other healthcare setting (past 3 years)? Percentage replying ‘Yes.’

USA 55.7 1.66 <0.0001 UK 70.9 2.42

Have you participated in the development of formal clinical practice guidelines (past 3 years)? Percentage replying ‘Yes.’

USA 49.6 1.67 <0.0001 UK 82.8 2

Have you reviewed another doctor’s medical records for the purpose of quality improvement (past 3 years)? Percentage replying ‘Yes.’

USA 55.0 1.66 0.8807 UK 54.5 2.73

Taking action (including relevant reporting) to deal with colleagues’ poor performance Have you had direct personal knowledge of a doctor who was impaired or incompetent to practise medicine in your hospital or practice? Percentage replying ‘Yes’ in past 3 years.

USA 16.5 1.23 0.3839 UK 18.7 2.14

In the most recent case, did you report that doctor to a hospital, clinical, professional society or other relevant body? Percentage replying ‘Yes.’

USA 65.3 3.77 0.2944 UK 72.7 5.7

In the most recent case did you have a personal discussion with that doctors about his/her problems? Percentage replying ‘Yes.’

USA 59.7 3.88 0.3923 UK 65.9 5.79

In the most recent case did you stop referring your patients to that doctor? Percentage replying ‘Yes.’

USA 72.4 3.7 <0.0001 UK 17.2 5.01

In the most recent case did you not report the doctor because you were afraid of retribution? Percentage replying ‘Yes’ (for doctors who had experience of an impaired colleague and decided not to report them).

USA 12.4 2.5 0.1717 UK 34.2 20.23

In the most recent case did you not report the doctor because you though someone else was taking care of the problem? Percentage replying ‘Yes’ (for doctors who had experience of an impaired colleague and decided not to report them).

USA 20.1 3.18 0.6993 UK 25.7 15.09

In the most recent case did you not report the doctor because you believed that nothing would happen as a result? Percentage replying ‘Yes’ (for doctors who had experience of an impaired colleague and decided not to report them).

USA 15.9 2.74 0.8297 UK 14.3 6.38

Respecting patients’ autonomy to choose between appropriate courses of clinical action and/or decline investigations or treatments

Have you prescribed a brand name drug when a generic was available because the patient asked for the brand name drug specifically? Percentage replying ‘Never.’

USA 18.8 1.27 0.2972 UK 21.4 1.95

Have you given a patient a referral to a specialist because the patient wanted it when you believed it was not indicated? Percentage replying ‘Never.’

USA 16.7 1.11 0.1023 UK 13.2 1.61

Maintaining confidentiality of information about patients and their conditions Have you intentionally or unintentionally revealed to an unauthorised person health information about one of your patients? Percentage replying ‘Never.’

USA 71.3 1.51 0.1181 UK 75.9 2.37

Being truthful to patients and to colleagues, including when things go wrong Have you told an adult patient or child’s guardian something that was not true? Percentage replying ‘Never.’

USA 89.4 1.05 0.014 UK 94.1 1.3

Have you not fully disclosed a mistake to a patient because you were afraid of being sued? Percentage replying ‘Never.’

USA 21.4 1.37 0.0017 UK 12.7 1.99

Avoiding inappropriate relationships with patients Have you provided direct patient care for a person with whom you have a financial relationship?

USA 8.7 0.94 <0.001 UK 0.8 0.42

Continued

518 BMJ Qual Saf 2011;20:515e521. doi:10.1136/bmjqs.2010.048173

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much more likely to agree about the need for periodic recertification examinations compared with UK doctors (23.4% UK vs 53.9% US, p<0.001). UK doctors were less likely that those in the US to

agree that all the benefits and risks of a procedure should be explained to the patient (‘completely agree’ UK 73.8% vs 88.4% US p<0.001). However, when things went wrong, UK doctors were significantly more likely than their US counterparts to agree that significant medical errors should always be disclosed to affected patients (completely agree 70.2% UK vs 63.5% US, p¼0.04). More US doctors reported that they had not disclosed an error to a patient at some time in the previous year because they were afraid of being sued (12.7% UK vs 21.4% US, p¼0.002). Sixty per cent of doctors in both countries agreed

with the statement that in all instances significantly impaired or incompetent colleagues should be reported to relevant authorities (completely agree 59.3% UK, 63.1% US, p¼0.26). Nearly a fifth of doctors had experience of an impaired or incompetent colleague in the previous 3 years (18.7% UK, 16.5% US, p¼0.38), and over two-thirds of these had reported this colleague to relevant authorities (72.7% UK, 65.3% US, p¼0.29). The commonest action taken by US doctors with knowledge of an impaired or incompetent colleague was to stop referring patients to that doctordan action much less commonly reported by UK doctors (17.2% UK, 72.4% US, p<0.001). Where doctors had not reported an impaired colleague to the authorities, the commonest reasons given were because they thought someone else was taking care of the problem (25.7% UK, 20.1% US, p¼0.70), because they were afraid of retribution (34.2% UK, 12.4% US, p¼0.17), or because they thought nothing would happen (14.3% UK, 15.9% US, p¼0.83).

Doctors in both countries endorsed statements supporting patient autonomy. Few doctors had declined to prescribe a branded drug when the patient asked for it (21.4% UK, 18.8% US, p¼0.30) or had not agreed to a patient’s request for a specialist referral even when the doctor did not think the referral was indicated (13.2% UK, 16.7%, p¼0.10). These are examples of areas where different values may conflictdfor example, behaviours associated with encouraging patient autonomy may conflict with those that promote delivery of the most cost effective care. Doctors from both countries agreed that they should

minimise disparities in care due to race, gender or reli- gion (completely agree 88.7% UK vs 84.2% US, p¼0.06), though fewer than one-fifth of doctors in either country had actually looked at data on health inequalities in their practice (14.1% US vs 12.4% US, p¼0.44). In terms of conflicts of interest, UK doctors were more

likely than those in the US to consider business rela- tionships with patients as ‘never appropriate’ (60.0% UK vs 46.7% US, p<0.001), and less likely to have provided care for someone with whom they had a financial rela- tionship (0.8% UK, 8.7% US p<0.001). While the majority agreed that doctors should put the patient’s welfare above their own financial interest, support was not universal (completely agree 82.3% UK, 78.7% US). The majority of doctors in both countries had received gifts from pharmaceutical companies in the previous year, though less commonly in the UK than in the USA (73.2% UK vs 83.3% US, p<0.001).

DISCUSSION

The study suggests that doctors in the USA and UK generally give strong support for the values espoused by their professional bodies, though with some important

Table 3 Continued

Behaviour (all in past year except where indicated) Country

Adjusted percentage replying ‘Yes’ SE p Value

Avoiding discriminationdfor example on grounds of race or creed Have you refused to provide medical services or give information about medical services based on your religious beliefs (past 3 years)? Percentage replying ‘Never.’

USA 94.9 0.76 0.1431 UK 97.0 0.98

Have you provided health-related expertise to local community organisationsdfor example school boards, parent-teaching organisations, athletic teams or local media (past 3 years)? Percentage replying ‘Yes.’

USA 40.9 1.63 0.0002 UK 29.1 2.51

Have you looked for data on possible disparities in care due to race, gender or income in your practice, clinic, hospital or other healthcare setting (past 3 years)? Percentage replying ‘Yes.’

USA 12.4 1.1 0.4373 UK 14.1 1.96

Values adjusted for country differences in gender, years since qualification, specialty, country of graduation and part-time working.

Home graduate: graduate from a medical school in the country of survey (USA/Canada or UK).

Working full time: $40 h/week.

BMJ Qual Saf 2011;20:515e521. doi:10.1136/bmjqs.2010.048173 519

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differences in both values and reported behaviours. Some of these may reflect differences in the organisation and management of healthcare in the two countries. For example, over 90% of doctors in both countries reported that their behaviour had been altered by clinical guide- lines in the previous 3 years, but doctors in the UK were much more likely to have participated in the develop- ment of clinical guidelines. In another survey, UK primary care physicians were more likely to report that they routinely used written guidance in clinical prac- tice.15 These differences may reflect the greater accep- tance by UK doctors of standardised approaches to care articulated by UK bodies such as the National Institute for Health and Clinical Excellence (http://www.nice. org.uk/), while comparative effectiveness research remains controversial in the USA.15

More than twice as many UK as US primary care physicians reported in the recent Commonwealth Fund survey that they routinely received and reviewed data on patient care.15 In our survey, only just over half of both UK and US doctors had actually taken part in peer review of a colleague’s records in the previous 3 years, but UK doctors were more likely to endorse the value of peer review of their colleagues’ medical records and more likely to have participated in a formal error reduction programme. Doctors in the US however were more than twice as likely to endorse the need for peri- odic recertification compared with doctors in the UK. These differences may reflect familiarity with the systems in which doctors are used to working, with systematic programmes of quality improvement having been rolled out across the UK National Health Service over the last 10 years,16 but recertification (or revalidation) yet to be developed in the UK while being common in the USA. In our survey, nearly a fifth of doctors in both the USA

and UK had direct personal experience of an impaired or incompetent colleague in the previous 3 years but one- third in both countries had not reported this colleague to a relevant authority. Of these, over half had talked to the doctor about their problem, and more than 20% had not reported the doctor because they thought someone else wasdealingwiththeproblem.However,34%ofUKdoctors did not report their colleague because they were afraid of retribution, possibly reflecting unsympathetic treatment of ‘whistleblowers’ which has been widely reported in the British medical press.17 18 Indeed, in a recent British Medical Association survey, 16% of doctors who had reported a concern about a member of staff said they were told that by speaking up, their employment could be negatively affected.19 In contrast to doctors from the UK, the commonest action reported by US doctors faced with an impaired colleague was to stop referring to that doctorda course of action not always open to UK doctors working within a more constrained healthcare system.

The great majority of doctors in both countries thought that medical errors should be discussed with affected patients, but US doctors were more than twice as likely as their UK counterparts not to have disclosed an error because they were afraid of being sued, possibly reflecting the different malpractice environment in which US patients are much more likely to sue their doctors.20 This difference may also account for the greater likelihood of US doctors agreeing that all risks and benefits of inter- ventions should be explained to patients. It was perhaps surprising that only 80% of doctors in

the two countries strongly agreed with the statement that ‘Doctors should put patients’ welfare above the doctor’s own financial interests.’ Our results suggest that US doctors were more accepting of potential conflicts of interest: they we

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