Professionalism, Second Opinions, and Keeping Ego Out of Medicine

In recent years, there has been a push to teach professionalism to medical students. This is in part a response to a perceived decrease in respect for physicians by the general public. Much of the emphasis on teaching professionalism has been on treating patients with respect and placing the needs of the patient over our own needs. I support this effort but would like to emphasize a different aspect of professionalism that seems to get less attention: the relationship we have with our colleagues.

Doing Our Duty

The duty of professionalism arises because medicine is a profession-we profess an oath to become members, we perform a task held in high regard by the public, and we promise to self-regulate. Given that this is the nature of medicine, we can easily now say something about how we must treat our colleagues in order to best uphold our oath and to best maintain the reputation of our vocation.

For Aristotle, a virtue is often found as the mean between two excesses that are vices. This model is appropriate for determining the virtuous, professional way we should treat our colleagues: show respect, but do not protect incompetence or misbehavior. Put another way, we have dual duties to respect our colleagues but also to protect our patients. When these duties conflict, our patients must come first. However, failing to respect our colleagues has negative effects on both the status of our profession and on patient care itself.

Egos, Judgment, and Second Opinions

One aspect of respecting our colleagues that I often find lacking is giving the benefit of doubt to our colleagues, especially when we have only a patient report or incomplete information. It is tempting to pass judgment on another doctor, particularly when a patient seeks a second opinion. Attacking the other physician who is not there to defend herself or himself is an easy way to gain a competitive advantage over our colleague/competitor.

Yet, in my experience, when I have the records and can see my colleagues’ thinking, I find myself affirming their decisions more often than challenging their conclusions. Even if I differ in the way I would handle the case, unless the chart shows real incompetence (and I cannot even recall an example of this), it is better to explain to the patient both sides and describe it as a difference in views, rather than a choice between a right and wrong therapy.

The psychological temptation to tear down another to build ourselves up must be resisted because the effect, from the patient perspective, is not simply to question the other physician but rather to question the profession of medicine itself. Because patients have no way to discern the truth without assistance, they are left wondering who to believe and left questioning the general integrity of physicians. We must choose language that does not criticize the other physician and that affirms that the recommendation offered is reasonable. If you disagree, offer an alternative based upon your judgment or experience. 

Respect but Do Not Protect

What should we do when a patient asks our opinion about a specialist that we actually hold in low regard? Unless you think the person in question should not be a physician (and if you have evidence of this you should be offering it to the state medical society), the clinical encounter is not a place to air our personal views or grievances with another physician. One of my partners has a great response to this kind of inquiry, “Yes, Dr. X is a good cardiologist, but for your condition I think Dr. Y would be a better choice.” You have directed the patient to the person you think is best without denigrating another.

If you need to say more, couch your answer in impersonal terms: “Dr. X chooses surgical solutions more readily than I do. I think you should consider this medical option before pursuing surgery.” Here, you have explained the difference in opinion, and given the actual reasons for the disagreement without disrespecting a colleague.

But respecting our colleagues and giving them the benefit of the doubt must have its limits. Protecting obvious incompetence or gross misbehavior is where this limit is reached. It harms patients, and it harms our profession if we fail to act when a colleague is harming the reputation of our profession with his or her behavior. The lesson to be learned from the Penn State Jerry Sandusky scandal is that keeping quiet about out-of-bounds behavior does not protect anyone except the guilty.

Finding the Virtuous Mean

Aristotle thought ethics was objective but less precise than other endeavors, such as math or science. I believe this is still true. Finding the virtuous mean can be challenging, but the goal must be to respect our colleagues while protecting patients if real incompetence or misbehavior is occurring.

Consider these postulates, which may be helpful when deciding the appropriate response to sometimes-challenging professional ethics questions:

▪ Charges of incompetence need to be based on evidence that goes beyond a patient report alone-get the records.

▪ Recognize and appreciate that for many medical problems there are several reasonable diagnostic and treatment options, and your choice is not necessarily the best. Have you ever evolved on a particular treatment, only to revert back to your original position? Some therapeutic humility when seeing patients in consultation or for a second opinion is quite helpful.

▪ If you suspect a colleague has made an error or harmed a patient with negligence, discuss this first with them and allow them to come forward. If they confirm the mistake but refuse to report, then take it further.

▪ Even in social settings, resist the urge to criticize a colleague. If he or she is really that bad, take it to the hospital Executive Committee or the State Boards, not the cocktail party.

▪ Report incompetence when there is good evidence that it is real and pervasive.

▪ Report illegal or immoral behavior with a lower threshold than you would report incompetence-it is not our job to investigate these kinds of claims, but doing nothing when the evidence supports out-of-bounds behavior is a type of complicity. You can report a suspicion as only a suspicion, or when the evidence is incomplete, just do not claim to know more than you actually know. If there is a reason to suspect, report. This allows the professionals to investigate and confirm, or to clear the other physician of the charges.

Finding the Aristotelian mean for collegial professionalism requires balancing the needs of our patients and the respect due to our colleagues. Ideally, neither should suffer, but sometimes this might not be possible. Our patients must always come first.