Despite the fact that seven years have passed since the Institute of Medicine’s landmark report on the epidemic of medical mistakes plaguing U.S. hospitals, experts continue to decry the lack of substantial progress in reducing substandard doctor performance. According to one renowned safety expert and co-author of the errors report, Lucian Leape, MD, Harvard School of Public Health, “Performance failures of one type or another are not uncommon among physicians, posing substantial threats to patient welfare and safety.”

In the Annals of Internal Medicine earlier this year, Dr. Leape estimated, “At least one third of all physicians will experience, at some time in their career, a period during which they have a condition that impairs their ability to practice medicine safely.” If that’s not frightening enough, he also warns that hospitals fail to routinely monitor physician performance and identify these problem doctors.

Unfortunately, hospital credentialing has largely been ineffective in making patients safer. A major problem, according to Leape, is that “Independence is so highly valued that physicians are loath to evaluate or confront a colleague who they perceive is having a problem.” Hospitals are not rushing to confront problem doctors either. Doctors denied admitting privileges or facing limitations in their hospital practice often drag the offending institution into court seeking to appeal the credentialing decision or be paid monetary damages.

A hospital’s inherent economic conflict of interest may also get in the way of disciplining a problem doctor if she or he admits many patients and contributes positively to the facility’s bottom line. Hospitals have a fiduciary as well as ethical responsibility to do everything possible to protect patients from preventable harm. Their continued failure to weed out substandard doctors violates that responsibility.

Simulation Technology
What to do? To improve the credentialing process, hospitals should be required to use simulation technology to routinely evaluate the performance of every doctor on staff so as to make better credentialing decisions. Pilots are trained to fly in flight simulators, which provide an exact replica of an airline’s cockpit. Physicians could be similarly trained, for example, to insert a breathing tube on a life-size dummy which would “breathe, bleed, and express pain” as a sick person would under real-life circumstances.

It makes sense to employ simulation technology train people who will perform risky tasks in order to evaluate the safety of their job performance, including unanticipated emergencies. As it stands now, unsuspecting hospitalized patients often become training fodder with their safety possibly compromised.

Pilots, as a condition of licensure, are required once or twice a year to go to a flight simulation center for an evaluation of their abilities. By contrast, doctors are licensed in virtual perpetuity and are not required to routinely demonstrate their competence.

Although relatively new to health care, simulation technology could do for hospitals and patient safety what it has done for pilots and the safety of flying – provide a way to both train and routinely evaluate a doctor’s competency, weed out substandard performers, and keep the public out of harm’s way in the process. But until that happens, a doctor’s hospital affiliation, no matter how prestigious, does little to assure a patient’s safety.

Arthur A. Levin, MPH, Center for Medical Consumers ©
December 2006