Letter to the editor: on patient safety: how well do we police ourselves?

To the editor, In his recent articles about patient safety, Dr. Lee [2, 3] highlights the importance of examining and understanding the role of orthopaedic surgeons and other healthcare professionals as “stewards of safety.” Dr. Lee summarizes the obstacles that physicians face: “The mechanisms available to physicians who want to clean up their practice communities are few, difficult to engage, and not always effective” [2]. In addition to these logistical impediments, physicians may be concerned about professional, legal, and ethical issues. The risk of being labeled as a traitor or snitch, being charged with defamation, and undermining the reputation of the profession as a whole, may discourage physicians from confronting colleagues about aberrant behavior. The reluctance that Dr. Lee describes—“shaking our heads in disgust and moving on … our natural instinct is to avoid that awkwardness” [2] — is a well-known phenomenon. In fact, Darley and Latane [1] described the “bystander effect” and “diffusion of responsibility” almost 50 years ago. Readers are looking forward to hearing specific, concrete recommendations regarding the implementation of Dr. Lee’s ideas [2]. Presumably the objectives of such a review process will be clarification, communication, and remediation, but how exactly will the community attain these goals? As Dr. Lee notes [2], morbidity and mortality conferences within a given institution may be effective, but their reach is limited. Similarly, the patchwork of different requirements by state licensing boards might not capture all outlier behavior. Many difficult and complex questions remain. How will a committee or board strike a balance between respecting physician autonomy and protecting patients? How will overseers protect each of the parties: The outlier who is being investigated (innocent until proven guilty), the physicians who are calling his or her conduct into question, and most importantly, the patients who have been compromised? What type and quantity of evidence will be required to substantiate the claims? How much of the inquiry will remain confidential and how much information needs to be shared so that other patients and referring physicians can make an educated decision about the outlier’s overall professionalism and competence? Will the committee have the authority to enforce its decisions, or will its recommendations serve as a guideline that is subject to negotiation? Dr. Lee has presented an important challenge to the community: The “‘everybody’s eyes and ears’ approach only works if everyone participates.” [2]. Protecting patient safety, improving healthcare quality, and continually reviewing professional standards will require a collective effort. The community must be willing to accept the difficult and sometimes unpleasant task of examining itself. On a positive note, the process may stimulate dialogue and support, thereby providing an opportunity for outliers to realign their priorities and renew their commitment to patient care. In the long run, the time and energy invested in this effort will surely benefit both patients and physicians.