Preventing the need for disciplinary actions against Canadian physicians.

Medicine has been organized as a profession across the developed world for almost two centuries.1 As part of belonging to a profession, physicians have developed and agreed to adhere to codes of ethics and/or standards of conduct. The use of professionalism to organize and deliver medical services is based on the understanding that medicine demands an expertise “not easily comprehensible to the average citizen,”2 that becoming a physician requires significant periods of education and training, and that physicians must serve the common good. Professional status confers significant privileges on physicians, including autonomy of practice and the right to self-regulate—that is, to set and enforce standards of practice. The right to self-regulate is also a fundamental obligation for the profession as a whole. The professional licensing bodies, which in Canada are the provincial colleges of physicians and surgeons and equivalent territorial bodies, are an important part of this right and obligation. Ultimately, the disciplinary action carried out by these bodies is the final enforcement of the profession’s standards.

Disciplinary action by medicine’s licensing organizations involving practising physicians receives relatively little attention in the medical literature. However, a growing body of published evidence supports the need to teach and evaluate professionalism in physician trainees. The article by Alam and colleagues published in this issue of Open Medicine describes the frequency and type of, as well as the specialty involved in, disciplinary actions against physicians in Canada over almost a decade. Although the authors found that no more than 1 in 1000 physicians in Canada had been subject to disciplinary action during that period, in order to protect patients it is important for the profession to understand the causes of disciplinary actions and to actively seek ways to reduce behaviours leading to disciplinary actions.

Alam and colleagues report two particularly interesting findings on the characteristics of physicians involved in disciplinary action. Most of the current medical literature on efforts to teach, promote and evaluate professionalism focuses on medical students and trainees. Indeed, Alam and colleagues suggest a need for greater inclusion of education on sexual misconduct in medical training curricula. On average, the physicians who were disciplined had been in practice for approximately 29 years before the disciplinary action, which suggests that strategies for continuing medical education for physicians in practice are also critically important. However, there is a paucity of literature on teaching and enforcing professional standards for practising physicians.3

The task of promoting and upholding the standards of conduct and perhaps decreasing the incidence of actions requiring discipline must be shared by the body of physicians in practice, not just the licensing bodies. Although discussions about professionalism are not easy and can elicit defensive reactions, “[p]romoting accountability for the behavior of our colleagues as well as ourselves deepens the investment we all share in our profession. This is the essence of self-regulation in medicine.”3(p 616) Our provincial colleges are increasingly seeking to support practising physicians in managing disruptive behaviour among colleagues and decreasing behaviours requiring disciplinary action. Useful resources such as the College of Physician and Surgeons of Ontario’s Guidebook for Managing Disruptive Physician Behaviour4 are available not just to educators but to all members of the profession to support our obligation for self-regulation.

Alam and colleagues also report that the predominant specialties involved in disciplinary action are family medicine, psychiatry and surgery. Health care organizations such as hospitals are increasingly mandated to develop codes of conduct as well as procedures for enforcing them. Many practitioners in family medicine and psychiatry, however, practise independently, outside of larger organizations and more often without regular teams or partners than other specialties. Thus, organizational policies and strengthened cultures of self-regulation may not have an impact on the incidence of actions requiring disciplinary action among independent and solo practitioners.

Ensuring an effective, transparent and fair system within our professional colleges to enforce the standards of conduct of medicine is essential to fulfilling our obligations for self-regulation. The right and obligation of self-regulation is designed to serve and protect patients. It is a privilege and a burden shared by all physicians and must be supported by all members of the profession.