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At the Intersection of Health, Health Care and Policy

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Survey Shows That At Least Some Physicians Are Not Always Open Or Honest WithG. Campbell

Lisa I. Iezzoni, Sowmya R. Rao, Catherine M. DesRoches, Christine Vogeli and EricCite this article as:

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By Lisa I. Iezzoni, Sowmya R. Rao, Catherine M. DesRoches, Christine Vogeli, and Eric G. Campbell

Survey Shows That At Least SomePhysicians Are Not Always Open

Or Honest With Patients

ABSTRACT The Charter on Medical Professionalism, endorsed by more

than 100 professional groups worldwide and the US Accreditation

Council for Graduate Medical Education, requires openness and honesty

in physicians communication with patients. We present data from a

2009 survey of 1,891 practicing physicians nationwide assessing how

widely physicians endorse and follow these principles in communicatingwith patients. The vast majority of physicians completely agreed that

physicians should fully inform patients about the risks and benefits of

interventions and should never disclose confidential information to

unauthorized persons. Overall, approximately one-third of physicians did

not completely agree with disclosing serious medical errors to patients,

almost one-fifth did not completely agree that physicians should never

tell a patient something untrue, and nearly two-fifths did not completely

agree that they should disclose their financial relationships with drug

and device companies to patients. Just over one-tenth said they had told

patients something untrue in the previous year. Our findings raise

concerns that some patients might not receive complete and accurate

information from their physicians, and doubts about whether patient-

centered care is broadly possible without more widespread physician

endorsement of the core communication principles of openness and

honesty with patients.

In its landmark 2001Crossing the QualityChasmreport, the Institute of Medicinelisted patient-centerednesscare that

respects patients preferences, needs,and valuesas one of six essential fea-

tures of a high-quality health care system.1 In his2002 users guide to that report, DonaldBerwick called patient-centeredness the truenorth that should guide all health reformefforts.2

In his confessions of an extremist,Berwickexpanded on this position.3 The Institute ofMedicine committees deliberations that ulti-mately led to patient-centeredness, he ex-plained, were a compromise position between

two extremes: the position stated by the latesociologist Eliot Freidson in his early conceptu-alization of medical professionalism (Trust us:

we know best what will help you) and the con-sumerist position (Let us know what you needand want, and that is what we will offer).3(p w3)

In arguing thatpatient-centeredness should bethe central, distinct, and dominant dimension ofhealth care quality, regardless of its relationshipto other dimensions, such as safety and effi-ciency, Berwick described three maxims thatguided his understanding: The needs of thepatient come first; Nothing about me with-out me; and Every patient is the onlypatient.3(p w560)

doi: 10.1377/hlthaff.2010.1137HEALTH AFFAIRS 31,NO. 2 (2012): 3833912012 Project HOPE

The People-to-People Health

Foundation, Inc.

Lisa I. Iezzoni is a professorof medicine at HarvardMedical School and directorof the Mongan Institute forHealth Policy atMassachusetts GeneralHospital, in Boston.

Sowmya R. Rao is anassociate professor in theQuantitative Health SciencesDepartment at the Universityof Massachusetts MedicalSchool, in Worcester.

Catherine M. DesRoches i s asenior researcher atMathematica Policy Research,in Cambridge, Massachusetts.

Christine Vogeli is a healthservices researcher at theMongan Institute for HealthPolicy.

Eric G. Campbell is anassociate professor ofmedicine at Harvard MedicalSchool and director ofresearch at the MonganInstitute for Health Policy.

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Open, transparent, and bidirectional commu-nication between patients and physicians is thefoundation of patient-centered care. Fundamen-tally, communicationby bothpatientsand physi-cians represents transmission of information,thoughts, and feelings so that they are satisfac-torily received or understood.4

In most clinical interactions, patients describe

symptoms and signs to inform clinical evalua-tions. Aftersynthesizingthis information,physi-cians indicate diagnoses and suggest treatmentplans. Beyond that, communication shapesinterpersonal relationships between patientsand physicians through mutual trust and empa-thy, understanding of patientspreferences and

values, and ultimately the course of care.511

Movements toward collaborative care, em-pathic listening, shared decision making, andculturally competent care reflect a growingunderstanding of the potentially therapeutic im-plications of patient-physician communica-

tion.7,12

15 In 1999 the Accreditation Council forGraduate Medical Education described inter-personal and communication skills as skillsthat result in effective information exchangeand teaming with patients.16 The council listedthose skills among six core competencies thatresidents must attain during their postgraduatetraining.

In recent years, the subject of communicationbetween patients and physicians has broadenedto encompass more than discussions of patientsimmediate clinical concerns. Specifically, it nowincludes information that physicians are ethi-

cally obligated to convey to patients and thatcould be essential to patient-centered care.

For instance, recognition of the high fre-quency of medical errors, the morbidity andmortality caused by those errors, and the result-ing risks of malpractice litigation has focusedattention on how and when physicians shoulddiscuss errors in their care with patients.8,1719

Another area of concern is how open and honestphysicians are in discussing clinical prognosesand the various risks and benefits of interven-tions with patients.2023

Other potentially important topics that merit

open communication between physicians andpatients include relationships between physi-cians and industry, reimbursement incentives,physicians investments in medical facilities, andgeneralconcernsabout conflicts of interest.21,24,25

Maintaining the confidentiality of patient infor-mation is also an issue: The Health InsurancePortability and Accountability Act of 1996 madethis both a professional and a legal obli-gation.26,27

The Charter on Medical Professionalism, en-dorsed by more than 100 professional groups

worldwide and by the Accreditation Councilfor Graduate Medical Education, addresses com-munication topics among its three guiding prin-ciples and ten responsibilities or commit-ments.28,29 The charters first principle, patientwelfare, notes that altruism contributes to thetrust that is essential to physician-patient rela-tionships, andit warns against threats from mar-

ket forces to this trust.The second principle, patient autonomy, re-

quires physicians to be honest with patients soas to foster informed decision making. Honestymust include promptly informing patients ofmedical errors and is one of ten professionalresponsibilities. Another responsibility entailsmaintaining appropriate relationships with pa-tients. The charter also exhorts physicians not toexploit patients for financial gain, instructingphysicians to manage conflicts of interest to re-tain patient trust.28,29

Despite endorsements by numerous profes-

sional associations, it is unknown how widelythe charters communication provisions are ac-cepted or followed by US physicians. In 2009 wesurveyed practicing physicians nationwide toexplore their attitudes and behavior regardingdifferent aspects of the charter. This article ad-dresses physician-patient communication con-cerns and related issues that affect patient-centered care.

Study Data And MethodsS ur v ey D e v e lop m e n t A n d T e s t ing For this

study, we revised the professionalism question-naire that we used in a 2004 national physiciansurvey.3033 That survey included batteries ofquestions addressing topics concerning profes-sionalism from each of the charters differentdomains. For the 2009 survey, we revised the2004questionsthat had notadequately discrimi-nated among respondents.34,35

To identify potential new topics for the 2009survey, we convened a fifteen-member, multi-specialty advisory group.We also conducted fourfocus groups with a total of forty physicians fromdiverse specialties. The focus-group moderator

addressed five broad topics, including honestywith patients.We pretested the revised question-naire with twenty-one practicing physicians.

The final questionnaire (for details, see theonline Appendix36) included five questionsabout attitudes and four questions about behav-ior related to physician-patient communication.Because we needed parsimonious question bat-teries to cover every charter domain withoutoverburdening respondents, we could not askabout all aspects of physicians attitudes andbehavior related to communication. Instead,


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we included nine questionsas tracermeasures ofattitudes and behavior.

Institutional Review Boards at the participat-ing institutions approved the questionnaire andadministration procedures. Otherarticlesreportfindingsfromthis project about different charterdomains, such as managing conflicts of interestand professional self-regulation.34,35

S a m p le A n d S ur ve y A d m inis t r at ionUsingthe American Medical Associations 2008Masterfile, we identified all US physicians inprimary care(internal medicine,family practice,and pediatrics) and four other specialties (car-diology, general surgery, psychiatry, and anes-thesiology). We excluded doctors of osteopathy,resident physicians, practitioners in federallyowned hospitals, retirees,physicians without ad-dresses, and those requesting no contacts. Fromthis pool of eligible participants, we randomlyselected 500 physicians within each of the sevenspecialties, for a total of 3,500 physicians.

The Center for Survey Research at the Univer-sity of Massachusetts, Boston, administered theeight-page survey in May 2009. The center sentsampled physicians the survey packet, whichcontained a cover letter; fact sheet; question-naire, with a sticker on the back containing arandom subject identification number; post-age-paid return envelope; and a $20 incentive.The center telephoned nonrespondents to solicitparticipation.

Of the 3,500 sampled physicians, 562 wereineligible because they were deceased, out ofthe country, practicing a nonsampled specialty,

on leave, or not actively practicing. Of the re-maining 2,938 eligible physicians, 1,891 com-pleted the survey (a 64.4 percent overall re-sponse rate). Response rates varied byspecialty, as follows: pediatrics, 72.7 percent;family practice, 67.5 percent; surgery, 65.1 per-cent; anesthesiology, 64.6 percent; psychiatry,64.0 percent; internal medicine, 60.8 percent;and cardiology, 50.6 percent.

For the results reported here, we eliminatedsixty-onerespondents whodid notsupplyusableZIP code information, which was required todetermine regional malpractice claim rates.

These sixty-one respondents had demographiccharacteristics similar to those of the includedrespondents.

Data Analysis We created binary dependentvariables from responses to the five attitude andfour behavior questions related to physician-patient communication. We used responses atthe highest or lowest ends of the response-category continuum, depending on which endbest represented charter precepts.

We focus here on extremes of the response-category continuum for two reasons. First, each

question addressed topics that the charter viewsas key components of professionalismitemsrepresenting core professional norms (such asattitudes that physicians should support com-pletely, not partially). Second, responses werenot distributed evenly across the categories butwere clustered at the extremes that representendorsement of charter precepts.

As independent (predictor) variables, we in-cluded respondents sex; underrepresentedminority status (race or ethnicity other thanwhite or Asian); years in practice (fewer than10, 1019, 2029, or 30 or more); graduationfrom a medical school outside the United Statesor Canada; specialty; and practice setting (uni-

versity or medical school, hospital or clinic,group practice, solo or two-person practice,and other). Our previous research had foundassociations between these factors and medicalprofessionalism.30,32,33 We hypothesized thatthese factors independently affect physicians

communication attitudes and behavior.Given a potential relationship between pa-

tient-physician communication and malpracticeclaims,1719,37 we also hypothesized that local mal-practice environments affect physicians atti-tudes and behavior. To create a proxy for thisfactor, we calculated total malpractice claims3033

paid per physician per state from the 2009National Practitioner Database, grouping thesenumbers into three groups (low, medium, andhigh).38

All analyses used weights to account for differ-ential sampling rates and nonresponse by spe-

cialty. We first examined bivariable associationsbetween dependent and independent variablesusing two-sidedttests for continuous variablesor chi-square tests for categorical variables totest for statistical significance. We used multi-

variable logistic regression models with associ-atedstandard errors to predict our binary-depen-dent variables, adjusting for the independent

variables listed above.39Analyses used the follow-ing statistical analysis software: SAS, version9.2; and SUDAAN, version 10.0.1.

Limitations Our study has several limitations.First, because of social desirability bias, or the

tendency of respondents to answer questions ina way that others will view favorably, our resultsprobably represent a lower-bound estimate ofthe actual frequency of communication failures.Second, although we achieved an excellent re-sponse rate for a physician survey, nonresponsebiasmightexist.We weighted results to adjust forthis possible bias,but weighting adjustments areimperfect.

Third, we cannot verify the accuracy of ourrespondents attitudes or behavior. We did notask why physicians engaged in behavior that

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runs counter to professional norms and princi-ples. In certain circumstances, physicians mighthave believed that their behavior was fully jus-tified.

Fourth, although we found intriguing associ-ations between communication concerns andphysician gender, these results require cautiousinterpretation. Gender is closely linked to physi-

cian specialty, which we also included in ouranalyses. However, we did not have sufficientnumbers of womenin some specialties toinclude

variables that explored the link between genderand medical specialty in our models.

Finally,to avoidburdening respondents andtoachieve acceptable response rates, we restrictedthe number of questions about each profession-alism domain in the multiple survey modules.Wetherefore did not ask respondents to provide de-tails about their communication experiences.Wealso did not offer respondents opportunities toexplain their responses or provide more-

nuanced responses.

Study ResultsExhibit 1 shows the demographic, professional,and practice characteristics of survey respon-dents. Most were male and white or Asian, hadgraduated from a US or Canadian medicalschool, and had practiced for more than twenty

years.Com m un icat ion A t t itud e s A n d B e h av ior

Exhibit 2 shows respondents communicationattitudes and behavior. The vast majority of

the respondents completely agreed that physi-cians shouldfullyinform patients about therisksand benefits of interventions, never tell a patientsomething that is not true, and never discloseconfidential information to unauthorized per-sons. However, more than one-third of respon-dents did not completely agree that it was neces-sary to disclose all serious medical errors toaffected patients or that it was important to dis-close to patients any financial relationships withdrug and device companies.

When asked about their own behavior in theprevious year, more than a tenth of respondents

said that they had told an adult patient or childsguardian something that was not true. Almostone-fifth said that they had not fully disclosedmistakes to patients for fear of being sued. Morethan one-quarter reported revealing unauthor-ized health information about a patient. Andmore than half said that they had described aprognosis more positively than the facts war-ranted.

Associations With Physician And Practice

Characteristics Appendix Exhibits 3 and 436

display results from multivariable logistic re-

gression models predicting responses that areconcordant with the charter for the five commu-nication attitudes and four behavior questions,respectively. Except for the behavior of fully dis-closing mistakes, all attitudes or behaviors weresignificantly associated with one or more physi-cian or practice characteristics, although nooverarching pattern appeared.

Physician gender was significantly associatedwith four of the nine responses: those concern-ing never telling patients something untrue,fully describing benefits and risks, disclosingfinancial relationships, and never having toldan untruth in theprioryear.In allfour instances,women were more likely than men to provideresponses consistent with charter principles.

Race or ethnicity was significantly associatedwith two responsesattitudes about never tell-ing an untruth and never disclosing confidentialinformation. In both instances, underrepre-sented minorities were more likely than white

or Asian respondents to report attitudes consis-tent with charter commitments.

Graduation from medical schools outside theUnited States or Canada was significantly asso-ciated with four responses. In three cases (nevertelling untruths, never disclosing confidentialpatient information, and never having revealedconfidential information), graduates from thesemedical schools were more likely than graduatesfrom US or Canadian schools to respond in waysthat were consistent with charter precepts. Inone case (attitude about disclosing financial re-lationships with drug and device companies),

the difference between the two groups was in-consistent.

Physician specialty was significantly associ-ated with four of the nine responses, althoughwithout consistent patterns relating to charterobligations by different specialties. For instance,general surgeons and pediatricians were mostlikely to completely agree about needing to dis-close all serious medical errors to patients,whilecardiologists and psychiatrists were least likelyto report this attitude (p


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tice, and local malpractice environment weresporadically associated to a significant degreewith reported attitudes and behavior. For exam-ple, more physicians (78.1 percent) practicing inuniversities or medical centers completelyagreedwiththe need to report allseriousmedicalerrors than physicians in solo or two-personpractices (60.5 percent; p 0:03).

Among physicians practicing in regions withthe lowest third of malpractice claim rates,68.9 percent completely agreed that physiciansshould fully disclose financial relationships withdrug and device manufacturers to patients,compared with 60.9 percent of physicians in re-gions with the highest third of malpracticeclaims (p 0:40).

DiscussionDespite widespread acceptance of communica-tion principles and commitments by profes-

sional organizations, substantial percentagesof US physicians did not completely endorsethese precepts, and many reported behaving inways that deviated from to these norms. Overall,approximately one-third of physicians did notcompletely agree with the need to disclose seri-ous medical errors to patients, almost one-fifthdid not completely agree that physicians shouldnever tell a patient something untrue, and nearlytwo-fifths of physicians didnot completely agreethat they should disclose their financial relation-ships with drug and device companies topatients.

Perhaps more important, one-fifth of physi-cians reported not fully disclosing medical mis-takes to patients because of fears of lawsuits,and

just over one-tenth said that they had told pa-tients something untrue in the previous year.

The survey results suggest that many physi-cians do not completely support the charter re-quirements related to communication with pa-tients. An alternative interpretation is thattreating support for the charter precepts asblack or whitephysicians either do or do notcompletely endorse and adhere to these princi-plesfails to recognize complexities of patient-

physician communication in everyday practice.Furthermore, although this survey was anony-

mous,manyrespondents wereprobablyaware ofwhich responses best fit expected professionalprinciples and obligations. These findings aretherefore likely to underestimate how oftenphysicians hold these attitudes or how often thisbehavior actually occurred. All of these interpre-tations raise questions about how often and inwhat contexts patients are receiving completeand accurate information from their physiciansthat can be essential to patient-centered care.

Despite the relative clarity and unambiguouslanguage of the charter precepts, many factorscan affect how and what physicians communi-cate to patients. Some might argue that knowingwhen to breach or bend these ruleswhen indi-

vidual patients require a different approachconstitutes clinical wisdom and true patient-cen-teredness. For instance, providing a patient withevery detail about his or her case is rarely fea-sible, nor is it necessarily desirable. Physicians

must sort through often contradictory and con-fusing information as their clinical assessmentsevolve and finally crystallize. Conveying manydetailssome of which may be erroneoustopatients might not prove helpful.

Some physicians may wonder about revealingerrors to certain patients if no serious harm re-sulted from them. Nonetheless, informing pa-tients fully about medical errors can reduce an-ger and lessen patients interest in bringingmalpracticelawsuits.17 Plaintiffdepositions fromforty-five lawsuits found that 71 percent cited

E x h ib i t 1

Characteristics Of Respondents To The Survey Of PhysiciansAttitudes And BehaviorRegarding The Charter On Medical Professionalism

Characteristic Number of respondentsWeighted percentof respondents

Sex

Female 539 32.9

Male 1,284 67.2Race or ethnicity

White or Asian 1,648 89.6Underrepresented minority 168 11.4

Location of medical school

United States or Canada 1,331 72.2Other country 494 27.8

Years in practice

Fewer than 10 210 12.41019 464 27.62029 569 30.730 or more 579 29.4

Specialty

Internal medicine 249 28.7Family practice 269 21.8Pediatrics 297 15.3Cardiology 218 6.4General surgery 263 7.2Anesthesiology 259 10.6Psychiatry 255 10.1

Practice setting

University or medical school 117 5.5Hospital or clinic 343 18.8Group practice 744 40.4Solo or two-person practice 401 22.0Other 223 13.3

SOURCE Authorssurvey of US physicians in seven specialties.

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underlying their failure to fully support profes-sional communication principles. Examiningcircumstances in which physicians feel justifiedin not complying fully with charter precepts isespecially important.

Another problematic area involved revealinginformation about financial relationships withdrug and device companies. Substantial num-

bers of physicians did not fully support disclos-ing these potential conflicts of interest to pa-tients. This finding is important, given theenactment of the Physician Payment Sunshine

Act of 2009, which requires companies to beginreporting payments to physicians in excess of$10 by March 2013.

Once these data become public, some physi-cians will probably encounter patients who wishto discuss potential financial conflicts of inter-est. Physicians who do not support public dis-closure might resist communicating this infor-

mation to inquiring patients or might makethese conversations difficult. Monitoring the ef-fects of the law on this aspect of physician-patient communication will be important.

Despite the limitations of our study describedabove, our findings raise concerns that somepatients might not be receiving complete andaccurate information from their physicians.

The effects of these communication lapses areunclear, but they could include patientslack ofinformation needed to make fully informed de-cisions about their health care.

These information deficits could contribute topoor-quality care by making patients less able tomake health care decisions that reflect their val-ues and goals. Our findings raise questionsabout whether patient-centered care is broadlypossible without more widespread physicianendorsement of the core communication princi-ples of openness and honesty with patients.

External financial support was providedby the Institute on Medicine as aProfession at Columbia University.

NOTES

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36 To access the Appendix, click on theAppendix link in the box to the rightof the article online.

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up to medical error. Health Aff(Millwood). 2010;29(8):154951.

41 Hagerty RG, Butow PN, Ellis PM,Lobb EA, Pendlebury SC, Leighl N,et al. Communicating with realismand hope: incurable cancer patients

views on the disclosure of prognosis.J Clin Oncol. 2005;23(6):127888.

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ABOUT THE AUTHORS: LISA I. IEZZONI, SOWMYA R. RAO,CATHERINE M. DESROCHES, CHRISTINE VOGELI & ERIC G. CAMPBELL

Lisa I. Iezzoni is aprofessor of

medicine at HarvardMedical School.

In this months Health Affairs, LisaIezzoni and coauthors present datafrom a 2009 survey of practicingphysicians nationwide to assesshow broadly doctors agree withand follow standards requiringopenness and honesty incommunication with patients. Forexample, the vast majority of

respondents agreed that physiciansshould fully inform patients aboutthe risks and benefits ofinterventions. However, nearly two-fifths did not completely agree thatthey should disclose their financialrelationships with drug and devicecompanies to patients. The authors

say that their findings raisedoubts about the viability ofpatient-centered care without morewidespread physician endorsementof openness and honesty withpatients.

Iezzoni is a professor ofmedicine at Harvard MedicalSchool and director of the MonganInstitute for Health Policy atMassachusetts General Hospital. In

addition to her academic andmedical affiliations, Iezzoni is amember of the Institute ofMedicine and serves on theeditorial boards ofHealth Services

Research and the Disability andHealth Journal. She received theDistinguished Investigator Award

from AcademyHealth in 2010.Iezzoni earned her medical degreefrom Harvard Medical School.


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Sowmya R. Rao isan associateprofessor at theUniversity of

MassachusettsMedical School.

Sowmya Rao is an associateprofessor in the QuantitativeHealth Sciences Department at theUniversity of MassachusettsMedical School, in Worcester, anda senior statistician at the Centerfor Health Quality, Outcomes, andEconomics Research at the Bedford

Veterans Affa irs Medical Center, inBedford, Massachusetts. Her mainresearch interest is thedevelopment of statistical methodsthat use survey data to addressquestions of epidemiologic andpublic health importance.

Rao received her doctorate inbiostatistics from BostonUniversity and completed apostdoctoral fellowship at theNational Cancer Institute.

Catherine M.DesRochesi s asenior researcher atMathematica PolicyResearch.

Catherine DesRoches is a seniorresearcher at Mathematica PolicyResearch, with fifteen years ofhealth services and survey researchexperience. Prior to joiningMathematica in 2010, she spentten years as a researcher andfaculty member at Harvard MedicalSchool and the Harvard School ofPublic Health. Her work withIezzoni, Campbell, Rao, and Vogeliwas awarded the Professionalism

Article Prize in 2010 by theAmerican Board of InternalMedicine Foundation.

DesRoches received a doctoratefrom Columbia UniversitysMailman School of Public Health.

Christine Vogeli isa health servicesresearcher at theMongan Institute.

Christine Vogeli is a healthservices researcher at the MonganInstitute. Her research focuses onphysician professionalism andhealth care quality. She received adoctorate in health policy andmanagement from the JohnsHopkins Bloomberg School ofPublic Health.

Eric G. Campbell i san associateprofessor of

medicine at HarvardMedical School.

Eric Campbell is an associateprofessor of medicine at HarvardMedical School and director ofresearch at the Mongan Institute.Over the past decade, his researchhas focused broadly onprofessionalism in medicine andhas empirically examined issuesrelated to conflicts of interest, self-regulation, care for the poor, andparticipation in civic activities.

Campbell received a mastersdegree in education, with aspecialization in adult education,and a doctorate in highereducation policy from theUniversity of Minnesota.

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