"Black Swans": Bad Doctors Reveal our Vulnerabilities and Opportunities in Medical Education

From the 7/31/2020 newsletter

Director's Corner

Bad Doctors, Rare but Devastating, Reveal our Vulnerabilities and Opportunities to Create Robust Character and Professionalism in Medical Education

Adina Kalet, MD, MPH

In this week’s Directors Corner, Dr. Kalet highlights what “black swans” or “bad apples” reveal about our vulnerabilities in medical education and what we need to do to ensure the public’s trust …

My heart sinks every time. In an era when trust in medicine and science is put to the test every single day, we do not need another “bad doctor” story. But there it is in the New York Times. Dr. Sapan Desai, who founded a company named Surgisphere while he was a surgery resident at Duke, provided aggregated, unverifiable – and likely falsified – data for two COVID-19 hydroxychloroquine studies published by Harvard Medical School researchers in Lancet and the New England Journal of Medicine. Dr. Desai refused to release the raw data when scientists around the world questioned the veracity of the studies. Both papers were rapidly retracted.

This type of “fake science” does immeasurable harm. It creates confusion. Critical public health messaging is interrupted, making the dissemination of actual findings more difficult. It threatens public confidence in much needed, ongoing clinical trials. It ruins trust in the medical profession. But while we would like to demonize this one “bad apple,” he is not the only one to blame. We must examine the system that enabled him to thrive.

Black Swans in Medicine

Misconduct by scientists and physicians is thought to be rare (although emerging evidence suggests otherwise). For the sake of argument, let’s say bad doctors are as rare as black swans. In the “black swan theory,” seemingly unpredictable events – like a physician willing to lie, falsify data, and harm patients – will have major negative effects. Institutional responses to individual bad actors are often weak and inadequate because of their supposed rarity. However, as philosopher Nassim Nicholas Taleb points out in two best-selling books (The Black Swan: The Impact of the Highly Improbable and Antifragile: Things that Gain from Disorder), systems should not dismiss the existence of black swans as rare, unpreventable aberrations but, rather, build robust systems that rise up and do not fail in the face of the unexpected or unimaginable. Creating such a system is healthy, lifesaving, and trust enhancing.

In the New York Times article, journalists Ellen Gabler and Roni Caryn Rabin interviewed dozens of people who either worked with or supervised Dr. Desai at different points in his pre-medical, medical, and surgical education (he is now a practicing fellowship-trained vascular surgeon). They described him as “a man in a hurry, a former whiz kid willing to cut corners, misrepresent information or embellish his credentials as he pursued his ambitions.” Nurses and fellow residents reported their concerns to leadership about Dr. Desai’s untrustworthiness and his routine dishonesty about everything from patient care to his whereabouts. He once lied that he didn’t answer pages because he had been performing a rare surgical procedure. Why wasn’t he stopped from progressing through training? Why would a residency, and then a fellowship, allow such a physician to graduate, effectively recommending him to the world for a lifetime of medical practice? What possible justification exists?

It Gets Worse

Dr. Desai did come close to being expelled from his vascular surgery fellowship at the University of Texas Health Science Center. His career was saved when a faculty member with whom he was doing research argued that the frequent complaints were a result of “personality differences and professional jealousy, not substantive deficiencies in surgical skill or patient care.” Unfortunately, this defense that others are merely envious is typical for “black swan” physicians and would have been a tip-off for anyone familiar with dealing with certain types of personality disorders.

He was given the opportunity to remediate his communication skills and went on to finish the program and enter practice. Not surprisingly, Dr. Desai soon had three malpractice claims against him at the community hospital in Illinois where he worked as a vascular surgeon before he left “for personal reasons.”

Remediation Works for Some, but Not All

As an expert in medical professionalism remediation, I have met many students, residents and colleagues who behaved in ways that “hit the radar” at least once. They have cheated on exams, plagiarized patient write-ups, had another student sign them into required sessions, or been disrespectful to members of the staff or of the faculty. I have even met a student or two who falsified scientific data; it is rare, but it happens. When confronted, the vast majority of these trainees show insight, are remorseful, remediate, and sincerely apologize to whomever they hurt including – and especially – their peers. In my experience, these are good prognostic signs. These students learn from remediation and never demonstrate egregious behavior again. Talk to me about the strategies that work.

However, some trainees – the superficially charming black swans – are exceedingly arrogant, disrespectful, and dismissive. They lack empathy for others and fiercely resist feedback. Occasionally, I have met a trainee who is unwilling to engage in any meaningful discussion about their behavior. As was apparently the case with Dr. Desai, if the person is especially brilliant or “awe- inspiring,” they are given second, third, and fourth passes even when their behavior imperils patient safety. Even though their behavior patterns satisfy diagnostic criteria for serious, difficult to treat personality disorders, their supervisors make excuses and justify choices by believing themselves compassionate.

Of course, we want all of our students to succeed, but truly bad behavior is corrosive. When a medical education program tolerates borderline clinical competence and unprofessional behavior, the community of peers notices. A lack of action is toxic to the educational and patient care environments. We run the risk of losing the trust of our other trainees and our communities if we fail to respond to lapses in professional behavior.

This Must Change. It is an Issue of Character.

Medical educators must face up to the challenge and work to ensure that consistent standards of competence, character, and caring are met by our trainees and ourselves. I believe educators in general do not openly address these issues because we feel we have neither the effective low-stakes, formative strategies nor the institutional support to tackle them when they arise. These barriers contribute to the “hidden curriculum” which tolerates a range of unprofessional behaviors.

Evidence to support remediation practices is mounting rapidly. In a recent review of the evidence, we and a group of international colleagues summarized what we do and don’t know about remediation. We concluded that well-run, effective remediation programs are reassuring to both the students who need them and to those who don’t. This takes some investment, but it is critical.

Our Obligation to the Future

Everyone’s professional judgement can lapse from time-to-time, especially when under unprecedented stress. There is, however, a very big difference between someone who lapses occasionally and someone with long-term patterns of unacceptable behavior.

One other thing: We need longitudinal data if we are to spot patterns. How do we know if there are ongoing concerns if we don’t “feed forward” professional behavior information about individual students and trainees? Only half of US medical schools have policies that support feeding forward while the other half feel strongly that to do so violates educational privacy. It is rare that a medical school provides honest information to residency training programs about lapses in professionalism or that these programs provide detailed information to future employers.

The best way to build robust, non-fragile systems is to take the assessment of professionalism and character development as seriously as we take the assessment of knowledge. Once we do this, we can build hardy, rigorous, and effective remediation programs for those who don’t meet the standards.

It should go without saying that not every medical student should become a physician, particularly when they exhibit patterns of egregious, life-threatening behavior. We must create systems that consistently harness judgment and courage to identify and confront the black swans. Those who lack the character strengths to be a physician should be dismissed.

I know that this is an exceedingly complicated issue, but I also know that this is one way we meet our societal obligation to care for the next generation by transforming medical education. Future patients, the integrity of science, and society will all suffer if we fail to act.

Adina Kalet, MD MPH is the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin.