We are all full of weakness and errors; let us mutually pardon each other our follies - it is the first law of nature. Voltaire

Doctors are human, and there will always be a few bad apples amongst them. After all, they are as vulnerable as anyone to all the maladies that can beset professionals in a highly- demand stressful profession. In any large population of individuals there will always be a small percentage of “problem” members, and this is true of the medical profession as well. “Problem doctors” or impaired physicians, whose performance persistently falters, pose a substantial threat to patient safety; 5% of practicing physicians could be considered problem doctors because their performance is unsafe and substandard. This is a term that has been used to encompass a wide range of behavior, including:

Unacceptable behavior

* Alcoholism

* Drug abuse

* Depression and other mental health problems

* Inappropriate sexual contact

* Burnout

* Professional incompetence

There are bad doctors (and bad nurses as well), but the fact that we tolerate them is just another systems problem. One of the definitions of the medical profession is that it is self-policing: it sets its own standards and enforces them through peer review. Despite this responsibility, it is undeniable that doctors and hospitals tend to protect their own, sometimes at the expense of patients.

Why we turn a blind eye

It can be scary to imagine that even though your personal doctor may have these problems, his colleagues will try to protect him. While many professional medical organizations ethically require doctors to report impaired doctors, most are party to a conspiracy of silence and turn a blind eye to the problem. There are many reasons doctors do not turn in their colleagues: * Most keep mum out of a misplaced sense of loyalty-they don’t want to get their friends into trouble

* Others believe that it’s none of their business-that someone else should be taking care of the problem

* Some feel that it’s not worth bothering about, as no action would be taken

* Some fear retribution if they rat-out on their peers

Technically proficient but disruptive physicians actually create an environment that is unsafe and stifle other caregivers from stepping forward to protect patients. These physicians can end up creating bad outcomes because they foster a culture of fear, rather than one of safety.

How to help

If physicians want to maintain their professional autonomy, they must become more involved in the self-regulation process. Their goal is to identify problem doctors early, before they jopardize patient safety. A system to do so should fulfill three criteria: * It should be objective, and should rely on data

* It should be fair, and all physicians should be evaluated on an annual basis according to the same measures, using an open and unbiased evaluation process

* Finally, the system should be responsive. When physicians with problems are identified, they must be treated promptly

For some physicians, feedback and internal counseling may be all that is necessary. Others may need further assessment, and perhaps referral to a program to help them to correct their deficiencies , so that they can continue to practice medicine, if possible. Others may be better served by being struck off the medical register, so that they can no longer harm patients, and are forced to pursue another career.

Most impaired physicians have difficulty with competence, conduct, or communication, and their colleagues must be willing to intervene when they suspect a problem. Incompetent or dangerous healthcare providers , and the institutions which harbor them, must be held accountable. This is essential in order to protect patients from the harm these problem doctors can cause; and to help the doctor as well.