Dishonesty, misconduct and fraud in medicine Are they a problem?

1. Dishonesty, misconduct and fraud in medicineAre they a problem? Nigel Bateman June 2011

2. Medicine is a profession. A profession- • is a vocation or calling implying service to others. • determines its own standards. • is accountable to patients and itself.

3. The “professional” physician. The “professional” physician displays- • concern for patients and colleagues. • a commitment to continuing professional development (knowledge, skills and behaviours). • integrity and intellectual curiosity. • a high standard of ethical conduct. From: Calman K BMJ 1994; 309: 1140-3.

4. Do we agree? Would you add anything?

5. Why discuss dishonesty, misconduct and fraud in relation to medicine? Because any or all of these behaviours is unprofessional and undermines trust in the profession.

6. Definitions • Dishonesty. Deceitfulness or fraudulence. • Misconduct. Improper conduct (unseemly, indecent or wrong). • Fraud. deceitfulness, criminal deception. use of false representation to gain an unjust advantage.

7. Dishonesty Institutional: • False reporting of activity or spending. • Failing to investigate complaints thoroughly. • Inappropriate descriptions in patient literature (facilities available or prognosis after treatment).

8. Dishonesty Individual: Education -plagiarism. -examinations. Achievement -Curriculum vitae. Academic and research -plagiarism. -gift (spurious) authorship. Financial -accepting gifts or bribes.

9. Misconduct or fraudDoing wrong knowingly Individual: • Failure to record information correctly. • Fabricating results. • Recording other people’s work as your own without attribution. • Altering records at a later date. Applies to clinical or research activity.

10. Do we teach about it in medical school? In 1967- 1970 – by example only. Did any of you receive any formal teaching on these subjects? USA 2011: Survey in 2010 of all medical schools in the USA: 44% of deans reported their institution had “at least some training on fraud and abuse”. J K Taitsman Educating physicians to prevent fraud, waste and abuse. NEJM 2011; 364: 102-103

11. Do they happen in medicine? • All the time. • Frequently. • Infrequently. • Rarely. • Never. A show of hands to decide.

12. Examples Fabricating results: • Dr U Siddiqui, consultant psychiatrist. Patients in a trial of a new treatment. BMJ 1988; 296: 306. • Mr M Pearce, Consultant Obstetrician. Report of a new procedure. Br J ObstetGynaecol 1994; 101: 716-7 and Randomised trial of HCG to treat miscarriage. • Br J ObstetGynaecol 1994; 101: 685-8

13. Examples Theft • R Gallo 1987; Falsely claimed to have discovered the virus that caused AIDS. Dishonesty Any example you know of!

14. How can it be stopped? Prevention: • Societal values • Education • Proper process - Research and ethics committees - Medical Director or Senior Partner

15. How can it be stopped? Detection Research - institutional review - external review - publication review Clinical - peer review - audit eg MMR meetings -complaints procedure Whistle blowing

16. Whistle blowing • A person who draws attention to wrongdoing (usually from within the organisation). • An employee who publicly discloses unethical or illegal practices in the workplace. Glazer MP and Glazer PM The whistle blowers… New York: Basic Books 1989 : 4

17. UK Example Bristol Paediatric Cardiac Surgery Dr S Bolsin consultant cardiac anaesthetist reported excess deaths in children operated upon at the Bristol Royal Infirmary Cardiac Surgical Unit. Results • A public enquiry lead by Sir Ian Kennedy. • Dr Bolsin emigrated to Australia where he became head of ITU at a Sydney hospital. • Two consultant surgeons disciplined by the GMC. • The paediatric cardiac surgical unit closed.

18. Was Dr Bolsin right to speak out? Was he treated justly?

19. Problem discussion groups Misconduct Dishonesty Whistle blowing

20. Problems Cheating in examinations 1. You are one of the external examiners in the final MB BS examination of a medical school. One of the students is found reading a medical textbook by the examiners after completing the clerking of her “long case” (40 minutes to take the history and examine a patient). This is against regulations. The student admits this but denies that it gave her any advantage. The student had won several clinical prizes and this is her first offence. Is this an offence? What should be the outcome? What are the implications for the medical profession?

21. Are tomorrow’s doctors honest? A survey of 676 medical students of all years at a medical school in the UK. 461 replies analysed. The “yes” column represents those considering the suggested action to be wrong Rennie SC and Crosby JR BMJ 2002; 322: 274-275.

22. Attitudes and behaviours of medical students on scenarios involving academic misconduct

23. Cheating in examinations 2. The written examinations for MRCPUK are composed of two or three 3 hour, 100 question, “best of 5” multiple choice papers. Candidates sit in assigned places in the examination hall. Invigilators are present. The invigilators are suspicious that candidate B is copying answers from candidate A who is sitting next to him/her. Candidate B is warned and the incident reported to the Examining Board. On analysis of the answer papers there is no evidence that candidate B gained advantage (B failed and A passed). However it is found that candidates Y and Z have submitted near identical answer papers and both have passed. The Board must decide what should be done. What should be the outcome for the four candidates? What are the implications for the medical profession?

24. The use of computer analysis to detect cheating in MRCPUK. Acinonyx is a program which compares the answers of one candidate with those of all the other candidates sitting that paper. It is run each diet of the examination. Duty for MRCPUK to ensure a fair test. Duty of candidates to behave honestly. Current policy: • Notify both candidates immediately by letter. • For any future examination both candidates will sit in isolation with an invigilator. • If cheating confirmed the GMC will be informed.

25. Beating Cheating This article describes how the automated analysis of test-taker’s answers to standardised tests can be used to detect cheating. Student answers (adjacent students or electronic), examiner information (advance information) or invigilator behaviour (bribes) are all found to be problems. The Economist Technology Quarterly 2011 June 4th; 6-9.

26. Plagiarism You are a medical student and have to write a dissertation which will contribute to your course grade. You are encouraged to look at sample dissertations of students of previous years in the library to get a feel for the standard required. You wish to write about the contribution of mitochondrial DNA to inherited disease and find a dissertation on the subject written by a student 3 years your senior who you do not know. You want to use much, but not all of the same material. • What should you do? • What should you not do?

27. Plagiarism What should be done: • Discuss the issue with the course organiser / supervisor. • Scrupulous attribution. What should not be done: • Pretend you have not read it and proceed. If in doubt choose another subject.

28. Academic dishonesty You are asked to referee for a paper for a reputable medical journal. It is the policy of the journal that reviews are signed and that the authors will receive a copy of your review. When you read the paper you notice 3 things which worry you: • There is an unusual consistency in some of the results rendering the statistical analysis “significant”. This is a surprising result and is not consistent with previous publications. • The discussion omits reference to two papers on the same subject which did not find this correlation. This biases the discussion. • The senior author (head of department) appears to have played very little or no part in the study or preparation of the manuscript. What are the issues which need to be addressed? Which of these should you include in your review? What else should you do?

29. Possible fabrication of results and gift authorship Your role as a referee: • Report facts and draw attention to inconsistencies or omissions in your review. • Write about suspicions to the editor of the journal under separate cover asking his/her advice as to how to proceed. It is the editors role to decide whether or not to challenge the authors.

30. Whistle blowing You are the senior house officer. Mrs Katz is a 54 year-old woman who has been on your ward for 9 days. She is in the terminal stages of breast cancer and is clear headed and aware. She has asked her doctor not to let her suffer. This has been accepted and is written in the notes as an advanced directive. One day Mrs Katz tells you she wants to live to see the birth of her first grandchild expected next week. Later that night you are called to attend Mrs Katz who has suffered a cardiac arrest. Your registrar, heading the team, decides not to resuscitate despite your information regarding Mrs Katz’s comment earlier in the day. You feel an error of judgement has been made. Your options are: - do nothing. • recount the incident to the consultant in charge. Please state reasons for your choice.

31. Student’s attitudes and potential bevaviour 1 A cohort study at a UK medical school. The consensus response to the 10 scenarios was one based on the opinion of experts in medical ethics, the law and policies issued by professional institutions (eg GMC). Also recorded were values recognition and action justification. 111 students enrolled at the beginning of year 1. They were also surveyed at the end of year 1 and in years 3, 5 and post year 5 (50).

32. Student’s attitudes and potential behaviours 2 Results Report incident (%) Pre year 1 18/50 (36) Post year 1 16/40 (40) Post year 3 11/30 (37) Post year 5 15/50 (30) Goldie J et al. Med Education 2003; 37: 368-375

33. Why are so few year 1 students willing to report the incident? Why does the medical course not change attitudes? What should be done about it?

34. Dishonesty, misconduct and fraud in medicine Do they happen in medicine? • All the time • Frequently • Infrequently • Rarely • Never A show of hands to decide.

35. What should we do about it - as individuals? - as a profession?

36. References 1 General: General Medical Council. Good Medical Practice. London GMC 2001. Calman K. The profession of medicine. BMJ 1994; 309: 1140-3. Wells F and Farthing M. Fraud and misconduct in biomedical research. 4th Edition. London. RSM Press, 2008. Taitsman J K. Educating physicians to prevent fraud, waste and abuse. NEJM 2011; 364: 102-3

37. References 2 Problems: Smith R. Cheating at medical school. BMJ 2000; 321: 398. Rennie SC and Crosby JR. Are tomorrow’s doctors honest? BMJ 2001; 322: 274-5. Goldie J et al. Students attitudes to whistle blowing as they pass through a modern medical school. Med Educ 2003; 37: 368-75