Actually, studies have shown that people in the same profession find it difficult to hold each other accountable. The effect is particularly pronounced in traditional, internal fields such as lawaccounting and medicine which have a history of self-regulation.
“It’s difficult for people in the same profession to effectively discipline peer misbehavior,” says Hatim Rahman, associate professor of management and organizations at the Kellogg School. “Professionals often turn a blind eye and look the other way.”
In response, regulators have launched transparency efforts—such as “sunshine laws” that make disciplinary proceedings publicly available—to help enforce professional accountability. This increased transparency should, in theory, encourage professionals to more easily criticize their peers.
But new research by Rahman and co-author Ece Kaynak of Bayes Business School reveals that even with extensive transparency measures, professionals still refrain from harshly disciplining peers who engage in misconduct.
Rahman and Kaynak uncovered this pattern among physicians, who rarely revoked their peers’ medical licenses when those peers were guilty of overprescribing opioids—which helped fuel one of the leading causes of death in America.
Each case investigated by the researchers was reviewed by a physician-led state medical board charged with maintaining a high standard of medical practice and ensuring the well-being of patients. In the vast majority of cases, however, the board refrained from imposing severe disciplinary action.
Amid America’s opioid epidemic, “doctors have been found guilty of overprescribing opioids,” says Rahman. “But we still found that the board rarely held them strictly accountable … even for exceptional, very extreme cases of misconduct.”
The findings demonstrate the severe limitations of self-regulation – for both minor and serious acts of misconduct – and highlight the imperative for outside intervention in many industries.
Innocent even when proven guilty
Each state has a medical board that has the sole right to discipline doctors regarding their medical license. In the situation for this study, which the researchers kept anonymous, the board, which consists of nine licensed physicians and three members of the public, meets six times a year to discuss cases.
Before a case reaches the board’s table, an administrative team — including state attorneys and a physician who previously served on the board — formally investigates the case, only bringing it up if disciplinary action is warranted. Therefore, the board only reviews cases in which the investigative team finds that the physician engaged in documented, egregious misconduct.
In 30 disciplinary board meetings from 2015 to 2019, investigators found 112 cases where a doctor was found guilty of overprescribing opioids. They reviewed internal board discussions for each case, qualitatively coding the data to identify major themes, and then categorized the different types of disciplinary outcomes.
Throughout the process, investigators found, medical board members made it clear they wanted to enforce accountability. They also recognized that the only outcome that sends a meaningful message to the professional community and the outside public is to revoke a physician’s medical license. Moreover, the board routinely agreed that the guilty doctors’ actions constituted “unethical conduct” and “gross negligence” and sometimes even violated the law.
And yet, the board nevertheless opted for relatively lenient measures for most doctors – recommending remedial actions such as peer monitoring and continuing professional education to help them become “safe” doctors.
“One of the things that surprised us was that this effect was true even for repeat offenders … for really serious misconduct that affects people’s lives and public health,” says Rahman.
The exception to the rule
In fact, the board revoked a doctor’s medical license in only six cases (out of 112).
All six cases involved a doctor who either completely failed to comply with the board’s demands or was sentenced to prison for his crime by the federal government.
“Physicians who don’t respond to the board to explain themselves, who don’t show some kind of remorse, they will be recalled, with almost no discussion,” he says. “Similarly, we saw that if the justice system sent a doctor to prison for essentially the same offenses, the board would revoke a doctor’s medical license, presumably because it would look very bad if the doctor kept his license in prison.”
Four factors limiting accountability
Why was the state medical board so unlikely to severely punish doctors for their misconduct—even in an issue as consequential as doctors overprescribing opioids?
The researchers identified several factors at play, which they collectively call “limited accountability.” The term refers to the manner in which those charged with holding offenders accountable impose only limited discipline.
1. Among physicians, the most important factor appears to be a shared professional belief in rehabilitation. Even in cases with repeat offenders or where misconduct led to patient deaths, the board preferred to give the doctor a second or third chance to learn from his mistakes.
The influence of shared professional beliefs is not exclusive to medicine, says Rahman. “All professions, whether they’re teachers, lawyers, accountants, have some professional rules when responding to peer misconduct. For police and military, there is one code of silence. In the case of doctors, there is this rejuvenating nature.”
2. Another factor that limits the board’s ability to effectively discipline guilty physicians includes bureaucratic inefficiencies.
The board is not only unpaid, but also has a tight window of time to consider a large number of cases. Additionally, doctors can appeal any board decision they disagree with, taking the case to an adversarial trial. And doctors are allowed to continue working normally until the date of the trial, which may not take place for several years. Feeling bound by these limitations, the board often opts for a lenient penalty that doctors are less likely to appeal, such as a probation or reprimand combined with continuing education and peer monitoring, since such light disciplinary actions set at least an immediate deterrent to medical malpractice.
“The bureaucratic inefficiencies that exist limit or limit the ultimate accountability that is imposed,” says Rahman. “There is a great quote from one of the board members that captures this theme perfectly: ‘The wheels of injustice move fast, but the wheels of justice move slowly.’
3. A third factor complicating accountability is the poor distribution of critical information between professional groups. For example, the details of a medical malpractice case are not made public until there is a final outcome. So, while doctors await conviction in one state, they can apply for a medical license to practice in a different state. Guilty doctors have successfully obtained new licenses by exploiting this gap in knowledge. In situations like this, board members prevent doctors from practicing in their state by barring a doctor from renewing their medical license. This step, however, does not prevent the physician from practicing in the new state in which the physician is licensed.
“It’s a concern not only between states in the U.S. but also between countries, especially in the global world we live in,” Rahman says. “There are exhibitions of doctors moving to states or countries that don’t know all the wrongdoing the doctors have been accused of.”
4. Finally, the researchers found that interpersonal feelings they occasionally have a role in limiting accountability. Board members appeared to be moved with sympathy and compassion for cases where guilty doctors made emotional pleas. Instead of saying it outright, Rahman says, board members phrased it as, “Oh, if we revoke or suspend the doctor’s license, they’re going to have a hard time finding another job,” or “I’ve seen that he’s made efforts to improve; let’s take that into account.”
Recommendations for more efficient setup
Increasing transparency has been the focus of initiatives seeking to improve professional accountability. In that study, for example, the state had enacted various transparency measures to help enforce accountability, including a sunshine law that required the board to make its disciplinary procedures and internal deliberations available to the public and a task force which has been installed to examine how opioid-related misconduct cases were disciplined.
But as this study shows, “transparency is not a panacea,” says Rahman. Transparency must be combined with other efforts, from stronger incentives—such as consequences for decision makers who let bad behavior go unaddressed—to providing adequate resources.
“It’s important for people who are responsible for accountability to have the necessary resources, including time and money, to be able to investigate and enforce accountability,” he says.
Rahman also emphasizes that accountability requires a collective effort, likely involving more people from different sectors. Decision makers, he explains, should include a diverse pool of expertise to ensure impartiality.
Understanding the limits of self-regulation—and how to improve it—will be critical to the many accountability issues that extend beyond physicians and the opioid epidemic. Rahman points to the field of artificial intelligence as a current example. Among some computer scientists and artificial intelligence experts, “there’s this notion of moving fast and breaking things,” says Rahman. The idea may be great for AI innovation, but it could have very serious implications for other industries. Hollywood writers and actors, for examplehave fought hard to prevent the use of artificial intelligence from “dehumanizing the workforce”.
“As we think about regulating AI, if we only involve AI experts, we’re unlikely to get systems that protect the public’s interests optimally,” says Rahman. “It’s not necessarily for lack of good intentions. it’s just that every profession and field has specific ways of thinking that create blind spots.”
