Playing fast and loose with the truth

Embellishing a CV or cutting a few corners might seem harmless, but they are dishonest and medical councils take such actions seriously. Sara Williams looks at “slight” indiscretions that could leave you in hot water

Dishonesty at any level can lead to being struck off the register

Dr S had been prescribing medication on the NHS and sending it to his mother in Africa for a year before his deception was discovered. He was reported to the police when a pharmacist noticed that the patient’s signature on one of his prescriptions was in the same hand as his own. Dr S was charged with a criminal offence and suspended from the medical register for three months.

All medical regulatory bodies take a dim view of dishonesty, according to Dr Tom Lloyd, MPS medicolegal adviser. “In the UK, for example, dishonesty comes under the GMC sanctions guidance as possible ‘erasure’, so dishonesty at any level can lead to being struck off the register. Whether that’s the outcome or not, it indicates how much the regulators disapprove of dishonesty.”

Even if a doctor manages to avoid being struck off, the other sanctions applied by medical councils can be devastating. “The effect on someone’s career would be different depending on the grade of doctor,” says Dr Lloyd. “For a junior doctor, even receiving a warning from the medical council can seriously harm your job prospects. And you can’t cover it up. If you don’t mention medical council sanctions against you in a job application and are found out, you’ll be in even more trouble.”

Why should doctors be truthful?

Doctors must make sure that their conduct justifies their patients’ trust in them, and the public’s trust in the profession

Dr Nigel Dudley, writing in the British Medical Journal, made a pertinent point when he compared doctors to lawyers. He said that “doctors should not be held to a lower standard than lawyers, who cannot be dishonest and continue to practise”.¹ This steadfast position is reflected in the strict stance taken by medical councils around the world regarding the honesty of their registrants. All have guidance on the behaviour and conduct expected of doctors. The wording may differ, but the sentiments are essentially the same and best summed up by the Medical Council of New Zealand’s unequivocal statement that "Good doctors … are honest and trustworthy and act with integrity.”²

“The expectations of doctors are very high,” explains Dr Lloyd. “Regulators don’t just look for things that go wrong medically. They have a big interest in probity and honesty. Doctors must make sure that their conduct justifies their patients’ trust in them, and the public’s trust in the profession.” The GMC makes this very clear in its guidance for fitness to practise panels: “Dishonesty, even where it does not result in direct harm to patients but is for example related to the doctor’s private life, is particularly serious because it undermines the trust the public place in the profession. Examples of dishonesty in professional practice could include defrauding an employer, improperly amending patient records or submitting or providing false references, inaccurate or misleading information on a CV and failing to take reasonable steps to ensure that statements made in formal documents are accurate.”³

Tampering with records

I realised that I hadn’t done a formal neurological examination. I couldn’t be bothered and I guessed that she was probably okay. After all, how many times do we really find something abnormal on these exams?

“I took the history from a patient and examined her. Then I went back to the doctors’ office and sat down to write my notes. As I was working away, I realised that I hadn’t done a formal neurological examination. I couldn’t be bothered and I guessed that she was probably okay. After all, how many times do we really find something abnormal on these exams? I wrote down, neurological exam: NAD.

“As it happened, later on the consultant examined the lady and found some very obvious weakness on one side. She then read my notes and came to ask me about my findings; I insisted that the weakness wasn’t there when I saw the lady. I couldn’t bring myself to tell the truth and I really messed up the final diagnosis. I still feel bad about it but I thought at the time that my reputation and even my career were at risk.”

Who hasn’t felt tempted at one time or another to take shortcuts like the junior doctor above? Luckily for him, he learned the inadvisability of doing so early in his career and won’t do it again. And, luckily for the patient, no harm stemmed from the doctor’s lack of honesty. The outcome could have been more serious for the patient, however, which is one reason that fabricating medical records carries considerable penalties.

“Recording that a patient’s blood pressure has been taken or a chest examination has been performed, when it has not, is dangerous as well as dishonest,” says Dr Lloyd. “Whatever you write in a medical record is a benchmark for that time; if it is not correct or changes later, it can create difficulties for the ongoing care of the patient.”

In a fitness to practise case in the UK, a doctor was reported by the Department of Work and Pensions (DWP) for recording that he’d examined a patient when he hadn’t. The DWP has a proforma for assessment for incapacity benefits and the doctor in question, having read the functional questionnaire, decided that the patient would qualify for benefits anyway. So he did not perform the required examinations, but nevertheless recorded that they had been completed. The patient complained to the DWP and the doctor, when confronted, confessed straight away. This did not save him from referral to the GMC, however. He was suspended from practice for two years while he waited for his hearing and then was suspended for a further three months. As he was unable to work during that time, he lost his job.

Altering the records retrospectively with the intention of passing off the addition as a contemporaneous entry is clearly dishonest

Falsifying patients’ records can be particularly tempting when something’s gone wrong and a doctor is worried that he will be found at fault. Altering the records retrospectively with the intention of passing off the addition as a contemporaneous entry is clearly dishonest. Bearing in mind that the notes will come under close scrutiny when the incident is investigated, it is also extremely foolhardy.

Dr F, a junior doctor from the south east of England, recounts her personal battle with temptation one night in A&E: “One night, as I walked into resus, the rest of the team were doing CPR on a patient. I heard the registrar say that, from the story, the patient had probably suffered a heart attack. As I approached, I realised that I had seen that man two days before in A&E. “I panicked and felt that it was my fault. I knew that nobody would have seen the previous card yet so I got hold of it. The patient had attended A&E with cellulitis in the arm when I saw him; it was probably unrelated to the heart attack but I still wanted to change the records to read ‘no chest pains, no breathlessness, not unwell’, just to cover myself. In the end, I couldn’t bring myself to do it but I came very close.”

Lying

Doctors who are discovered to have lied on their CV can expect a hefty sanction

Doctors are expected to be truthful, and regulators take evidence of lying very seriously, whether it be making false claims about qualifications and experience to get a job, plagiarism or signing fraudulent certificates. Lee McQueen may have landed a job despite being caught lying on his CV on the BBC’s The Apprentice, but Dr McQueen would not have been so lucky.

“Doctors who are discovered to have lied on their CV can expect a hefty sanction because the regulator would want to send a message to the profession,” comments Dr Lloyd. “The penalty would depend on the facts of the individual case. But I know of doctors who have been struck off for lying on their CV.” This becomes particularly serious if a doctor obtains work using false qualifications, and even more so if they get personal gain from private practice.

Fraud

One of the most common allegations of fraud against doctors concerns billing healthcare insurers

Healthcare fraud is a global problem diverting tens of billions of dollars from patient care each year.⁴ Not all the fraud takes place on a grand scale, however. Much of it may seem trivial in itself, but it all adds up to a drain on a country’s resources. One of the most common allegations of fraud against doctors concerns billing healthcare insurers. The coding systems they use tend to be complicated and can be confusing, so it is essential that private practitioners ensure these are administered correctly and that claims are scrupulously checked, otherwise an allegation of fraud could be hard to defend.

Last year, there was a significant case at the GMC where a number of insurers, AXA PPP, BUPA, Norwich Union Healthcare and Weston Provident, led a case against a gastroenterologist for “upcoding”. It was reported as the “first straightforward up-coding case to result in suspension”.⁵ The doctor claimed on a therapeutic code for oesophagogastro-duodenoscopies, rather than the diagnostic code; the former paying more than the latter. “When doctors undertake treatment in private practice, they claim money back from their insurers using certain codes, which can be lettered or numbered. Sometimes the code isn’t very clear and doctors, instead of checking with the companies, put down the code they think is right,” explains Dr Lloyd.

“Recently it appears as if insurers are keeping a close eye on what is being claimed and, in some cases, carrying out detailed audits. Doctors must be sure of the code they are using, and contact their insurer if they need clarification.” Professor Merrilyn Walton from the University of Sydney reports similar stories in Australia. She says that doctors who appear before the regulator on overservicing charges often say that they misunderstood the administrative requirements.⁶

False conclusions

All doctors should be aware of the standards of conduct expected of them and take them seriously, because their regulators certainly do. Regulators are responsible for maintaining the integrity and reputation of the profession, and are therefore inclined to deal severely with those whose conduct falls below standard.

While it might seem that they impose harsh penalties on transgressions that would be tolerated outside the profession, they have good reason to take a hard line. Dishonesty on the part of doctors can not only jeopardise patients’ lives and wellbeing, but can also erode public trust in the profession. As Mark Twain said: “A lie can travel halfway around the world while the truth is putting on its shoes.”

References

1. Dudley, N, Dishonest Doctors Should not Continue to Practise, Letters, BMJ, 324, 547 (2002)
2. MCNZ, Good Medical Practice (July 2008).
3. GMC, Indicative Sanctions Guidance for Fitness to Practise Panels (April 2005) S1–9, para 44.
4. Transparency International, Global Corruption Report 2006 Cambridge University Press.
5. Insurers Hail Important Fraud Case First, Post Magazine (17 April 2008)
6. Walton, M, The Trouble with Medicine, Allen and Unwin (1998).