04/01/2007 - 22:00

Establishing a code of conduct in the life sciences

Laura H. Kahn

Laura H. Kahn

A general internist who began her career in health care as a registered nurse, Kahn works on the research staff of Princeton University's ...

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Should life scientists make an oath analogous to the Hippocratic oath that newly minted
physicians make in the belief that they will "do no harm" once they utter the hallowed words? The
goal of a Hippocratic oath for life scientists would be to instill a sense of professionalism and
responsibility so that they will not engage in potentially harmful activities. A number of
advocates have supported the establishment of an oath for life scientists as a way to address
concerns about potential future bioterrorists.

But has the Hippocratic oath instilled a sense of responsibility in all physicians? Are they all
exemplary in their conduct, ethics, and professionalism? Of course not. There have been many highly
publicized, and not so publicized cases, of "bad apple" physicians. While the vast majority of
physicians are highly ethical and responsible, some are not. Unfortunately, the medical profession
does not have a good track record in policing itself.

Part of the problem is the entire medical education process. The main obstacle to becoming a
physician is acceptance into medical school. Once accepted, students can perform poorly and still
make it through the system, emerging on the other side to practice medicine on unsuspecting
patients. For example, Maxine A. Papadakis and colleagues found a
strong association between unprofessional behavior in medical school and
subsequent disciplinary action by state medical licensing boards. They studied 235 graduates of
three medical schools who were disciplined by one of 40 state medical licensing boards (between
1990-2003) and 469 control physicians who were matched by medical school and graduation year.

They found that irresponsible behavior and diminished capacity for self-improvement
independently predicted future disciplinary actions threefold compared to the control group of
physicians who were not disciplined. Examples of irresponsible behavior in medical school included
unreliable attendance at clinic and not following up on activities related to patient care. Failure
to accept constructive criticism, argumentativeness, and a poor attitude were examples of
diminished capacity for self-improvement. Lack of motivation, lack of enthusiasm, and passivity
showed poor initiative.

Despite these known serious behaviors and personality traits, these individuals were allowed to
continue their medical education and graduate. Paraphrasing a one-time oath is not going to reverse
years of poor behavior.

What were the unprofessional behaviors once these physicians began to practice? The most
frequent type of violation--at 15 percent--was use of drugs and alcohol. Eleven percent were
disciplined for unprofessional conduct. Two categories--negligence and conviction of a crime--were
tied at 6 percent. Other types of unprofessional behavior included sexual misconduct, fraud or
inappropriate billing practices, and conduct that might harm the public. Another type of violation,
separate from unprofessional behavior, was incompetence which constituted 6 percent of
violations.

Unfortunately, seriously dealing with these bad apple physicians is frequently delayed until
after a patient is harmed and/or dies. In other words, oversight primarily relies on litigation
after the fact. This is much too late. These individuals should never have been allowed to graduate
from medical school in the first place.

Once a student finishes medical education and training, the system of oversight by medical
licensure is fragmented. Each state has its own licensing board, so if a physician gets disciplined
in one state, all he or she has to do is move to another state. (This is also the case for nurses,
and there have been several high-profile cases in which criminally negligent physicians and nurses
continue to practice by skipping from state to state.)

Instead of mandating meaningful changes, Congress enacted the Healthcare Quality Improvement Act
in 1986, which established a
National Practitioner Data
Bank
(NPDB) that the Department of Health and Human Services maintains. The law requires that
hospitals, professional licensing boards, and other health care entities report to and retrieve
data from the NPDB in order to have up-to-date information about physician competencies. The data
is not available to the general public, and the overall usefulness of the NPDB has come into
question.

A news report in the June 9, 2001 issue of
The Lancet reported that managed care companies and hospitals are routinely failing to
report poorly performing physicians to the NPDB, as required by law, according to a study conducted
by the Office of the Inspector General of Health and Human Services. The study found that the NPDB
was incomplete and inaccurate. The American Medical Association has opposed efforts to gather
information on physicians and prefers that these efforts remain with state licensing boards. For a
fee, the public can inquire about their physician's professional history from the
Federation of State Medical Boards.

However, state licensing boards
rarely revoke
or suspend licenses. A better system would be
national
licensure
such as pilot licensure with the Federal Aviation Administration. The safety needs in
medicine have been compared to those in the aviation industry; medical licensure done at the
federal level would be far more efficient and effective than the current piecemeal, state-by-state
approach.

So how do these challenges of oversight apply to life scientists? For life scientists, the
educational process is quite different than for medical students. Unlike medical students who can
repeat failed exams and courses many times, life sciences graduate students in the United States
can fail and be removed from their programs at several points. They can fail if they don't pass
their master's degree generals exams or if they don't pass their doctoral level thesis defense.
Many students take years to finish their thesis, and one would expect that their thesis advisers
would provide close, one-on-one supervision of their work over several years.

Also, graduate students do not typically enter the process expecting a guaranteed well-paying
career. (Of course, they usually don't take on the large debt that medical students typically incur
for their studies either.) Academic positions are not easy to come by and competition is fierce. In
contrast, depending on the specialty and location, physicians are usually in high demand.

A Hippocratic oath for life scientists would be nice window dressing, but it would simply be
that. The more important method to ensure that graduating life scientists are ethical and
responsible citizens is the oversight provided by their laboratory supervisors, mentors, and/or
thesis advisers. These individuals have an important role in watching their students' behavior over
the years. Those who show irresponsible behavior and a diminished capacity for self-improvement
should not be allowed to graduate (as should be the case in medical school). Graduate schools (and
medical schools) should develop policies and procedures for problem students. Behavioral
infractions should be carefully documented and should be just as important in the evaluation of a
student's academic future as the traditional graduation requirements.

This effort should extend globally. In other countries, different issues might arise that could
impact on behavior beyond having formal codes of conduct.

For example, while Australian universities have a
code of good practice for
postgraduate research studies and supervision, there are economic incentives that undermine this
policy. According to an Australian microbiology professor, who prefers to remain anonymous, the
Australian federal government provides core funding for essentially all universities and encourages
intense competition for graduate student scholarships. These scholarships are quite generous:
Students do not pay tuition fees or income tax, yet amazingly, they are still eligible for all
full-time student discounts both in Australia and overseas. The scholarships range from $19,000 to
$40,000 per annum.

The big flaw in the Australian system is the heavy financial leverage of completing PhD degrees.
There is a push to "corporatize" the universities so the output of an academic institution is
partly assessed by the number of PhDs that it graduates. Therefore, there is a great incentive to
push people through, regardless of their academic ability or behavior, in order to improve the
institutions' graduation statistics. This policy modifies behavior at all levels of academia and
does not create a healthy environment for instilling high standards of professional conduct and
ethical behavior in graduating researchers.

The bottom line is that on a global scale, this issue is far more complex than simply having a
code of conduct or having students recite a Hippocratic oath upon graduation. In order to ensure a
professional, ethical, and competent workforce, many factors must be taken into account, including
students' academic performance, responsible behavior, attitude, and perhaps most importantly, a
willingness to accept criticism. Other issues that might influence students' behaviors must also be
considered, including economic incentives, as well as the political and social academic
environments in which they work.