Introduction

This case study is one in a series with commentaries by the American College of Physician's Ethics, Professionalism and Human Rights Committee and the Center for Ethics and Professionalism. The series uses hypothetical examples to elaborate on controversial or subtle aspects of issues not addressed in detail in the College's Ethics Manual, the Physician's Charter on professionalism, or other College position statements. The fifth edition of the ACP's Ethics Manual, the Physician's Charter, and additional College policies on ethics, professionalism, and human rights issues are available at http://www.acponline.org/ethics/ethics_man.htm or by contacting the Center for Ethics and Professionalism at 215-351-2839.

Case History

William Smith, MD, a respected internist and nephrologist, is on the staff of a multi-specialty group practice affiliated with a medical school. He sees patients, teaches, and conducts research on hypertension.

Late one afternoon, Dr. Smith sees an established patient. The patient is a 51-year-old male executive who has struggled with obesity, hypertension, and type 2 diabetes mellitus. The patient does not have diabetic retinopathy or neuropathy, but does have nephropathy. His most recent serum creatinine was 1.8 mg/dL and hemoglobin A1C 7.9%. Because the patient previously reported some exertion-associated chest pain, Dr. Smith had him undergo an exercise treadmill study and consult with a cardiologist. The patient now returns to Dr. Smith for review of the treadmill test and consultation.

The patient appears upset. In response to Dr. Smith's question, "Are you upset?" the patient exclaims, "I have never been as degraded as I was by the cardiologist. Without saying 'Hello,' he said that obesity was the cause of my problems and that people like me would save him a lot of time if we'd only lose weight. Needless to say, I was mortified and promptly left." Dr. Smith notes that the patient's treadmill study was diagnostic for ischemia and that the patient would likely need a coronary angiogram.

The patient was referring to Dr. White, a professor of medicine. Dr. White is an expert on ischemic heart disease and has published hundreds of papers. Because of his prodigious and successful research career, Dr. White has brought fame and millions of dollars of research grants to the institution.

On campus, however, Dr. White is known for treating physician colleagues and especially, nurses, administrators, and others, poorly. He berates trainees, calling them "stupid" or other pejorative terms in front of other colleagues and trainees, and even patients. He advocates that physicians should "Tell patients like it is" about diagnoses, treatment plans and prognoses without concern for empathy. Notably, some of Dr. White's former and current trainees have adopted some of his behaviors. Many physicians, allied health colleagues, and trainees avoid Dr. White. The institution's patient affairs office receives a steady stream of complaints about Dr. White. But colleagues have not often formally complained.

Other patients of Dr. Smith have had bad experiences with Dr. White, returning in tears from a consultation. Colleagues have similar stories, with a common thread: despite Dr. White's reputation as an expert in heart disease, his bedside manner frequently results in unhappy patients.

Dr. Smith is frustrated that Dr. White's disruptive behavior results in poor patient care and wasted time. He calms his patient, explains the results of the treadmill study, and arranges for a consultation with a different cardiologist. After taking care of his patient and leaving his office late, Dr. Smith wonders what to do next.