Physician, heal thyself: the potential crisis of conscience in Canadian medicine
What if your faith in doctors having conscience was shaken?
The Globe and Mail, 31 May, 2019
Reproduced with permission
"I'm really sorry," I said, picking the magnifying glass off the floor and checking it wasn't cracked. "I think it's okay."
It was my third day on the witness stand, testifying against doctors from the hospital where I still worked. I couldn't read the tiny numbers on the document disclosing how much my colleagues were paid, and the hospital lawyer had offered it to me, to end the theatre.
"He's just softening you up before cross-examination," my lawyer had said with a wry smile, standing at the podium.
Afterward, I wondered why I'd apologized, in a full courtroom, to this man who had taken a wrecking ball to my life over the previous 10 years. Then it occurred to me: to apologize is a sign of a conscience.
Doctors are expected to have one. Their job is to heal the sick and save lives, and that role evokes an image and expectation of beneficence – doing only good. Doctors invest in that image when they espouse a code of conduct descended from the Hippocratic oath: "I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrongdoing." Patients also invest in that image and expectation. When illness strikes, they must often put their lives, their confidence and their most vulnerable selves in the hands of doctors they barely know. The expectation of conscience is at the core of the medical pact.
But what if your faith in doctors having conscience was shaken?
I am a cardiologist, and in 2001, physician colleagues made false allegations against me, shutting down a publicly funded research program and unravelling my career and my life. They had many chances to tell the truth, and to limit the damage over the course of 16 years, but they chose not to. My shocking personal experiences have led me to think deeply about the problem of doctors who act without conscience at work – and what that could mean for patients.
I can't remember when I first wanted to be a doctor, but I do remember learning about the awesome power of illness to take lives as a child. I wanted to fight against that. My learning journey took a little longer than most: After high school, I studied and trained for 17 years to become both a medical specialist and a scientist qualified to conduct research independently. In 1998, I was hired as the first cardiologist with full research credentials, a PhD, at Halifax's Dalhousie University. I was to take care of patients with weakened heart muscle, or heart failure, for half my time, and spend the rest finding new treatments for this condition.
One day, a few weeks in, I was paged to clinic, and it felt like a rescue. All that morning in my windowless office, it had been as if the oxygen were running low. I was shuffling through research articles, casting about for inspiration, but instead, the conflicting arguments and data I read about left me dazed. I was having a shaky start; I couldn't come up with a research plan.
When I opened the door to the clinic room, I could see right away his legs were swollen. I walked in and introduced myself as the staff cardiologist to the man, a retired politician who wore his hospital gown with improbable dignity. But even as I put out my hand to shake his, he made no attempt to disguise his wariness of me.
I could understand why. He was one of the first patients with heart failure I would have taken care of in the heart-function clinic, and since his heart attack a decade earlier, he had received perfectly smooth treatment from an illustrious grey-haired cardiologist. The politician's clinic notes gave me pause, though. Given his original heart muscle damage, it was extraordinary he'd survived his heart attack in the first place, and a borderline miracle he didn't die after from the long-term effects of his weakened heart muscle. I could scarcely believe he had never before had fluid swelling in his legs, or shortness of breath from waterlogged lungs. He was mildly irked as we went through his symptoms, but when we got to discussing a plan, the politician seemed reassured to find I'm a good explainer, and we parted on good terms.
The nurse then asked me to see another patient. This man was sitting forward in the chair, with his elbows on his knees and his hands holding his head. His gown hung forward, hiding the wasting of his torso. His heart failure had been diagnosed only a few months before. Despite the fact his heart function was twice as good as the politician's, he had been in hospital with fluid swelling five times. He spoke with a lethargic economy of words, as though my questions no longer mattered. I checked his medication list. He was already on all the right pills. I had nothing more to offer. I still remember the trouble I had meeting his eyes.
The juxtaposition between those two patients bothered me. The driving force of heart failure is the weakening of heart muscle, and so logic dictates that the owner of the weakest heart should fare worst, and if not, there had to be a reason. I called for their hospital records and spent a good hour immersed in their histories, searching through the array of non-heart function differences that could have explained the paradox. I found no answers. Then a thought crossed my mind: What if it was the stability of heart function that mattered rather than the degree of weakening? I rushed back to my office to start reading. My question in clinic that day sparked a theory, and that theory eventually launched our heart-failure research program.
The experiments we designed to test our theory were uniquely suited to my research training in heart mechanics. We wanted to find out how patients' heart-muscle function responded in the moments after a small change in blood returning to the heart. Would the hearts of stable and unstable heart-failure patients react differently?
As researchers from medicine and engineering, we came together with purpose, but it was our patients who were the most determined to find answers. They would tell us that they knew it was too late for them, but they hoped it would help someone else. Charities and government agencies awarded us generous grant funding from precious donations, federal and provincial tax dollars. Our preliminary results were both surprising and exciting; we had been partly right. The stable and unstable patients' hearts did respond differently, but we had to revise our original theory. Our data pointed to a seemingly important effect of changing blood flow on unstable hearts that we hadn't anticipated. Our preliminary findings led to more grant funding for the next step, which we hoped would mean new treatment opportunities for unstable heart-failure patients. We just needed to study two more patients to finish and publish our first dataset.
That's when disaster struck – not because of a problem with the research, nor an unlucky break, but because of a reckless act that triggered a grim change in the course of my life.
I had chosen not to include a senior male colleague in the research. That was my call to make as the research lead, based on the needs of the team. But he was more than displeased by my decision: He launched a campaign of complaint letters against me – sending 10 in total, and mostly in secret – and enlisted powerful allies, including the head of cardiology and the head of the department of medicine. I was accused of dangerous research practices. They fabricated allegations that I failed to communicate with other doctors about the research, and falsely claimed that this put patients at risk. The hospital took emergency action, banning me from the clinic where our research patients came from.
I had documentation to prove the allegations were untrue, but that didn't matter; the hospital hired lawyers to prosecute me and shield the accusers. That encouraged more false allegations, and the lawyers kept expanding their investigation, stretching it out for almost four years.
In the meantime, with the research program on hold, the hospital gave my accusers complete power over my working life. They provoked me with unreasonable demands, daring me to lash out, which would prove I was a problem. I had to find restraint and hold it together every day, while caring for sick patients.
When that game didn't work, their tactics grew darker. They complained I wasn't seeing enough clinic patients, and simultaneously insisted I be sent to a psychiatric facility abroad – but as a patient. That wasn't based on any medical assessment or opinion; it was simply their demand. I had visions of One Flew Over the Cuckoo's Nest.
I called the university provost. "You have to understand," he said. "It's a power play."
He was right. But the university sat on its hands.
"They'll have to send me there first," my lawyer said flatly, after I called him in a panic. Only then did I calm down enough to function, and the hospital backed off, never to mention my supposed severe mental illness again.
Still, the research program collapsed. I was so traumatized by fear over what I'd be accused of next, every single day, that I lost the capacity to think about my future, let alone research. I lived in dread that the hospital board's interminable investigation would render a decision, ending my career. It took all my grit just to walk into the hospital each morning. Since we had no proper access to patients, I had run out of grant money to pay our research staff. The students and trainees were also gone; the research lab was no place for them, given that career-ending false allegations were being thrown around and acted upon.
After four years, the hospital board finally admitted there was no basis for the clinic ban (an emergency variation of my hospital privileges), but instead of apologizing, the board members claimed I brought it on myself. I was first dumbstruck, and then horrified. I couldn't have found another job as a doctor elsewhere because they had destroyed my reputation; I was stuck there.
My only option left was to sue the hospital to clear my name. And through the 10 years it took to get my case to trial, the hospital kept my accusers in power. I survived this only through the support of other doctors, through coworkers who bubble-wrapped me with kindness, appreciative patients and my amazing lawyers.
Then finally, in 2016, the jury returned a rare verdict: Capital District Health Authority, they said, had acted in bad faith or malice toward me. I received the largest damages award for loss of reputation in Canadian legal history. The Nova Scotia Court of Appeal would later outline how every level of medical and hospital leadership had a hand in the bad-faith agenda, dismissing the staggering number of allegations against me with one statement: "Dr. Horne's conduct did not constitute a risk to patient safety, nor did it negatively impact the delivery of patient care."
When those words sank in, I finally felt unchained. As I slowly adjusted to my deliverance, I was almost bewildered by the lightness and small joys of normal life.
Taking stock of what had happened was a longer process for me. There would be no remedy for the public's loss of a research program, and no apology for the breaches of public trust that led to its demise. I remembered that my ordeal could have been cut short nine years earlier, and perhaps the research data could have been saved. In desperation, I had referred the head of cardiology to the College of Physicians and Surgeons of Nova Scotia, for making false allegations against me under oath. With the documentation I gave them, I thought it was an open-and-shut case.
"What do you hope to get out of this?" the committee chair asked me impassively.
"It's as though he thinks he belongs to a club, and as long as he's in that club he'll be protected. I'd like to know what this medical community stands for," I replied.
I found out. The college cleared him of wrongdoing after an investigation.
Surveys show that Canadians generally do trust their medical professionals, but there has been surprisingly little research on how patients judge whether they are in the hands of a good doctor. An Irish study in 2003 found that personal characteristics such as being a good listener and friendliness, as well as professional competence, were important to patients.
But the appearance of beneficence is occasionally misleading. In fact, a person completely without conscience may be charming and persuasive. Such a person can make sophisticated use of deception to conceal their motivations and advance their self-interest. Of course, patients should have agency over their judgment on whether their doctor is a person of conscience, but we cannot leave them completely to fend for themselves. Patients may only have the doctor's personal demeanour in a brief encounter to go on. Underlying motivations matter, too, because trust that a physician will put the patient's interests first is at the heart of a healthy doctor-patient relationship.
We have some data on what draws people to become doctors. While 85 per cent of first-year Canadian medical students identified the doctor-patient relationship as a factor that influenced them to select a career in medicine, 28 per cent identified prestige and 53 per cent cited earning potential. Being attracted to prestige and money does not make someone a bad doctor, but it creates a moral vulnerability. Those trappings of power are ubiquitous in medicine, and they create temptation. Furthermore, if a substantial proportion of doctors are receptive to those temptations, a culture could develop in which unethical behaviour is normalized.
Formal medical-school curriculums emphasize the importance of compassion and empathy, but there is evidence that medical students' empathy in fact declines through medical school. There is increasing concern about a "hidden curriculum" in which future doctors can be exposed to negative role models who, according to a 2018 position paper published in Annals of Internal Medicine, "directly contradict classroom lessons and expectations of patients, society, and medical educators." Because medicine is hierarchical, the most influential among these role models are senior doctors, who demonstrate to doctors-in-training (and the rest of us) what behaviour is
acceptable and what traits are associated with success. Because of this, disrespect and cynicism shown by senior doctors can spread like a contagion.
What if a doctor were only motivated by the trappings of power? What if a doctor were competent and effective, but had no conscience? If a doctor tramples over patients' hopes for the future through research, and dehumanizes a colleague to the point of indifference to having caused their life to unravel, where is the line they would not cross? How can we be sure they wouldn't dehumanize a patient? If a doctor were to decide a patient didn't matter, that patient's care and health would be jeopardized.
Because wrongdoing on the part of one doctor can undermine public confidence in the entire profession, doctors have historically enforced their own professional standards. In Canada, provincial medical colleges regulate doctors. These colleges are run by senior doctors and part of their role is to discipline doctors whose actions amount to conduct unbecoming a physician. Both colleges and hospitals have a duty to protect patients and the public from a physician who is likely to harm them, but acting without conscience at work is not always viewed as a red flag.
Toronto-based doctor Gideon Koren, for instance, wrote anonymous poison pen letters to colleagues, then denied having done so. He almost got away with it, too: His downfall was licking the envelopes, leaving the DNA evidence that ultimately outed him. In reprimanding Mr. Koren, the College of Physicians and Surgeons of Ontario described those letters as "vicious diatribes," and highlighted his failure to express remorse – another way of saying that he acted without conscience. Neither SickKids nor the college viewed his indifference to his breach of trust as a sign he could harm patients. Mr. Koren continued to oversee
Motherisk, a SickKids program whose flawed drug testing destroyed families. He has subsequently resigned his medical licence while under renewed investigation.
Another SickKids doctor – Charles Smith, a pediatric forensic pathologist – was referred to the college three times between 1992 and 2001, with little impact on his career. His reckless expert opinions had resulted in two innocent mothers being charged with killing their own children. Instead of expressing remorse for the suffering he caused, Mr. Smith denied wrongdoing, with "preposterous and contradictory" statements, including a claim that the presiding judge had privately told him he was right. The college and the doctors supervising him protected Mr. Smith instead of the public. It took 14 more years – and more tragedies – before Mr. Smith was exposed. By then, his expert opinions had led to multiple wrongful convictions for child murder.
Despite having put the public at risk and damaged public confidence in our medical system, the medical leaders who shielded Mr. Koren and Mr. Smith have never faced cross-examination in court, leaving unanswered questions about their motivations. Nevertheless, the independent investigations into these cases point to how doctors acting without conscience can flourish in our medical culture: these doctors cultivate close relationships with those who supervise them, entangling and enlisting leaders in their damaging agendas. This may explain why hospital and college processes can perform so poorly in policing the problem, and why, other than in Halifax, the medical community has remained largely silent
This problem cannot be dismissed as limited to SickKids or Halifax. Key players from my case (doctors and health-care leaders) went on to hospital leadership roles in Alberta, Saskatchewan and Manitoba. Others were appointed to leadership positions at the Royal College of Physicians and Surgeons of Canada, the Canadian Patient Safety Institute and the Healthcare Insurance Reciprocal of Canada. Three past presidents of the Canadian Cardiovascular Society testified against me at my trial. Three players remain professors at Dalhousie University, role models for future doctors. Crucially, not one person involved in that campaign has formally expressed remorse to me.
We do not know how many have subsequently served on college panels disciplining other doctors, as this information is not publicly available. However, one alumnus of my case is embroiled in a second lawsuit – for his role as a decision-maker in another doctor's hospital disciplinary review out west.
We should be concerned about doctors who act without conscience at work, particularly because such doctors can evade accountability. We need a frank public discussion about what Canadians expect of their doctors and those who lead their health care institutions. The solution must include true arm's length investigations when powerful doctors are suspected of workplace misconduct. Such doctors have the potential not only to damage the lives of patients, the public and colleagues directly, but they may shape the thinking of morally vulnerable doctors and future doctors around them, through their not-so-hidden curriculum: that acting without conscience is a path to success. That should worry us all.
Since my ordeal has ended, I have been blessed with a second chance to help build a better future for patients with heart disease. Some of my colleagues have made it possible for me to start a new research program in an area unconnected to the loss and despair of the past. These colleagues who were not responsible for what happened, but are doing what they can to right a wrong, they are acting with conscience.
So am I. That means telling my story so that it can offer lessons and spark debate; wisdom grows from the winding together of many voices. My patients have taught me the importance of being true to one's values when navigating adversity, and having survived a professional death sentence, I am bolder now. I see speaking out as a necessary part of my efforts to be a good doctor. The medical profession's code of silence around this issue needs to be dismantled, as a matter of conscience. Only then will we be able to properly evaluate, understand and manage it. A doctor's job is to safeguard the welfare of patients, after all.
Gabrielle Horne is a cardiologist and researcher at Dalhousie University and the QEII Health Sciences Centre in Halifax. She also has a Master of Fine Art in creative nonfiction from the University of King's College and is writing a book about her experiences.
Note: In 2018 the Nova Scotia Court of Appeal reduced the damages awared to Dr. Horne by the jury to $800,000.00. Her legal fees for the ordeal were in excess of $1.3 million. Commenting on the outcome, Dr. Horne said:
Having been through the justice system I can say that it’s mentally extremely punishing to go through this experience, and if you have to be so wealthy that losing that $1.3 million isn’t a problem and you have to be so tough as to go through all of this, I just don’t think there are many people that could feel they could get justice from the system.
Campbell F. NS doctor's 14-year legal battle cost a 'staggering' $1.3m [Internet]. Truro News. 2018 Mar 01. (Cited 2019 Sep 22).
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