Why We Struggle to Hold Colleagues Accountable

Indeed, studies have shown that people in the same profession have a difficult time holding each other accountable. The effect is particularly pronounced in traditional, esoteric fields like law, accounting, and medicine that have a history of self-regulation.

“It’s hard for people in the same profession to effectively discipline peer misconduct,” says Hatim Rahman, an associate professor of management and organizations at the Kellogg School. “Professionals often turn a blind eye and look the other way.”

In response, regulatory bodies have pursued transparency efforts—such as “sunshine laws” that make disciplinary proceedings publicly available—to help enforce professional accountability. This heightened transparency should, in theory, encourage professionals to more readily censure their peers.

But new research by Rahman and coauthor Ece Kaynak of Bayes Business School reveals that, even with extensive transparency measures in place, professionals still refrain from imposing strict discipline on peers who engage in misconduct.

Rahman and Kaynak uncovered this pattern among medical doctors, who rarely revoked their peers’ medical license when those peers were guilty of overprescribing opioids—which contributed to fueling one of the leading causes of death in America.

Each case the researchers investigated was reviewed by a physician-led state medical board tasked with upholding the high standard of medical practice and ensuring the well-being of patients. In an overwhelming number of cases, however, the board refrained from enforcing strict disciplinary action.

Amid an opioid epidemic in America, “the physicians were found guilty of overprescribing opioids,” Rahman says. “But we still found the board rarely held them strictly accountable … even for egregious, very extreme cases of misconduct.”

The findings demonstrate the acute limitations of self-regulation—for minor and severe acts of misconduct—and underscore the pressing need for outside intervention in many industries.

Innocent even when proven guilty

Each state has a medical board that has the sole right to discipline physicians with regards to their medical license. In the state 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 deliberate on cases.

Before a case lands on the board’s table, an administrative team—including state lawyers and a physician who previously served on the board—formally investigates the case, only funneling it through if disciplinary action is warranted. As such, the board only reviews cases in which the investigative team finds the physician engaged in documented, egregious misconduct.

Across 30 disciplinary board meetings from 2015 to 2019, the researchers identified 112 cases where a physician was found guilty of overprescribing opioids. They examined the board’s internal deliberations for each case, qualitatively coding the data to identify salient themes, and then categorized the different types of disciplinary outcomes.

Throughout the proceedings, researchers found, the members of the medical board explicitly stated that they want to enforce accountability. They also acknowledged that the only outcome that sends a meaningful signal to the professional community and external audiences is revoking a physician’s medical license. Moreover, the board routinely agreed that the guilty physicians’ actions constituted “unethical conduct” and “gross malpractice” and sometimes even violated the law.

And yet, the board nonetheless opted for comparatively lenient measures for most physicians—recommending rehabilitative actions such as peer monitoring and continuing professional education to help them become “safe” physicians.

“One of the things that surprised us was that this outcome was true even for repeat offenders … for really serious misconduct affecting people’s lives and public health,” Rahman says.

The exception to the rule

In fact, the board revoked a physician’s medical license in only six cases (out of 112).

All six cases involved a physician who was either entirely unresponsive to the board’s requests or sentenced to prison for their crime by the federal government.

“The physicians who don’t respond to the board to explain themselves, who don’t show some sort of contrition, those are the ones the board will, with almost no deliberation, revoke,” he says. “Similarly, we saw that if the judiciary system sent a physician to prison for essentially the same offenses, the board would revoke a physician’s medical license possibly because it would look really bad if the physician kept their license in prison.”

Four factors limiting accountability

Why was the state medical board so unlikely to strictly punish physicians for their misconduct—even on such a consequential issue as doctors overprescribing opioids?

The researchers identified several factors at play, which they collectively term “bounded accountability.” The term refers to the way in which individuals in charge of holding guilty people accountable institute only limited discipline.

1. Among medical doctors, the most prominent 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 physician a second, or third, chance to learn from their mistakes.

The influence of shared professional beliefs is not exclusive to medicine, Rahman says. “All professions, whether they’re teachers, lawyers, accountants, have some professional norms when reacting to peer misconduct. For the police and military, there’s a code of silence. In the case of physicians, there’s this rehabilitative nature.”

2. Another factor limiting the board’s ability to effectively discipline guilty physicians involves bureaucratic inefficiencies.

The board is not only unpaid but also has a narrow window of time to review a high load of cases. Furthermore, physicians can appeal any board decision with which they disagree, taking the case to a contested trial. And the physicians are allowed to continue working as normal until the trial date, which might not take place for several years. Feeling bound by these constraints, the board often opts for a lenient penalty that physicians are less likely to appeal, like a probation or reprimand coupled with continuing education and peer monitoring, since such light disciplinary actions at least set up an immediate roadblock for physician misconduct.

“The bureaucratic inefficiencies that exist kind of limit or bound the ultimate accountability that’s imposed,” Rahman says. “There’s a great quote by one of the board members that perfectly captures this issue: ‘The wheels of injustice move rapidly, but the wheels of justice move slowly.”

3. A third factor that complicates accountability is the poor distribution of critical information between professional groups. For example, the details about a case of physician misconduct are not released until there is a final outcome. So, while physicians await sentencing in one state, they can apply for a medical license to work in a different state. Guilty physicians have successfully received new licenses by exploiting this gap in knowledge. In situations like this, board members prevent physicians from practicing in their state by disallowing a physician from renewing their medical license. This step, however, does not prevent the physician from practicing in the new state in which a physician is licensed.

“It’s a concern not just between states in the U.S. but also between countries, especially in the global world that we live in,” Rahman says. “There are exposés of physicians who move to states or countries that don’t know about all the malpractice the physicians have been accused of.”

4. Finally, the researchers found that interpersonal emotions occasionally have a role in limiting accountability. The board members seemed to be moved to sympathy and compassion for cases where guilty physicians made emotional appeals. Rather than expressing it explicitly, Rahman says, the board members framed it as, “‘Oh, if we revoke or suspend the physician’s license, it will make it hard for them to get another job,’ or ‘I’ve seen that they made attempts to get better; let’s take that into consideration.’”

Recommendations for more-effective regulation

Increasing transparency has been the centerpiece of initiatives trying to improve professional accountability. In this study, for instance, the state had instituted several transparency measures to help enforce accountability, including a sunshine law requiring the board to provide its disciplinary proceedings and internal deliberations to the public and a task force installed to scrutinize how opioid-related misconduct cases were being disciplined.

But as this study shows, “transparency is not a panacea,” Rahman says. Transparency needs to be coupled with other efforts, from stronger incentives—such as repercussions for decision-makers who let misconduct slide—to the provision of sufficient resources.

“It’s important for people who are in charge of accountability to have the requisite resources, including time and money, to be able to investigate and enforce accountability,” he says.

Rahman also emphasizes that accountability demands a collective effort, likely involving more people from different fields. The 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 questions of accountability that extend beyond doctors and the opioid epidemic. Rahman points to the field of AI as a current example. Among certain computer scientists and AI experts, “there’s this notion of move fast and break things,” Rahman says. The concept can be great for AI innovation but can potentially have very serious consequences for other industries. Hollywood writers and actors, for instance, have battled hard to prevent the use of AI from “dehumanizing the workforce.”

“As we think about regulating AI, if we involve AI experts only, we’re unlikely to get systems that protect the public’s interests optimally,” Rahman says. “It’s not necessarily because of a lack of good intentions; it’s just that every profession and field has certain ways of thinking that create blind spots.”