Like many baby-boomers who grew up in the era of the Vietnam War and protested it on college campuses, I came to resent authority and relish free speech. So, I was curious to read on 鶹ý that a Mayo Clinic doctor was fired for publishing a book that included criticism of Mayo's handling of the COVID-19 crisis. Apparently, the physician failed to follow Mayo's publication policy, which required Mayo officials to review the book prior to publication.
I also read about a pediatrician working as a health official in Tennessee. She was fired after to get teens vaccinated for COVID-19 -- Tennesseans lag behind much of the nation in COVID-19 vaccination rates. have been fired or threatened termination from their jobs for speaking out against policies and practices that put patients at risk, and their concerns are not merely COVID-19 related. Judging by the experience of those physicians and the Mayo doctor, it appears that speaking out, especially about controversial issues, can result in career suicide. But none of this is new.
Over 20 years ago, of 465 emergency physicians revealed that approximately 25% felt their jobs were threatened by voicing quality of care or equitable compensation concerns. A confirmed that emergency physicians continue to experience anxiety about job security, and physicians in other specialties fear they may lose their jobs after about unsafe conditions. To silence them, a prominent New York health system emailed staff members telling them that if they talk to the media without permission, they "."
Several colleagues have confided in me that they have worked for companies they believe are unsafe or unethical, yet they hesitate to speak out because of the prospect of losing their jobs. One individual told me he "was in the throes of a difficult situation," and was trying to navigate through it with the aid of a labor attorney. What could be so terrible, I thought, that my colleague had to enlist an attorney to help him resolve his situation? Then I flashed back to a time in my own career when I assumed the role of chief medical officer (CMO) of a hospital. On my first day at work, the former CMO unceremoniously appeared at my doorway and shouted, "You're working for snakes." He was correct. I left that job in less than 2 years. And my colleague ended up relocating to take a job more in line with his values.
In present day, some highly vocal and opinionated doctors have resorted to social media to air their grievances. They really put their jobs on the line, however. Rule number one for physicians using social media to protest a cause is that they should think of the internet as the : Passengers along for the ride listen to the conversation and never forget.
Internet transgressions are not necessarily blatant. For example, a credible group of researchers published an article examining the social media habits of surgical residents with the intent to "" by making them aware of how their posts on Facebook, Twitter, and Instagram may affect patient and public perceptions. However, the result backfired. The young surgeons were not empowered at all. Rather, they felt targeted and violated -- the researchers had never obtained permission to access their online accounts -- and the resulting backlash forced the researchers to retract their article and the journal editors to issue an apology.
Yet, the idea of empowering physicians is gaining traction because doctors are increasingly becoming employees trapped in systems that are not working for them or for the benefit of their patients. Physicians continue significant concerns regarding their ability to speak out about the quality of care and financial incentives that favor the bottom lines of healthcare systems over the safety of patients. Doctors who choose to speak their mind increasingly feel they will be ignored, censored, or fired, often .
Of course, there's an important distinction between a doctor speaking out against unfair policies or in the interest of a patient, and those who are breaking a law or putting patients at risk. For example, health providers have been fired or reprimanded by state medical licensing boards for posting content that identifies patients, which is a clear HIPAA violation. Others have lost their jobs for espousing radical or unfounded beliefs and for making racist comments.
But the line between good and bad, right and wrong, isn't always so clear. The question then becomes, how can doctors be given the space to speak out in a manner that promotes autonomy and protects patient safety while ensuring they aren't causing harm? Until healthcare systems recognize and change those policies that unjustly quiet physicians, it falls on doctors to work within the bounds of the system to make their voices heard.
A good rule of thumb is that if a policy harms or has the potential to injure patients, the physician should speak out and "." To comply with bad medical practices is a violation of the covenant between the doctor and the patient. Physicians must have the fortitude, however, to leave their jobs when it becomes apparent that their concerns are disregarded by institutions or that they might be censored for advocating for patients.
Moreover, prior to accepting a job, physicians should become aware of their institution's policies regarding publishing (op-eds, articles, books, etc.) and posting on social media. I thoroughly enjoyed working in this industry the latter half of my career, yet I felt gagged by some companies' publication policies that required pre-clearance, as in the case of the Mayo Clinic. Depending on my employer's policies, I either refrained from publishing or I published with a disclaimer, such as: "The author's opinions are his own and not necessarily those of [the company, institution, professional organization, etc.]"
As much as I dislike the idea of censoring physicians, I recognize there are limits to free speech. At least I had the autonomy to accept or not accept a job offer. It can't be called censorship when you voluntarily agree to abide by the rules, and then break them.
Arthur Lazarus, MD, MBA, is a member of the Physician Leadership Journal editorial board and an adjunct professor of psychiatry in the Lewis Katz School of Medicine at Temple University in Philadelphia.