"But who will guard the guardians?" is an ancient question referring to the failure of regulatory bodies to regulate themselves. In medicine, a physician's colleagues are often the first to notice physical or mental impairment compromising patient safety. But bonds of friendship or fear of reprisal may impede the ethical duty to put patients first. Consider the following case:

Dr. Brown, a respected surgeon, comes to Dr. McCory for a chronic sinus problem. During the eight months of treatment, Dr. McCory notices Dr. Brown's increasing forgetfulness and confusion. She suspects he has an Alzheimer's type dementia. When Dr. McCory suggests he see a specialist, Dr. Brown angrily refuses. Dr. Brown's daughter calls Dr. McCory and recounts, "Yesterday he put his laundry in the oven and left for work. If I hadn't stopped by, the house might have burned down." No patients have been harmed, but Dr. Brown's surgical team recently witnessed several near misses in the O.R. They are reluctant, however, to question the competence of this revered colleague.

If Dr. McCory's diagnosis is correct, are there considerations justifying breach of physician-patient confidentiality? If so, how should the breach occur so as to minimize harm to Dr. Brown?

Generally when we think of impaired physicians, drug and alcohol abuse immediately come to mind. But other forms of physical and mental illness may also jeopardize patient safety. While Dr. Brown maintains the physical stamina to perform surgery, increasing confusion and forgetfulness compromise his medical judgment and place patients in harm's way. The fact that no one has been injured is not a sufficient rationale for ignoring Dr. Brown's impairment.

Dr. McCory should first discuss her diagnosis and treatment recommendations with Dr. Brown, including her advice that he refrain from surgery, at least until his condition can be fully assessed. If he refuses, Dr. McCory should tell Dr. Brown that she must report this aspect of his condition to the appropriate hospital authority, since her obligation to protect patients overrides her duty to maintain confidentiality about Dr. Brown's dementia.

Legally Dr. McCory may find herself in a gray area. The Illinois Medical Practice Act generally protects patient confidentiality. If patients—including physician patients—cannot trust physicians, they may put themselves and others at risk by refusing to seek medical care. However, the law also requires reporting and monitoring physicians whose impairment endangers patients. Under the AMA Code of Medical Ethics physicians are required to report impaired and incompetent colleagues, and courts have considered professional ethical standards in adjudicating physician conduct.

Dr. McCory's ethical duty to report Dr. Brown's dementia does not justify gossip or other inappropriate communications. She should report to the proper institutional body—those with a legitimate need to know in order to assess Dr. Brown's condition and maintain patient safety.