TRANSACTIONS OF THE AMERICAN CLINICAL AND CLIMATOLOGICAL ASSOCIATION, VOL. 128, 2017
Ethics and Professionalism 2016 C. RONALD MACKENZIE, MD NEW YORK, NEW YORK
ABSTRACT Whether a reaction to events in the clinical arena, a consequence of technological innovation, or the legitimization of the marked ethos in health care, the field of medical ethics has become a complex domain in our time. Indeed, the ubiquity of ethical dilemmas in the provision of health care is well documented with more than 99% of primary care physicians reporting ethical problems arising in the conduct of their practices (1–3). Although commentary relating to this domain has most often originated in the primary care setting, hospital-based medicine and its ethics committees are another fertile source, as is medical research. Yet when one examines subspecialty medicine, a remarkable dearth of analysis and discourse pertaining to medical ethics emerges. This discussion is an attempt to address this deficit, at least as it pertains to one subspecialty: rheumatology. Leading with a brief overview of medical ethics writ large, perceptions concerning the ethical challenges arising in current rheumatic disease practice will be presented, hopefully enhancing awareness and sensitivity to the ethical challenges arising in modern day medical practice.
MEDICAL PROFESSIONALISM Although medical ethics focuses primarily on the care of patients and populations, its reach is broad encompassing four major sectors that define the field in the current day. There is “bioethics,” a contemporaneously evolving and compelling casebook of real-life ethical dilemmas of which Karen Ann Quinlan was amongst the first examples. Often endof-life (sometimes at life’s beginning) in their nature, such clinical dilemmas have spawned the formation of ethics committees now in virtually every hospital in the country. There are also the challenges arising in research; the Tuskegee trial a highly publicized example. Third are the
Correspondence and reprint requests: C. Ronald MacKenzie, MD, 535 East 70th Street, 6th Floor, New York, New York 10021, Tel: 212-606-1669, E-mail: [email protected]. Potential Conflicts of Interest: None disclosed.
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ethical challenges arising from the restructuring of medical care; examples of “organizational ethics” include the advent of Health Maintenance Organizations (HMOs) and large hospital systems and their consequent impact on physician autonomy, activity overseen by such groups as the Joint Commission. Finally, “professional ethics” or “medical professionalism” constitutes a fourth domain and is the focus of this presentation. Although most physicians could articulate what they believe the term medical professionalism connotes, for the purpose of this discussion the definition employed by the American Board of Medical Specialties is here shown: “A belief system in which group members (“professionals”) declare to each other and the public the shared competency standards and ethical values they promise to uphold in their work and what the public and individual patients can and should expect from medical professionals.” (4)
At the core of such declarations is the promise to acquire, maintain, and advance a value system grounded in the conviction that the medical profession exists to serve the interests not only of patients but the greater public as well. Further, there are commitments to the maintenance of the knowledge and skills necessary for good medical practice (competency) as well as the capacity to effectively direct and deliver the profession’s specialized knowledge and skills (the art of medicine). Now, before moving on to how these issues pertain to the field of rheumatology: Why did such work seem necessary? The stimulus came in the form of a paper published several years earlier (5) in which investigators described a remarkable deficiency in the discourse pertaining to medical ethics in the rheumatology literature, their search of more than 400,000 published manuscripts yielding only 104 (0.026%) with ethically based content. For a field so challenged by chronic, disabling disease and yet hope in the form of new (but expensive) therapies, this conspicuous disconnect spawned the work that here follows.
ETHICAL CHALLENGES IN RHEUMATOLOGY To inform the conversation concerning the current ethical challenges faced by the rheumatology community, the American College of Rheumatology (ACR) Committee on Ethics and Conflict of Interest conducted a national survey of its membership to identify the most
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common ethical issues affecting their subspecialty. Published in Arthritis & Rheumatology in 2013, the following summarizes the study (6). The objectives were (1) to learn of the perceived frequency of ethical issues in rheumatology; (2) to identify activities that pose ethical problems in rheumatologic practice with two additional objectives (not presented herein); (3) to determine the extent of education and selfperceived ethical knowledge of ACR members; and (4) to determine member interest in and to suggest content for future ACR-sponsored educational activities related to bioethics. For their methods, the survey included 12 closed-ended questions addressing five core areas: 1) ethical dilemmas in daily practice; 2) ethical concerns in basic and clinical research; 3) influence of industry; 4) ethics of regulatory policies, potential conflicts, and disclosure; and 5) personal education and interest in ethics. Two open-ended questions asked respondents to list ethical issues most relevant to rheumatology and to provide commentary. Data analysis was descriptive. The results showed that 771 responses were received. Respondents believed that ethical issue arise most frequently in practice and in clinical research. As shown (Figure 1), members responded that the most frequent domain in which ethical dilemmas arise is clinical research (almost 60%), followed by practice (44%) with such problems believed to be less common in basic science research (26%). However, when asked about true ethical lapses, that is, a failure to uphold an ethical standard that one purports to believe, the rates were lower: 18% clinical practice, 17% clinical research, and 7% basic science (Figure 2). The most common practice-related ethical issues were costs to patients and society for expensive treatments and profits from infusions. Additional concerns included profiting from infusions, accepting gifts from pharmaceutical companies, and profiting from imaging. With respect to process-related concerns practicing defensive medicine, not spending enough time with patients, caring for the uninsured, and practice productivity obligations were cited as points of tension. In addition, more than half of respondents perceived multiple ethical issues regarding relationships with industry, the most prevalent being serving on the board of directors (76%), participating in speaker’s bureaus (66%), and serving as a consultant for a pharmaceutical company (61%). Industry-related activities considered to have the least ethical implications were meeting with company sales representatives (39%) and medical liaisons (30%). Sixty-five percent believed that rheumatologists should disclose any industry-related activities to their patients. Participants were also asked to list the three ethical issues most relevant to their practice environment and to describe how these issues posed
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Fig. 1. How often do ethical dilemmas occur in rheumatology?
Fig. 2. How often do ethical lapses occur in rheumatology?
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problems. Four hundred ninety participants responded to this question, and the responses were grouped into themes by consensus. Profiting from infusions and ancillary services were the most commonly cited ethical concerns. Providing care that was overly aggressive and using finances generated by these services to cover existing infrastructure expenses were also cited. Physicians’ relationships with pharmaceutical companies were considered to pose diverse ethical problems ranging from preferentially prescribing drugs, financial gain from enrolling patients in clinical trials, and influencing the content of expert rheumatology discourse. Providing care for patients with limited or no insurance posed ethical dilemmas in terms of access to care and in influencing coding to increase reimbursement. Indeed, embellishing coding for all patients regardless of insurance was also viewed as a way to compensate for general under-payment and as a way to obtain medications for patients who would otherwise not be covered by their insurance. Further, using new costly medications in lieu of effective older and less expensive drugs was considered unethical not only from the perspective of excessive cost but also from the point of view of consultants using their expert status for personal and financial gain. Reference to the practicing of defensive medicine came up frequently, had many dimensions, and was often considered forced upon rheumatologists to maintain viable practices. In a second open-ended component, participants were asked to volunteer additional comments. Most of the 179 individuals who provided comments expanded on the major issues already identified; however, several new topics were identified. Some respondents stated that concerns about medical ethics are over-emphasized and not in touch with the realities of rheumatology practice. Others commented that rheumatologists might have the fewest ethical issues because they are in a low-cost specialty and “the problem is far larger in the total world of medicine.” Conflicts with institutions to generate revenue from rheumatology practices were perceived as sometimes adversarial. Further identified were the many potential ethical dilemmas arising in the physicians’ relationships with their patients, ranging from lack of adequate time to spend with patients, addressing non-compliance, embellishing records at patients’ requests, and using online communication. Respondents were also concerned about threats to their professionalism and autonomy citing ethical problems arising in their relationships with other physicians. Some respondents even had strong opinions about the role of the ACR, particularly with respect to relationships with pharmaceutical companies and being more active in patient advocacy. The results of this survey suggest that ethical problems in rheumatology are of concern to the professions’ membership and give support
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to a call for a proactive endorsement of initiatives and programs, the development of policies and the provision of consultation to assist practitioners in dealing with the ethical challenges they confront. In closing, while historians continue to debate the origins of medical ethics and professionalism, the 1847 American Medical Association’s (AMA’s) Code of Medical Ethics is a reasonable place to start. Fashioned after the writings of the Manchester physician Thomas Percival, who in his book on professional etiquette coined the term “medical ethics,” the AMA code is the first of its kind, for any profession, anywhere. Fast-forwarding almost 170 years, the discourse pertaining to medical professionalism is highlighted by the 2016 adoption of the first comprehensive revision of the AMA Code of Medical Ethics in 50 years (7,8). Its grounding principles set standards of conduct that serve to fashion ideals of ethical behavior for our profession and help us address such core questions as: Who are we? How can we be better? What ought we to do and why? How should we do it?
REFERENCES 1. Hurst SA, Perrier A, Pegoraro R, et al. Ethical difficulties in clinical practice: experiences of European doctors. J Med Ethics 2007;33:51–7. 2. Lo B, Schroeder SA. Frequency of ethical dilemmas in a medical inpatient service. Arch Intern Med 1981;141:1062–4. 3. Robillard HM, High DM, Sebastian JG, et al. Ethical issues in primary health care: a survey practitioners’ perceptions. J Community Health 1989;141:9–17. 4. Available at: www.theabfm.org/about/guidelinesforprofessionalism.pdf. Accessed on January 20, 2017. 5. Caplan L, Hoffecker L, Prochazka AV. Ethics in the rheumatology literature: a systemic review. Arthritis Rheum 2008;59:816–21. 6. MacKenzie CR, Meltzer M, Kitsis KA, et al. Ethical challenges in rheumatology: a survey of the American College of Rheumatology membership. Arthritis Rheum 2013;65(10):2524–32. 7. Code of Medical Ethics. American Medical Association 2016. Available at: www.amaassn.org/go/code. Accessed on January 20, 2017. 8. Brotherton S, Kao A, BJ Crigger. Professing the values of medicine: the modernized AMA code of medical ethics. JAMA 2016;316(10):1041.
DISCUSSION Nestler, Richmond: Wonderful talk....I wonder if you could address what I see as an ethical issue that effects all academic centers and is top-down. In other words, senior leadership in many places are focused on the changing healthcare system we reimburse in the system. Fee-for-service versus macro-bundle care, quality, etc. And it seems to me
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that the organization then imposes or dictates to the physicians how they should practice to optimize revenue. Where are we on that continuum? Which seems to me to contradict the notion that you should simply do what is in the best interest of the patient regardless of the payor system. So I wonder if you have any comments about that? MacKenzie, New York City: Well, I think that’s probably a reference that the locus of control has shifted away from us. It’s beyond a trend. Maybe it’s just a reality that can never be changed. I don’t think it assaults the need for us to push as hard as we possibly can against forces such as that. I think Dr. Brem pointed out a good example of the struggle he had in acquiring approval to get the medication for brain tumors. They persevered, and were ultimately successful. I think those are the kinds of battles that we have to wage as individuals or as departments or as larger groups to modify the impact of those kinds of decisions that you’re raising. Barondess, New York City: Thank you for that thoughtful presentation. In relation to the questions you left us with, I wonder if you’d comment on what it appears to be an increasing trend at clinical practice in an aging population. It is the extrusion of patients on Medicare from clinical practices on the basis of their Medicare coverage. How should we think about that? What should we do? Patients whose insurance coverage is confined to Medicare are increasingly being invited to leave medical practices and that strikes me as rather a dilemma for us. MacKenzie, New York City: Well, that is a big dilemma and for those of us who practice in New York City, it’s extraordinarily prevalent. I don’t know what the solution to that is. Obviously physicians are exerting their autonomous decisions about how they want to structure their professional activity or their business related activity. I think it’s problematic to consider that it should be legislated against. I am not sure there is a solution to that other than appealing to these concepts of professionalism that those kinds of decisions tend to assault. Barondess, New York City: Do you think influential medical societies should take a public position on that problem? MacKenzie, New York City: Yes, I think that they should. Baum, New York City: Lovely talk....At Einstein in the first few days of orientation we have our students actually create an oath and a colleague had led that effort for a number of years. It’s really an inspiring document ....it’s usually about three quarters of a page and it includes everything that probably everyone in this room would applaud, and does applaud when its read. And then one can watch over the next 3 or 4 years of the students progressions with school....A number of these vows of ethics and professionalism sort of erode away before one’s very eyes. It’s quite distressing to see in many cases. Do you have any comments about that? MacKenzie, New York City: Yes, I’m actually aware of that practice. In some places it has replaced the reciting of the Hippocratic Oath. I think it does clearly involve an engagement by the students that goes far beyond just simply reciting an oath, whether it’s been modified or otherwise. I guess I have a question about that for you and that is this: Is it a matter of the timing? I mean obviously you picked students in their first year when they are highly idealistic and the system hasn’t really had its impact. Would it be more meaningful actually to have a mid-course correction or early correction and do it at the end? And the second question I have for you is, do you actually revisit with them as a class what they set out in their first year at the end before they graduate. Baum, New York City: Yes, and Yes. We have them actually modify the oath in the second year and then again it’s talked about before graduation. But one gets the feeling that the heart and soul behind its creation is not necessarily mirrored in the continued statement of the oath. I personally find that discouraging.
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Weinblatt, Boston: I’d like you to comment about the increasing use of concierge practices..... Some of them actually being sponsored by academic medical centers and also the practice, including at institutions you know well in which surgeons do not accept insurance and bill the patients the full rate of their visits and the ethics of that. MacKenzie, New York City: This is a similar theme to Dr. Barondess’ question. So, yes, I think we have lost or are about to lose a faculty member in our division to a concierge practice within a few weeks. I think that is just a downstream version of exactly what Dr. Barondess was bringing up....and I don’t know what the solution to that is. You know, in our department there is a requirement at least when one begins, to be relatively broad in terms of one’s participation in insurance plans. That isn’t enforced throughout the entire career of the physicians. I would say that rheumatologists have done a lot better job. We regard this as an ethical standard and maintain that compared perhaps to the orthopedic surgeons in our hospital. I think that the only way that is going to change is by a mandate. And that would have to be a mandate at our place by the physician-inchief and the surgeon-in-chief. They might just simply have to live with whatever the consequences of that in terms of people leaving. Thibault, New York City: Thanks very much for bringing this very important issue to this esteemed audience. Just two comments: One about Jerry Barondess’ very important note. I’ll remind everybody that since the late 60s, virtually everybody in medicine has been trained with Medicare money. It would not be inappropriate that there be, in fact, a legal requirement that in exchange for that training, we would agree to take care of Medicare patients. And we might start that movement. Secondly, in regard to the loss of idealism of our students is well documented. While curricula in professionalism and ethics are important and now are much more prevalent, huge amounts of data show the most powerful impact on student and resident: behavior and idealism are the role models that they have or don’t have. And we need to hold up a mirror to ourselves and our systems and are we acting in the most appropriate way to be role models and examples? And I think that is an exceedingly important issue and I thank you for bringing this topic to our audience. MacKenzie, New York City: Well, I think that is clearly exceedingly important, and our responsibility, that all of us really bear. And I think it gets increasingly harder and harder with the demands of modern-day practice, and we just need to keep it in the forefront of our minds. So, anybody interested in reading the best paper on mentoring ever, should consult The Transactions of the American Clinical and Climatological Association, Volume 106, pp. 1–24, 1995, “A Brief History of Mentoring.” The President’s Address by Jeremiah A. Barondess! Thank you very much!
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Ethics and Professionalism 2016 C. RONALD MACKENZIE, MD NEW YORK, NEW YORK
ABSTRACT Whether a reaction to events in the clinical arena, a consequence of technological innovation, or the legitimization of the marked ethos in health care, the field of medical ethics has become a complex domain in our time. Indeed, the ubiquity of ethical dilemmas in the provision of health care is well documented with more than 99% of primary care physicians reporting ethical problems arising in the conduct of their practices (1–3). Although commentary relating to this domain has most often originated in the primary care setting, hospital-based medicine and its ethics committees are another fertile source, as is medical research. Yet when one examines subspecialty medicine, a remarkable dearth of analysis and discourse pertaining to medical ethics emerges. This discussion is an attempt to address this deficit, at least as it pertains to one subspecialty: rheumatology. Leading with a brief overview of medical ethics writ large, perceptions concerning the ethical challenges arising in current rheumatic disease practice will be presented, hopefully enhancing awareness and sensitivity to the ethical challenges arising in modern day medical practice.
MEDICAL PROFESSIONALISM Although medical ethics focuses primarily on the care of patients and populations, its reach is broad encompassing four major sectors that define the field in the current day. There is “bioethics,” a contemporaneously evolving and compelling casebook of real-life ethical dilemmas of which Karen Ann Quinlan was amongst the first examples. Often endof-life (sometimes at life’s beginning) in their nature, such clinical dilemmas have spawned the formation of ethics committees now in virtually every hospital in the country. There are also the challenges arising in research; the Tuskegee trial a highly publicized example. Third are the
Correspondence and reprint requests: C. Ronald MacKenzie, MD, 535 East 70th Street, 6th Floor, New York, New York 10021, Tel: 212-606-1669, E-mail: [email protected]. Potential Conflicts of Interest: None disclosed.
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ethical challenges arising from the restructuring of medical care; examples of “organizational ethics” include the advent of Health Maintenance Organizations (HMOs) and large hospital systems and their consequent impact on physician autonomy, activity overseen by such groups as the Joint Commission. Finally, “professional ethics” or “medical professionalism” constitutes a fourth domain and is the focus of this presentation. Although most physicians could articulate what they believe the term medical professionalism connotes, for the purpose of this discussion the definition employed by the American Board of Medical Specialties is here shown: “A belief system in which group members (“professionals”) declare to each other and the public the shared competency standards and ethical values they promise to uphold in their work and what the public and individual patients can and should expect from medical professionals.” (4)
At the core of such declarations is the promise to acquire, maintain, and advance a value system grounded in the conviction that the medical profession exists to serve the interests not only of patients but the greater public as well. Further, there are commitments to the maintenance of the knowledge and skills necessary for good medical practice (competency) as well as the capacity to effectively direct and deliver the profession’s specialized knowledge and skills (the art of medicine). Now, before moving on to how these issues pertain to the field of rheumatology: Why did such work seem necessary? The stimulus came in the form of a paper published several years earlier (5) in which investigators described a remarkable deficiency in the discourse pertaining to medical ethics in the rheumatology literature, their search of more than 400,000 published manuscripts yielding only 104 (0.026%) with ethically based content. For a field so challenged by chronic, disabling disease and yet hope in the form of new (but expensive) therapies, this conspicuous disconnect spawned the work that here follows.
ETHICAL CHALLENGES IN RHEUMATOLOGY To inform the conversation concerning the current ethical challenges faced by the rheumatology community, the American College of Rheumatology (ACR) Committee on Ethics and Conflict of Interest conducted a national survey of its membership to identify the most
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common ethical issues affecting their subspecialty. Published in Arthritis & Rheumatology in 2013, the following summarizes the study (6). The objectives were (1) to learn of the perceived frequency of ethical issues in rheumatology; (2) to identify activities that pose ethical problems in rheumatologic practice with two additional objectives (not presented herein); (3) to determine the extent of education and selfperceived ethical knowledge of ACR members; and (4) to determine member interest in and to suggest content for future ACR-sponsored educational activities related to bioethics. For their methods, the survey included 12 closed-ended questions addressing five core areas: 1) ethical dilemmas in daily practice; 2) ethical concerns in basic and clinical research; 3) influence of industry; 4) ethics of regulatory policies, potential conflicts, and disclosure; and 5) personal education and interest in ethics. Two open-ended questions asked respondents to list ethical issues most relevant to rheumatology and to provide commentary. Data analysis was descriptive. The results showed that 771 responses were received. Respondents believed that ethical issue arise most frequently in practice and in clinical research. As shown (Figure 1), members responded that the most frequent domain in which ethical dilemmas arise is clinical research (almost 60%), followed by practice (44%) with such problems believed to be less common in basic science research (26%). However, when asked about true ethical lapses, that is, a failure to uphold an ethical standard that one purports to believe, the rates were lower: 18% clinical practice, 17% clinical research, and 7% basic science (Figure 2). The most common practice-related ethical issues were costs to patients and society for expensive treatments and profits from infusions. Additional concerns included profiting from infusions, accepting gifts from pharmaceutical companies, and profiting from imaging. With respect to process-related concerns practicing defensive medicine, not spending enough time with patients, caring for the uninsured, and practice productivity obligations were cited as points of tension. In addition, more than half of respondents perceived multiple ethical issues regarding relationships with industry, the most prevalent being serving on the board of directors (76%), participating in speaker’s bureaus (66%), and serving as a consultant for a pharmaceutical company (61%). Industry-related activities considered to have the least ethical implications were meeting with company sales representatives (39%) and medical liaisons (30%). Sixty-five percent believed that rheumatologists should disclose any industry-related activities to their patients. Participants were also asked to list the three ethical issues most relevant to their practice environment and to describe how these issues posed
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Fig. 1. How often do ethical dilemmas occur in rheumatology?
Fig. 2. How often do ethical lapses occur in rheumatology?
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problems. Four hundred ninety participants responded to this question, and the responses were grouped into themes by consensus. Profiting from infusions and ancillary services were the most commonly cited ethical concerns. Providing care that was overly aggressive and using finances generated by these services to cover existing infrastructure expenses were also cited. Physicians’ relationships with pharmaceutical companies were considered to pose diverse ethical problems ranging from preferentially prescribing drugs, financial gain from enrolling patients in clinical trials, and influencing the content of expert rheumatology discourse. Providing care for patients with limited or no insurance posed ethical dilemmas in terms of access to care and in influencing coding to increase reimbursement. Indeed, embellishing coding for all patients regardless of insurance was also viewed as a way to compensate for general under-payment and as a way to obtain medications for patients who would otherwise not be covered by their insurance. Further, using new costly medications in lieu of effective older and less expensive drugs was considered unethical not only from the perspective of excessive cost but also from the point of view of consultants using their expert status for personal and financial gain. Reference to the practicing of defensive medicine came up frequently, had many dimensions, and was often considered forced upon rheumatologists to maintain viable practices. In a second open-ended component, participants were asked to volunteer additional comments. Most of the 179 individuals who provided comments expanded on the major issues already identified; however, several new topics were identified. Some respondents stated that concerns about medical ethics are over-emphasized and not in touch with the realities of rheumatology practice. Others commented that rheumatologists might have the fewest ethical issues because they are in a low-cost specialty and “the problem is far larger in the total world of medicine.” Conflicts with institutions to generate revenue from rheumatology practices were perceived as sometimes adversarial. Further identified were the many potential ethical dilemmas arising in the physicians’ relationships with their patients, ranging from lack of adequate time to spend with patients, addressing non-compliance, embellishing records at patients’ requests, and using online communication. Respondents were also concerned about threats to their professionalism and autonomy citing ethical problems arising in their relationships with other physicians. Some respondents even had strong opinions about the role of the ACR, particularly with respect to relationships with pharmaceutical companies and being more active in patient advocacy. The results of this survey suggest that ethical problems in rheumatology are of concern to the professions’ membership and give support
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to a call for a proactive endorsement of initiatives and programs, the development of policies and the provision of consultation to assist practitioners in dealing with the ethical challenges they confront. In closing, while historians continue to debate the origins of medical ethics and professionalism, the 1847 American Medical Association’s (AMA’s) Code of Medical Ethics is a reasonable place to start. Fashioned after the writings of the Manchester physician Thomas Percival, who in his book on professional etiquette coined the term “medical ethics,” the AMA code is the first of its kind, for any profession, anywhere. Fast-forwarding almost 170 years, the discourse pertaining to medical professionalism is highlighted by the 2016 adoption of the first comprehensive revision of the AMA Code of Medical Ethics in 50 years (7,8). Its grounding principles set standards of conduct that serve to fashion ideals of ethical behavior for our profession and help us address such core questions as: Who are we? How can we be better? What ought we to do and why? How should we do it?
REFERENCES 1. Hurst SA, Perrier A, Pegoraro R, et al. Ethical difficulties in clinical practice: experiences of European doctors. J Med Ethics 2007;33:51–7. 2. Lo B, Schroeder SA. Frequency of ethical dilemmas in a medical inpatient service. Arch Intern Med 1981;141:1062–4. 3. Robillard HM, High DM, Sebastian JG, et al. Ethical issues in primary health care: a survey practitioners’ perceptions. J Community Health 1989;141:9–17. 4. Available at: www.theabfm.org/about/guidelinesforprofessionalism.pdf. Accessed on January 20, 2017. 5. Caplan L, Hoffecker L, Prochazka AV. Ethics in the rheumatology literature: a systemic review. Arthritis Rheum 2008;59:816–21. 6. MacKenzie CR, Meltzer M, Kitsis KA, et al. Ethical challenges in rheumatology: a survey of the American College of Rheumatology membership. Arthritis Rheum 2013;65(10):2524–32. 7. Code of Medical Ethics. American Medical Association 2016. Available at: www.amaassn.org/go/code. Accessed on January 20, 2017. 8. Brotherton S, Kao A, BJ Crigger. Professing the values of medicine: the modernized AMA code of medical ethics. JAMA 2016;316(10):1041.
DISCUSSION Nestler, Richmond: Wonderful talk....I wonder if you could address what I see as an ethical issue that effects all academic centers and is top-down. In other words, senior leadership in many places are focused on the changing healthcare system we reimburse in the system. Fee-for-service versus macro-bundle care, quality, etc. And it seems to me
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that the organization then imposes or dictates to the physicians how they should practice to optimize revenue. Where are we on that continuum? Which seems to me to contradict the notion that you should simply do what is in the best interest of the patient regardless of the payor system. So I wonder if you have any comments about that? MacKenzie, New York City: Well, I think that’s probably a reference that the locus of control has shifted away from us. It’s beyond a trend. Maybe it’s just a reality that can never be changed. I don’t think it assaults the need for us to push as hard as we possibly can against forces such as that. I think Dr. Brem pointed out a good example of the struggle he had in acquiring approval to get the medication for brain tumors. They persevered, and were ultimately successful. I think those are the kinds of battles that we have to wage as individuals or as departments or as larger groups to modify the impact of those kinds of decisions that you’re raising. Barondess, New York City: Thank you for that thoughtful presentation. In relation to the questions you left us with, I wonder if you’d comment on what it appears to be an increasing trend at clinical practice in an aging population. It is the extrusion of patients on Medicare from clinical practices on the basis of their Medicare coverage. How should we think about that? What should we do? Patients whose insurance coverage is confined to Medicare are increasingly being invited to leave medical practices and that strikes me as rather a dilemma for us. MacKenzie, New York City: Well, that is a big dilemma and for those of us who practice in New York City, it’s extraordinarily prevalent. I don’t know what the solution to that is. Obviously physicians are exerting their autonomous decisions about how they want to structure their professional activity or their business related activity. I think it’s problematic to consider that it should be legislated against. I am not sure there is a solution to that other than appealing to these concepts of professionalism that those kinds of decisions tend to assault. Barondess, New York City: Do you think influential medical societies should take a public position on that problem? MacKenzie, New York City: Yes, I think that they should. Baum, New York City: Lovely talk....At Einstein in the first few days of orientation we have our students actually create an oath and a colleague had led that effort for a number of years. It’s really an inspiring document ....it’s usually about three quarters of a page and it includes everything that probably everyone in this room would applaud, and does applaud when its read. And then one can watch over the next 3 or 4 years of the students progressions with school....A number of these vows of ethics and professionalism sort of erode away before one’s very eyes. It’s quite distressing to see in many cases. Do you have any comments about that? MacKenzie, New York City: Yes, I’m actually aware of that practice. In some places it has replaced the reciting of the Hippocratic Oath. I think it does clearly involve an engagement by the students that goes far beyond just simply reciting an oath, whether it’s been modified or otherwise. I guess I have a question about that for you and that is this: Is it a matter of the timing? I mean obviously you picked students in their first year when they are highly idealistic and the system hasn’t really had its impact. Would it be more meaningful actually to have a mid-course correction or early correction and do it at the end? And the second question I have for you is, do you actually revisit with them as a class what they set out in their first year at the end before they graduate. Baum, New York City: Yes, and Yes. We have them actually modify the oath in the second year and then again it’s talked about before graduation. But one gets the feeling that the heart and soul behind its creation is not necessarily mirrored in the continued statement of the oath. I personally find that discouraging.
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Weinblatt, Boston: I’d like you to comment about the increasing use of concierge practices..... Some of them actually being sponsored by academic medical centers and also the practice, including at institutions you know well in which surgeons do not accept insurance and bill the patients the full rate of their visits and the ethics of that. MacKenzie, New York City: This is a similar theme to Dr. Barondess’ question. So, yes, I think we have lost or are about to lose a faculty member in our division to a concierge practice within a few weeks. I think that is just a downstream version of exactly what Dr. Barondess was bringing up....and I don’t know what the solution to that is. You know, in our department there is a requirement at least when one begins, to be relatively broad in terms of one’s participation in insurance plans. That isn’t enforced throughout the entire career of the physicians. I would say that rheumatologists have done a lot better job. We regard this as an ethical standard and maintain that compared perhaps to the orthopedic surgeons in our hospital. I think that the only way that is going to change is by a mandate. And that would have to be a mandate at our place by the physician-inchief and the surgeon-in-chief. They might just simply have to live with whatever the consequences of that in terms of people leaving. Thibault, New York City: Thanks very much for bringing this very important issue to this esteemed audience. Just two comments: One about Jerry Barondess’ very important note. I’ll remind everybody that since the late 60s, virtually everybody in medicine has been trained with Medicare money. It would not be inappropriate that there be, in fact, a legal requirement that in exchange for that training, we would agree to take care of Medicare patients. And we might start that movement. Secondly, in regard to the loss of idealism of our students is well documented. While curricula in professionalism and ethics are important and now are much more prevalent, huge amounts of data show the most powerful impact on student and resident: behavior and idealism are the role models that they have or don’t have. And we need to hold up a mirror to ourselves and our systems and are we acting in the most appropriate way to be role models and examples? And I think that is an exceedingly important issue and I thank you for bringing this topic to our audience. MacKenzie, New York City: Well, I think that is clearly exceedingly important, and our responsibility, that all of us really bear. And I think it gets increasingly harder and harder with the demands of modern-day practice, and we just need to keep it in the forefront of our minds. So, anybody interested in reading the best paper on mentoring ever, should consult The Transactions of the American Clinical and Climatological Association, Volume 106, pp. 1–24, 1995, “A Brief History of Mentoring.” The President’s Address by Jeremiah A. Barondess! Thank you very much!
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