Consultations on ethics are not limited to the curbside
■ Where can physicians seek help when they have ethical dilemmas?
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The author polled several local practice environments to see what is available to doctors and who took advantage of these resources.
Reply: I offer the medical environment of small- to mid-sized group practices in my community of Greeley, Colo., to discover how smaller clinics and practices here managed ethics concerns. I queried the Greeley Medical Clinic, the one large multispecialty clinic in town (about 80 physicians); Family Physicians of Greeley, the largest family practice group (21 physicians at three locations); a cardiologist from the Cardiovascular Institute (22 cardiologists and cardiovascular surgeons); and residents and attending physicians in the North Colorado Family Medicine training program -- a three-year fully accredited family practice residency program with 24 residents and 10 attending physicians.
Our nonprofit 398-bed hospital serves the town's population of about 100,000, as well as northern and eastern Colorado, southern Wyoming and western Nebraska and Kansas, for a referral population of about 250,000. It has 220 staff physicians, including all 22 members of the Cardiovascular Institute and 12 hospitalists.
I asked these medical professionals the following questions: How does your practice deal with ethical dilemmas -- both those involving patients and those involving problems with physician behavior or performance? Are there any typical ethical questions you encounter? Are you satisfied with the mechanisms you have for resolving such conflicts?
Not surprisingly, the hospital had the most formal arrangement, having established an ethics committee about 20 years ago. The committee meets monthly, is chaired by a university philosophy professor and is composed of 12 to 20 volunteer members of the medical and lay communities. The committee hears ethics consults (perhaps half a dozen a year) and provides a forum for ethics education and discussion. Consult requests may be brought to the committee by patients, families or any member of the health care team.
Responses to the question about management of patient care dilemmas were similar. Nearly all said they "curbside" other docs -- usually within the practice, but sometimes outside. All said they were aware of the option of using the hospital ethics committee, and none would hesitate to use it, although almost none had.
Each practice has a slightly different mechanism for dealing with physician-related ethical issues such as behavior problems. At the Greeley Medical Clinic, questions about a doctor's conduct are referred to the medical director. If the director cannot resolve the problem alone, it goes to the seven-member clinic board elected by the shareholders, which can sanction, dismiss or order the physician to take corrective measures.
The Family Physicians of Greeley convenes a group of two or three doctors, with one physician designated to address physician issues for that year, then investigate and decide on a course of action. If the group believes dismissal is in order, it must bring the recommendation to the entire practice group for approval.
Members of the Cardiology Institute, because they are all employed by the hospital, refer physician concerns to the hospital chief medical officer, who proceeds with an investigation following hospital protocol. If the physician matter relates to quality of care, it is addressed by quality improvement mechanisms.
The most common ethical issue cited by the doctors was financial -- most pressingly how to take care of uninsured and underinsured patients. It also was cited as the most difficult to resolve. The region has a substantial population of patients who are uninsured and underinsured and a number of people who are not legal residents, complicating availability of nonemergency services.
Interestingly, many physicians, particularly older doctors, felt they had adequate resources to deal with ethical issues and that doctors should be able to handle most such problems alone or with a curbside consult. Many of the younger physicians said they would prefer more options and training. The younger doctors tended to curbside their older colleagues.
It is difficult to know whether these physicians do not need and would not use additional ethics resources if they became available. None of the physicians I spoke with reported any formal ethics training, and none had ever practiced in a setting that had such resources -- an active in-house consult service, for example, regular ethics grand rounds or an easily obtainable outpatient ethics consult.
Sometimes services are not perceived as useful when and where they don't exist. Before our hospitalist program started 18 months ago, for example, most doctors saw no need for hospitalists; now most local physicians consider them indispensable. These same physicians may be living without ethics services simply because they are not available.
Although mechanisms for resolving patient care questions seem to be adequate for many physicians, it is not clear that mechanisms to address "doctor problems" are. A recent article by The Associated Press suggested that many doctors don't report troubled colleagues, and I suspect my region is no exception.
The mechanisms for reporting are cumbersome and not at all user-friendly. Through the years, we have all seen episodes of physician behavior reported in the regional and national media and wondered, "Who knew what? And when? Was anything was reported? And, if so, was anything done about it?"
Many years ago, I reported a physician in a neighboring area for using a dangerous off-label treatment that clearly endangered a patient. I learned only years later that a letter of admonition was issued four years after the fact, and the physician was still practicing. My experience makes me think that the procedure itself discourages reporting, and the evidence for the effectiveness of self-regulating in medicine has not been encouraging. An article and editorial in the July 14 issue of The Journal of the American Medical Association tend to bear this out.
Of the two types of ethics issues identified by colleagues in my town -- patient-related and physician-related -- most physicians seemed satisfied with available mechanisms for resolving the former, though I continue to suspect they might find more extensive ethics services useful were such services available. Less comfort surrounds concerns about physicians' ethical violations. Although each of us must take responsibility for confronting doctors who violate professional norms, such responsibility should be supported by practical, useful mechanisms both for reporting and for helping such doctors improve their practices or behaviors.
Patricia A Mayer, MD, medical director, Hospice and Palliative Care of Northern Colorado; associate professor, Bioethics Program of Union Graduate College/The Mount Sinai School of Medicine