There’s the ideal world, and then there’s the real world. Humans have a wonderful hubris in forever trying to get the twain to meet, and a necessary humility in examining ways that they don’t. That’s as true in medicine as anywhere else.
The Charter on Medical Professionalism, endorsed by the U.S. Accreditation Council on Graduate Medical Education and more than 130 professional groups worldwide, contains three fundamental principles: the primacy of patient welfare; respect for patient autonomy, and promotion of social justice. Who wouldn’t want that? A physician’s professional responsibility as spelled out in the charter entails honesty (including disclosure of medical error), patient confidentiality, maintaining trust by managing conflicts of interest, and much more.
Yet, more than 10% of 1,891 practicing U.S. physicians surveyed recently in seven specialities said that they had told adult patients or a minor’s parent or guardian something that was not true, Ben A. Rich, J.D., Ph.D. noted during a session on ethics at the annual meeting of the American Academy of Pain Medicine.
Results of the survey of physicians in internal medicine, family practice, pediatrics, cardiology, general surgery, psychiatry, and anesthesiology also showed that 20% of physicians had not fully disclosed mistakes to patients out of fear of malpractice litigation.
More than 33% said they do not agree that physicians necessarily must disclose all serious medical errors to affected patients, or that it’s important to disclose to patients any financial relationships with drug and device manufacturers (Health Affairs 2012;31:383-391).
More than 25% of the physicians said they had revealed unauthorized information about a patient. More than 50% had described a prognosis to a patient more positively than the clinical facts warranted.
Women were more likely than men to practice consistently within the Charter on Medical Professionalism, as were physicians from racial and ethnic minorities, the survey found.
It’s comforting to note that a majority of physicians seem to adhere to the professional principles, and perhaps we shouldn’t be too hard on those who admit their actions sometimes diverge from the ideals, said Dr. Rich, professor of medicine and director of the Bioethics Program at the University of California, Davis. The “messy facts” of real cases show the challenges that physicians face in trying to help patients while also respecting their autonomy while also being honest, etc.
One example: A published case of a 45-year-old licensed practical nurse whose license had been suspended due to her medical problems. She was being treated for migraine headaches by a psychiatric neurologist and was on gabapentin, topirimate, propranolol for prophylaxis, oxycodone for breakthrough headaches, and IM injections of meperidine and hydroxyzine for breakthrough pain. She signed a contract with her physician saying she would only take narcotic medications that he prescribed and would not seek painkillers from emergency departments (Nursing Journal 2007;29:35-40).
“She violated that contract repeatedly and with impunity and was becoming a `frequent flyer’ in the local E.D.s.,” Dr. Rich said. Her physician persuaded her to get inpatient treatment, but afterward she relapsed and continued E.D.-hopping in pursuit of pain meds. One local E.D. suggested to her physician that he be notified whenever she turned up in an E.D. Her physician suggested instead that the E.D. do what he had resorted to doing — injecting her with saline and telling her it’s meperidine.
Some E.D. physicians gave her medications just to get her out the door. Others refused to give her any narcotics for her pain because of her addiction and violations of her contract. All the healthcare providers in the medical group of one emergency department signed a letter to the patient telling her that if she came there for treatment, she would be evaluated and treated with non-narcotic medications recommended by her treating neurologist but she would no longer be given narcotics.
Which, if any, of these approaches pass ethical scrutiny? What would you do if you were her neurologist or saw her in pain in the emergency department?
The group that sent her a joint letter was “at least trying a collaborative approach and putting her on notice about how she would be treated if she continued to present there,” Dr. Rich said.
The lengthy Ethics Charter of the American Academy of Pain Medicine lists many physician duties, including this “intriguing” one, he noted: Any reports to law enforcement of attempts to acquire pain medications illegally should be based on confirmed firsthand information.
“Some of my colleagues at UC Davis are working on a manuscript right now where we’re finding it’s not as clear as one might hope” when deciding whether you have a duty to report a patient to law enforcement or a duty not to report to law enforcement because reporting the patient may infringe upon patient confidentially, not to mention potentially violating the Health Insurance Portability and Accountability Act (HIPAA), he said.
The messiness of real life doesn’t diminish the importance of standards, it just reinforces the need for ideals to guide us as we muddle our way through the real world.
Dr. Rich has been a consultant to KOL, L.L.C.
–Sherry Boschert (@sherryboschert on Twitter)