Wednesday, November 12, 2014

Family Medicine: Loyalty

I noticed a loyalty rating of physicians in some hospital literature recently.  I cringed.  My patients came to mind when I read the word loyalty.  I am loyal to them.  They are loyal to me.  (OK, it isn't perfect loyalty, but often it is "Til death do us part").

I have no similar category for hospitals.  Some might say they are generic marketing units, with the "best practices" (me-too sales pitch of the week) noted in their marketing pitch in such a way that one might think they actually had an original "service line" or product idea.  I've not seen recent evidence of their inclusion of my specialty, Family Medicine, in any of their "best practices" or product lines.

When Ohio eliminated the corporate practice of medicine act, thus allowing non-physicians to employ physicians, the medical profession became mis-directed toward not being a profession any longer.  A profession is allowed to exist by the citizenry through our legislature if the profession agrees to police its own member and enforce its own ethical code.  With the shameless enabling of the bankruptcy of millions of Americans through unnecessary and over priced practices, we have bailed out as a profession.  Is our loyalty shifting to hospitals?

I am a member of the American Medical Association.  Here are the Principles of Medical Ethics from the AMA for members:

Principles of Medical Ethics


The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self. The following Principles adopted by the American Medical Association are not laws, but standards of conduct which define the essentials of honorable behavior for the physician.

Principles of medical ethics

I. A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.
II. A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.
III. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.
IV. A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.
V. A physician shall CONTINUE to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.
VI. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.
VII. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.
VIII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount.
IX. A physician shall support access to medical care for all people.
Adopted June 1957; revised June 1980; revised June 2001.

The principles of Medical Ethics simplified:  There are four basic principles of medical ethics. Each addresses a value that arises in interactions between providers and patients. The principles address the issue of fairness, honesty, and respect for fellow human beings.
  • Autonomy: People have the right to control what happens to their bodies. This principle simply means that an informed, competent adult patient can refuse or accept treatments, drugs, and surgeries according to their wishes. People have the right to control what happens to their bodies because they are free and rational. And these decisions must be respected by everyone, even if those decisions aren’t in the best interest of the patient.
  • Beneficence: All healthcare providers must strive to improve their patient’s health, to do the most good for the patient in every situation. But what is good for one patient may not be good for another, so each situation should be considered individually. And other values that might conflict with beneficence may need to be considered.
  • Nonmaleficence: “First, do no harm” is the bedrock of medical ethics. In every situation, healthcare providers should avoid causing harm to their patients. You should also be aware of the doctrine of double effect, where a treatment intended for good unintentionally causes harm. This doctrine helps you make difficult decisions about whether actions with double effects can be undertaken.
  • Justice: The fourth principle demands that you should try to be as fair as possible when offering treatments to patients and allocating scarce medical resources. You should be able to justify your actions in every situation.
            from Medical Ethics for Dummies by Runzheimer and Johnson

With increasing evidence of loyalty to hospitals instead of patients, we have to refresh our professional insights and realign with our patients.  Our approach to clinical guidelines leans away from autonomy toward "Bonus- Based Medicine".  "First do no harm" doesn't align well with all the CT Scans we're administering (80 million 3 years ago) that will contribute to 29-30 thousand cancers annually soon.  Etc., Etc.

Is there a way out of our disastrous mis-direction as a (pseudo)- profession?

I'm a bit old fashioned and my loyalty is with my patients.

What do you think?

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