Ethical Dilemmas Create Difficult Choices Physicians often have to balance conflicting goals for their patients. Ethical dilemmas in medicine go back to the ancient Greeks, but new ones are arising all the time. These new dilemmas are spawned by trends, such as the need for doctors to see as many patients as possible, the growth of physician employment, or our growing use of smartphones and other forms of telecommunications. They can also be spawned by events, such as the current opioid epidemic, or by scientific breakthroughs, such as advances in genetic research. These issues affect physicians across all specialties. What ties all of these dilemmas together is how much they can tug at doctors' basic values: the need to uphold patients' health, allow patients to help decide their care, and keep patients informed about their treatment, to name a few. Here are five new ethical dilemmas that doctors face—along with suggestions on how to deal with them. 1. Less Time With Patients Might Lead to Poorer Care The dilemma: Physicians are facing growing pressures to keep their visits brief, making it harder in some cases to provide the correct diagnosis and ensure excellent outcomes. Issues About Short Visits Physicians are under enormous pressure to see as many patients as possible, says Clarence H. Braddock III, MD, vice-dean for education at the David Geffen School of Medicine at the University of California, Los Angeles (UCLA). "In a high-volume primary care practice, the standard amount or time allotted for each patients is 10-12 minutes," says Braddock, lead author of a 2005 paper, "The Doctor Will See You Shortly: The Ethical Significance of Time for the Patient-Physician Relationship."[1] Braddock says that short visits force many doctors to concentrate on immediate biomedical issues, such as dealing with a high blood-pressure reading, rather than exploring psychosocial aspects of the patient's life. "True, high blood pressure needs to be addressed," Braddock says, "but the patient's issues are also important." Tips on Dealing With the Time Dilemma Time management may not be the answer. Doctors who complain about not having enough time with patients are often urged to improve their time management skills, but this option is limited if the problem is not having enough time in the first place, Braddock says. When time management is improperly applied, it can mean cutting corners on patient care. In a Medline search, Braddock and his coauthors turned up 1500 citations on "time management" but not one on "time management" and "medical ethics." Hear out all of the patient's complaints. Physicians sometimes manage the appointment time by limiting the patient to one or two complaints per visit. Indeed, one doctor went so far as to post a sign saying patients were limited to just one complaint per visit.[2] Not letting patients bring up all their complaints may mean that you miss the most important one, Braddock says. A better way to deal with patients' lists of complaints, he says, is to let them run through all of them, and then prioritize what needs to be dealt with in the current visit. "You ask the patient, 'What are things you'd like to talk about today?'" he says. "And when they are through with that complaint, you don't cut them off. You say, 'OK, anything else?' and so on, until they've gone through their list." He says this eliminates the "doorknob question"—when you are about to leave the room and the patient brings up an issue that might be the most pressing one of all. "Be quick, but don't hurry." Braddock says he loves this advice from the late John Wooden, the former UCLA basketball coach. You have to keep moving, but when you're too hasty, things can go wrong, he says. He counsels the residents he oversees against being abrupt with patients. "The patient might be just getting to the thing that really bothers them, and the doctor says, 'Oh, sorry, our time is up,'" Braddock says. "I tell my residents, 'Don't be so arbitrary about time.' " If you allow patients to go through their full list, would it take a lot more time? Braddock says doctors often overestimate the time needed to complete a conversation. Indeed, one study found that doctors thought they had spent more than 8 minutes telling patients about their condition and treatment, when they actually had spent an average of 1.3 minutes.[3] Being ethical can take more time. Being an ethical, caring physician may simply require taking more time, Braddock says. For instance, the California Department of Motor Vehicles requires physicians to report patients who may be too impaired to drive anymore. But losing one's license is a major blow, especially in the car culture of Los Angeles. Braddock says making sure that reporting the patient is the right judgment call requires spending some time with them to determine the extent of their impairment—and perhaps even talking with the spouse or adult children as well. To Whom Do You Refer Your Patient? 2. Pressure to Refer to In-House Could Deny Patients Better Care The dilemma: Employed physicians may have to balance mandates to keep referrals within the organization with the need to provide patients with high-quality care that is not overly expensive. Issues With In-House Referrals One key reason why hospitals buy up practices is so that more patients will use hospital services. Initially, many hospitals were reluctant to press this expectation with newly acquired practices, but that is changing, according to Theresa Hush, CEO of Roji Health Intelligence, a performance consultant for physician groups, many of which are owned by hospitals. "We're seeing more restrictions on doctors to refer within the organization," she says. "Organizations are tracking referrals and sharing the information with their doctors. Doctors might get reports about referrals that make them look negative—a kind of peer pressure. Getting the physicians to look at their data is one of important changes." Accountable care organizations (ACOs) add a new dimension to the trend. Traditionally, some hospitals may have pressured physicians to increase expenses, but ACOs would like them to keep referrals low—possibly risking that they provide too little care. Tips on Dealing With the Referral Dilemma Try to remove the obligation from your contract. Employers hold more sway over employed physicians' referrals when they actually have a clause in the employment contract obligating the physician to make in-house referrals whenever possible, according to an article by the Arkansas-based Mitchell Williams law firm.[4] When physicians are negotiating their employment contract, they can try to get the clause removed. Take advantage of exceptions to your referral obligation. Under the Stark Law, hospitals cannot stop employed physicians from referring outside the system if, in their judgment, it is in the patient's best medical interests, Mitchell Williams stated. In addition, Stark bars the referring physician from stopping the patient from insisting on going to an outside doctor or test facility. However, hospitals have other ways of pressuring doctors to keep referrals within the system. Their boss may review their referral report with them and even tie referral levels to eligibility for bonuses. However, the latter approach could violate the Stark Law if not properly structured. Physicians who refer outside a lot may insist that these outside providers have lower complication rates, but they'd better have data to back up their claims, says Thomas Dent, MD, medical director at Roji Health. "The organization probably has very exact outcomes data and will want check out your claims," he says. Inform patients of your conflict of interest. Employed physicians should reveal to patients the organization's expectation that they should refer patients in-house, says William Andereck, MD, a general internist who is medical director of the medicine and human values program at California Pacific Medical Center in San Francisco. "You need to tell the patient, because this is a conflict of interest," he says. "Conflicts of interest are not wrong, but they do have to be revealed." The Principles for Physician Employment by the American Medical Association (AMA) are in agreement with Andereck. The principles stipulate that employed physicians should disclose "explicit or implicit" referral agreements to patients.[5] Tell patients if there is an EHR default program. Some hospitals have a program in their electronic health record (EHR) system in which the default is to refer patients in-house unless the referring physician overrides the default.[6] "If organizations are using computerized referral systems with preferred clinicians as a default, that needs to be disclosed," says Matthew DeCamp, MD, assistant professor at the Johns Hopkins Berman Institute of Bioethics. Dealing With the Drug Overdose Crisis 3. Reducing Opioid Dosages Could Leave Patients Suffering The dilemma: In response to the opioid epidemic, state and federal regulators have been setting limits on the opioid dosages that physicians prescribe. But some patients need higher dosages to control their pain, and abruptly lowering dosages can cause painful withdrawal symptoms. Issues With Reducing Opioid Dosages Years ago, the issue was that physicians in general were prescribing too many opioids. But physicians have been cutting back opioid prescriptions for 5 years in a row, according to an AMA survey.[7] Another recent survey found that about 23% of pain patients were no longer being prescribed opioids, and about 48% were being prescribed opioids in lower dosages.[8] State and federal regulators, however, have recently been issuing rules on the dosages doctors are allowed to prescribe. As of July 2017, 23 states had enacted legislation with some type of limit, guidance, or requirement related to opioid prescribing, according to one count.[9] In proposed rules, the Centers for Medicare & Medicaid Services (CMS) initially proposed a definite ceiling of 90 mg morphine equivalent units (MME) for prescriptions. After an outcry from prescribers and patients, CMS produced a final rule under which the 90-MME limit would trigger a "hard safety edit" requiring pharmacists to talk with the prescribing doctor about the appropriateness of the dose before filling the prescription.[10] Even though it was a bit of a concession, the final rule troubles Michael Erdek, MD, associate professor of anesthesiology at Johns Hopkins. "There can't be an absolute ceiling on opioid dosages," he says. "Patients are very individualized." Whereas before, the concern was physician overprescribing, "underprescribing is much more of an issue now that it has been," he says. Establishing a ceiling could backfire, says Travis Rieder, PhD, research scholar at the Johns Hopkins Berman Institute of Bioethics. "Radical reductions in prescribing could actually increase illicit drug overdose deaths," he says. "If patients were cut off by their doctor, many of them might go to the black market." Tips on Dealing With the Opioid Dilemma Consider other therapies besides opioids. In some cases, Erdek says, physicians can prescribe patients other substances. Examples include anticonvulsants, such as gabapentin; tricyclic medications, such as nortriptyline; and muscle relaxants and anti-inflammatory drugs, he says. Rieder adds that physical therapy could possibly replace drugs in some cases. Sometimes doctors may reach for the prescription pad rather than "have a long, hard discussion about the patient's pain," he says. "Physical therapy requires much more commitment from the patient than a prescription." Go easy on patients with a profound dependence. "Legacy patients," those who have been on opioids for years or even decades, can be on very high doses, and "the prospect of going off those meds is terrifying," Rieder says. "Removing patients from opioids too fast put them at risk for depression and suicide." "Dosages should be reduced gradually," Erdek says. "Do it in a thoughtful, methodical manner, with communication and respect," he says. Consult with pain specialists. Primary care physicians (PCPs) have the option of asking pain specialists about opioid dosages and use of alternative therapies, Erdek says. But PCPs should not try to hand over their opioid patients to pain specialists, because "the pain clinics would be overflowing," he says. "We advocate shared responsibility at Hopkins," Erdek says. "We allow referring physicians to write these prescriptions under our guidance." Electronic Communication With Patients 4. Worry That Providing Telehealth Services Might Create Inferior Care The dilemma: Telehealth—electronic communication with patients—has been a godsend for patients in remote areas and may take the place of some routine visits, but critics argue that in other cases it may be a poor substitute for face-to-face appointments. Issues With Using Telehealth The alternative may be doing nothing. When patients run out of their medications and their regular doctor is out of town, using a telehealth service may be the only option, according to David Fleming, MD, an ethicist at the University of Missouri School of Medicine and a member of the Council on Ethical and Judicial Affairs (CEJA) at the AMA. "Telemedicine may be the only solution," he says. Surging interest. Our love affair with emails, smartphones, and texting has made us a lot more comfortable with texting doctors, applying video-voice technology, and even using remote patient monitoring. Payers, if anything, are slower in adapting to our tastes, but they're moving in that direction. Medicare, which has long covered telehealth in rural areas, expanded coverage in 2015 to patients with multiple chronic conditions.[11]UnitedHealthcare has expanded coverage options for virtual physician visits for patients in self-funded employer health plans.[12] And Kaiser Permanente, the integrated delivery system, now provides more visits virtually than in person.[13] Holdouts are disappearing. In 2016, the AMA dropped a stipulation that physicians needed to have a standing relationship with the patient before they could use telehealth.[14] And in late 2017, Texas—the last state to require a patient relationship for telehealth—dropped that requirement.[15] The AMA must have seen the writing on the wall, says Kenneth Goodman, PhD, director of the University of Miami Institute for Bioethics and Health Policy. "In ethics, you don't want to be in the position of suggesting that everyone is unethical except for you," he says. Guidelines for telehealth can be hard to follow. Goodman contends that the new AMA guidelines are vague at points. For example, the guidelines state, "Although physicians' fundamental ethical responsibilities do not change, the continuum of possible patient-physician interactions in telehealth/telemedicine give rise to differing levels of accountability for physicians."[16] All well and fine, Goodman says, but the guidelines don't elucidate what "differing levels of accountability" might be. Statements by Fleming, who was not a CEJA member when the policy was drafted, induce similar head-scratching. "Telehealth is more effective when the doctor already knows the patient," he says, mentioning other factors as well. But after establishing that it's better when physicians know the patient already (the old AMA policy), Fleming then discounts the need for a previous relationship (the new AMA policy). "Relationships are always important to successful clinical outcomes," he goes on to say, "but relationships can be equally well-formed via telehealth as compared to in-person visits." Tips on Dealing With the Telehealth Dilemma Telehealth is a better fit for some specialties. Telemedicine is popular in specialties that look at images, such as dermatology and radiology, Goodman says. "There is no hard-and-fast rule that doctors have to see patients," he says, noting that pathologists rarely do so. On the other hand, Fleming notes that PCPs are less likely than specialists to use telehealth. He says this may be because of the expense of setting up a telehealth base for patients to use. (For patients to use telehealth in rural areas, Medicare requires them to be in a doctor's office, hospital, or other facility, and not at home.[17]) Tell patients how telehealth works. AMA policy says that the telehealth physician "should provide information patients need about the distinctive features of telehealth/telemedicine, in addition to information about medical issues and treatment options." Disclose its limitations. The new AMA policy says physicians ought to "inform users about the limitations of the relationship and services provided." However, the limitations are anyone's guess, because they have not yet emerged in scientific studies, Goodman says. A 2015 Cochrane review found that outcomes were the same for telehealth and office visits for heart failure, mental health, substance abuse, and dermatology.[18] And a more recent study found that telehealth actually provided better outcomes than just office visits for patients with chronic conditions.[19] But research is still in its early stages, and evidence-based limits on the use of telehealth may eventually arise, Goodman maintains. "We do not fully understand the implications of this new technology," he says. "For a couple of thousand years, we believed in contact between doctors and patients. What if we discover that we've lost something valuable and precious?" Consider having someone else examine the patient. Current AMA policy states that in some cases, physicians may want to arrange "having another health care professional at the patient's site conduct the exam or obtaining vital information through remote technologies." Consider the need for follow-up care. Telehealth providers should advise patients "about how to arrange for needed care when follow-up care is indicated," the current AMA policy states. They should also "encourage users who have primary care physicians to inform their primary physicians about the online health consultation." Growing Knowledge of Genetics 5. Giving Genetic Test Results While Being Unsure of How to Interpret Them The dilemma: Genetic testing can help you determine a patient's predisposition toward a disease, but test results can be hard to interpret and may cause patients unnecessary anxiety. Issues With Genetic Tests Genetic tests are becoming ubiquitous. There are 75,000 genetic tests on the market, and 10 new ones enter the market every day, according to a new study.[20] In addition, 97% of insurers cover genetic screening, and Medicare covers affected patients for genetic testing as long as they have a qualifying history.[21] And for the first time, the FDA has allowed direct-to-consumer (DTC) testing, without a prescription. In 2017 and 2018, the agency approved two DTC tests by 23andMe, a company that had been providing ancestry reports.[22,23] Some doctors are beginning to routinely order genetic tests. Geisinger Health System recently announced that it will now offer patients DNA sequencing as part of routine preventive care, and Geisinger will pay for the testing.[24] However, when genetic testing became possible, many doctors had already completed their training, and they're nervous about having to interpret results. In a recent survey of PCPs in New York State, only 14% were comfortable interpreting genetic test results.[25] Doctors may misinterpret test results. In a recent study, doctors who had treated fewer than 21 patients with breast cancer were less confident in discussing test results with patients, more likely to order the test without referral to a genetic counselor, and less likely to delay surgery to get genetic test results first.[26] Indeed, physicians interpreting genetic tests for breast cancer often order mastectomies for women who don't need them. Fully one half of women who undergo bilateral mastectomy after genetic testing don't actually have mutations linked with higher risk for additional cancers, according to a 2017 study.[26] Tips on Dealing With the Genetic Testing Dilemma Be able to converse with patients about genetic testing. Many patients expect doctors to talk about genetic testing. Even when patients order DTC tests on their own, many of them want doctors to interpret them. In a survey, 61% of patients believed that physicians have a professional obligation to help interpret genetic test results.[27] Pay close attention to family history. It's wise to suggest testing when there is a significant family history of a disease that can be tested for. In a $4 million malpractice award against a physician, a patient who developed ovarian cancer alleged that her physician should have understood from her family history that she needed to be evaluated.[21] Refer patients to an expert. Unless you have significant training in genetic testing, consider referring patients to an expert in a genetic testing, such as an experienced physician or a genetic counselor. There are more than 4000 certified genetic counselors, according to the National Society of Genetic Counselors. Most of them work in a clinic or hospital, and often work with obstetricians, oncologists, and other doctors, the society says. Test results are often ambiguous and need to be read by an expert. "A positive result does not always mean you will develop a disease, and it is hard to predict how severe symptoms may be," according to the National Human Genome Research Institute.[28] "Inevitably, every time you answer one question [about genetic test results for cancer], you raise more questions," said Len Lichtenfeld, MD, deputy chief medical officer for the American Cancer Society, in an interview with WebMD. "We're still learning what the mutations mean, and we're still learning what impact particular mutations may have for a particular individual."[29] You may decide to withhold some test results. If you do have expertise in reading genetic test results, you'll still have to deal with the dilemma of whether to reveal information that the patient cannot act on. For example, reporting a susceptibility to Alzheimer disease or Huntington disease can only bring anguish to the patient because there are no cures. Not revealing health information to a patient would seem to violate a basic tenet of modern bioethics, which is that patients should not be kept in the dark about diagnoses of cancer and other diseases. However, having a predisposition toward a disease is not the same as having the disease; genetic tests often reveal predispositions that do not progress into the disease.[30] Be selective about tests for children. Children whose parents order genetic testing for them have no say over the matter, so it's important to be selective about ordering tests, says Joel Frader, MD, a pediatrics professor and bioethicist at Northwestern University. Even if parents don't tell their children about a test result showing an increased risk for sudden death due to heart arrhythmia, for example, they may still treat the child differently, he says. Knowing this, parents may still go ahead with the test, but many ethicists think they should hold off on tests for adult-onset diseases, such as breast cancer. The test should be deferred until the child is old enough to participate in it, according to one expert.[31] Source
