By Matthew DeCamp, M.D., Ph.D., Lois Snyder Sulmasy, J.D., for the American College of Physicians Ethics, Professionalism and Human Rights Committee
Annals of Internal Medicine, March 16, 2021
The environment in which physicians practice and patients receive care continues to change. Increasing employment of physicians, changing practice models, new regulatory requirements, and market dynamics all affect medical practice; some changes may also place greater emphasis on the business of medicine. Fundamental ethical principles and professional values about the patient–physician relationship, the primacy of patient welfare over self-interest, and the role of medicine as a moral community and learned profession need to be applied to the changing environment, and physicians must consider the effect the practice environment has on their ethical and professional responsibilities. Recognizing that all health care delivery arrangements come with advantages, disadvantages, and salient questions for ethics and professionalism, this American College of Physicians policy paper examines the ethical implications of issues that are particularly relevant today, including incentives in the shift to value-based care, physician contract clauses that affect care, private equity ownership, clinical priority setting, and physician leadership. Physicians should take the lead in helping to ensure that relationships and practices are structured to explicitly recognize and support the commitments of the physician and the profession of medicine to patients and patient care.
Business Practices, Employment, and Ethics: Recommendations
- ACP Recommendation 1: Ethics and professionalism must be emphasized and explicitly addressed in the implementation of business practices and employment relationships, including in the face of external motivators for clinicians, such as financial incentives.
- ACP Recommendation 2: Contract provisions affecting practice should align with the ethical commitments of physicians and be subject to negotiation that recognizes that alignment.
- ACP Recommendation 3: Confidentiality clauses should not interfere with patient well-being, respectful professional relations, or the individual and collective responsibility of physicians to promote patient best interests, community health, and quality improvement.
- ACP Recommendation 4: Physicians should consider carefully whether to sign an employment contract that permits termination without cause. Provisions related to termination should be reciprocal and time-limited.
- ACP Recommendation 5: The net value of private equity investment in physician practices for patients, physicians, and medicine is unclear. Systematic studies of this trend on patients, medicine, and society are needed.
- ACP Recommendation 6: Organizations and employers should recognize and appropriately value time for patient–physician encounters and engage patients and physicians in priority setting across all aspects of health care.
Business practices can challenge the ethics and professionalism of individual physicians and the collective responsibility of the medical profession to patients. The social mission of institutions can be challenged as well.
Physicians, whether in training, newly graduated, or with decades of experience, must be aware of the effect business practices, employment terms, and contracts can have on ethics and professionalism. National organizations, such as the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education, and medical schools and residency programs should develop strategies for and educational materials on these issues. Because details matter, physicians must be prepared to ask questions about arrangements and feel empowered to advocate for practices that promote patient health and the patient–physician relationship. If a practice or policy harms or has the potential to harm patient care, the physician should speak out and “resist and even refuse to carry it out”.
It is also important for physicians to inform patients when these arrangements affect practice. Doing so preserves trust in the patient–physician relationship and helps make patients and society more aware of forces shaping the practice of medicine. Physicians should be actively involved as a major force.
The practice of medicine must be defined by the ethics of medicine. Efficiency and productivity are important but secondary to serving the needs of patients. Intrinsic motivations of service, professionalism, and clinical integrity must guide physicians and be respected by institutions and health systems. Trust in systems, individual clinicians, and the patient–physician relationship demands no less.
The challenges to care and medical practice during and after the COVID-19 pandemic underscore the need to reemphasize the ethical foundation of medicine. The commitment to ethics in the response of clinicians to COVID-19 has helped sustain the profession and society in the emergency. Some see in COVID-19 an important “lesson that the system can be reset” to better serve both patients and clinicians. Looking anew at the environment in which care is delivered, physicians should lead in ensuring that business relationships explicitly recognize and support the fundamental and timeless commitments of physicians and medicine to patients.
By Don McCanne, M.D.
The excerpts posted here for this policy paper include the abstract, the recommendations, and the conclusion. But they do not begin to adequately address today’s ethics and professionalism considering the dramatic changes taking place in medicine, especially in the business of medicine. The American College of Physicians has made the full policy paper available for free at the link above, and it should be read in its entirety.
The policy paper is still inadequate because it fails to reject some of the approaches that fall more under the heading of business rather than medicine, although they do stress the primacy of the patient and the patient-physician relationship. As you read the paper, you will be able to identify some of the areas for which they suggest ethical principles that should be applied, but some of these are structural issues that should be rejected.
You’ve heard it many times before and we’ll say it once again, we need to begin with a comprehensive restructuring of our health care financing system by enacting and implementing a model that automatically has ethical principles built in. Of course, that model is a single payer, improved Medicare for All national health program. It’s a system built around the patient, and that’s where you want to begin. If we finally get the model right, the ethics will follow.
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