Doctors “Bending” Ethical Norms to Best Serve Their Patients who can’t Bend their Joints

ethical-medical-dilemmasRheumatic diseases, such as rheumatoid arthritis and lupus, are a common cause of disability. they affect all sectors of the population, diminish quality of life and have a significant social impact.

Yet, despite the benefits of early treatment and effective therapies, access to rheumatologic services may be difficult, involving long wait times, even difficulties finding providers.

C. Ronald MacKenzie, MD, a rheumatologist at Hospital for Special Surgery in New York City conducted a survey among rheumatologists entitled “Bending’ Ethical Norms to Serve Patients’ Interests:Tensions in Medical Professionalism,” to examine the medical, moral and ethical dilemmas doctors face when trying to do what’s best for their patients in the current health care environment.

The study was published in the October issue of the journal Arthritis and Rheumatism. When people receive a diagnosis, the cost of effective treatment may render it unaffordable for many,” says Dr. MacKenzie. “While an optimal or fair system would mitigate these impediments to care, our survey of the American College of Rheumatology members suggests that this is often not the case. In fact, physicians report they frequently find themselves in situations of ethical conflict in an effort to best serve their patients.”

The survey consisted of 14 closed-ended and two open-ended questions and was sent to 5,500 members of the American College of Rheumatology.

Physicians reported ways in which they see themselves as ‘bending’ ethical standards and presented justifications for doing so. Examples included ‘embellishment’ of symptoms to help patients obtain prior authorization from insurance companies; stretching the truth to obtain diagnostic tests and necessary medications and or physical therapy.

rheumatismThe delivery of medical care takes place in a particular social context, and when this context includes conditions that are unfair, healthcare practitioners may be forced to struggle with ethical conflicts, making trade-offs that may go unrecognized or are not adequately discussed.”

Medicine is not merely the scientifically based treatment and care of illness. It also involves ethical issues of right and wrong. In some cases, tough ethical dilemmas force doctors and other health care providers to make difficult decisions, all while upholding the Hippocratic oath to which all doctors are bound.

In today’s health care world, where the number of health care options can be great, medical ethics is of particular concern.Awareness of this problem and its consequences is only the first step in finding solutions to the challenges that physicians face.

Fixing the system in which physicians feel they have to ‘bend’ ethical norms and compromise ethical principles in order to provide the care their patients need, is clearly what’s so desperately needed.

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Physician, Heal Thyself!

An unwavering work ethic is a hallmark of many health professionals. But a new survey finds that when a doctor is sick, such dedication to duty can have serious consequences.

A poll of 150 attendees of an American College of Physicians meeting in 2010 revealed that more than half of resident physicians had worked with flu-like symptoms at least once in the last year and one in six reported working sick on three or more occasions during that time.

The survey conducted by researchers at the University of Chicago Medicine and Massachusetts General Hospital also asked the doctors whether they believed they’d ever directly transmitted an illness to a patient.  Shockingly, nearly 10 percent of respondents answered yes, and more than 20 percent believed other residents had passed on an illness to a patient. So much for the Hippocratic Oath and the promise to do no harm!

The results published in the Archives of Internal Medicine are further evidence of a culture of self-sacrifice long prevalent in medicine. Researchers say a physician’s sense of loyalty to already-overwhelmed peers, along with a commitment to patient care, often conflicts with an ethical stance against exposing patients and staff to an illness or compromised performance.

Resisting the pressure to work when ill can be particularly difficult for young doctors,” said study author Anupam B. Jena, MD, PhD,. “A work-first, self-second attitude is often seen as ideal among peers, superiors and even patients.”

In the first known account of the reasons for presenteeism among doctors-in-training, more than half of respondents cited obligation to colleagues who’d be forced to cover their duties or an obligation to patient care as the top reasons for not taking a sick day.

Far fewer, a mere 12%, indicated they’d worked when ill due to concerns their colleagues would think they were “weak” and 8% came to work sick because they felt pressured to repay colleagues for coverage.

Seniority appeared to be a factor in the results. Second-year residents were more likely than first-years to select responsibility to patient care as a reason for presenteeism. Gender differences were also brought to light with female residents more likely to work sick and cite patient care as the reason. Female residents were also more likely to report fear of being perceived as weak as a motive for not taking time off.

While time away from the office carries a similar stigma in other high-pressure professions, a business  executive showing up sick to the boardroom is significantly less worrisome than a doctor with flu treating patients. An otherwise healthy doctor can often recover quickly, but an infected patient with an already-compromised immune system may not.

Clearly it’s time for doctors to stop playing superheroes.  Presenteeism needs to be addressed and eliminated. Given the intellect of most doctors it shouldn’t be too difficult for them to understand that refraining from work while ill is the most professional way to ensure responsible and safe care for patients.

A word to my doctors – if  what you’ve got is contagious or makes you so sick that your judgment is clouded – STAY HOME!