ACP MedicineACP Medicine CE:I On Being a Physician–1
David C. Dale, m.d., f.a.c.p. Daniel D. Federman, m.d., m.a.c.p.
Medical practice is constantly changing. Almost daily there is important new information regarding basic disease mecha- nisms and new therapies. There is a constant need to reconsid- er how we diagnose and treat both common and rare diseases. The way that hospitals and clinics are organized, how we pay for health care, and how our services are evaluated are also changing. The future promises more changes, some of which will undoubtedly increase the burden of illness and the work for physicians. Population growth, poverty, and emerging in- fectious diseases, as well as inactivity, dietary changes, and obesity, are worldwide problems that have immense medical implications. Other changes are coming rapidly that should improve health care and be helpful to physicians—new infor- mation technologies to aid in obtaining current medical infor- mation and record keeping, applications of discoveries from basic sciences and the human genome project to make diagno- sis more precise and treatments more specific, and the develop- ment of new drugs and vaccines on the basis of increasing un- derstanding of normal physiology and disease processes.
Although change is a watchword for medicine, many as- pects of medicine are not changing rapidly; some of these are the most important and most satisfying aspects of being a physician. In the community and in the patient-doctor relation- ship, physicians are still seen as persons skilled in the art of healing and in teaching others about health and disease. Physi- cians are still the ones who receive the extensive training, the li- censure by the state, and the approval of society to provide all levels of care: to give advice for a healthy life, to examine and diagnose illness, to prescribe drugs to relieve suffering, and to care for those who are seriously ill and dying. Although physi- cians now share the many responsibilities involved in patient care and work closely with nurses, physician assistants, phar- macists, technicians, therapists, and family members of pa- tients, it is still the physician who bears most of the responsibil- ity for the care of the patient.
Being a patient's physician carries many responsibilities and requires at least three attributes. First, knowledge of the applic- able biomedical science and clinical medicine is necessary to understand a patient's problem. There is no limit to the knowl- edge that may be needed, but it is important to be able to an- swer correctly the patient's questions, such as “How did this happen to me?” and “Will I be better soon?” The physician needs to understand disease processes well enough to identify and categorize a patient's problem quickly. It is important, and sometimes critical, to know whether the problem will resolve spontaneously or whether detailed investigations, consulta- tions, or hospitalization is needed. A thorough and up-to-date understanding of diagnosis and treatment is essential for the day-to-day exchange of information that occurs between physicians as they solve the problems of individual patients and work together to organize systems to improve patient care.
Second, some specific skills are necessary to diagnose and treat a patient. The ability to communicate—both to speak and to listen—is essential, especially for physicians providing pri- mary care. Effective and sensitive communication can be chal-
lenging in communities characterized by diverse cultures and languages. At times, the physician must be, in part, an anthro- pologist to grasp the patient's understanding of illness and of the roles of patient and doctor. Knowing how to communicate empathically is also invaluable: It is important to welcome each patient at every visit, to reach out and hold the hand of a trou- bled person, and to express understanding and concern. The ability to balance the time spent with the patient and the time required for organizing services for the patient in a busy prac- tice is an increasingly important skill.
The physical examination remains a fundamental skill; the ability to recognize the difference between normal and abnor- mal findings, adjusting for age, sex, ethnicity, and other factors, is crucial. Good record keeping is essential—with regard to both a written record and a mental record—so that the circum- stances of visits are remembered and changes in a patient's ap- pearance or other characteristics that may not have been recorded can be recognized. With practice and attention, these skills—history taking, physical examination, and record keep- ing—can grow throughout a professional lifetime. Other as- pects of care, such as selecting and performing diagnostic tests, procedures, and treatments, require evolving expertise. For all physicians, it is necessary both to practice medicine and to study regularly to maintain all of these essential skills.
The third, but by no means least important, attribute is the physician's responsibility to the patient and the medical com- munity to conform to appropriate professional and ethical con- duct. The first principle of the doctor-patient relationship is that the patient's welfare is paramount. Putting the patient first necessitates understanding the patient and the patient's values. It often means spending precious personal time explaining ill- ness, determining the best method of treatment, or dealing with emergencies. It places the physician in service to the pa- tient. Ethical conduct includes seeing clearly and acknowledg- ing situations in which the physician's interest may conflict with the interest of the patient. Ethical conduct also requires recognizing and acknowledging conflicts of interest in profit- ing from the prescribing of services and treatments, owner- ships of equities and properties, and personal and business re- lationships. Finally, personal exploitation of the intimacy and privacy of the doctor-patient relationship is never allowed.
Thus, the work of the physician—recognizing illness, pro- viding advice and comfort, relieving pain and suffering, and dealing with illness and death—has not changed much even since ancient times. On another level, however, the work has changed greatly. Better medical record keeping, quantitative observation, meticulous experimentation, and carefully con- ducted clinical trials have contributed to the rapid evolution of medical practice in this century. Simultaneously, medical education at the undergraduate, graduate, and postgraduate levels has been dedicated to the organization of a truly scien- tific knowledge base and its translation into intellectually co- hesive approaches to understanding disease. Extraordinary advances in the biologic sciences, the development of medical and surgical specialties, and the explosion of medical infor- mation have brought with them great benefits. They have also added to the costs and the potential costs of almost every aspect of health care.
I O N B E I N G A P H Y S I C I A N
© 2005 WebMD, Inc. All rights reserved. October 2005 Update
ACP Medicine CE:I On Being a Physician–2
Efficiency and cost containment are now watchwords of the payers for health service. Practice guidelines, hospital care pathways, and other efforts to codify the practice of medicine are receiving much attention. When based on good evidence, these efforts are beneficial; they save precious resources—time and money—for both patients and physicians. The develop- ment of managed care in the United States has created a new challenge for physicians: to serve as advocates for their pa- tients. In this role, physicians are responsible for overcoming organizational, geographic, and financial barriers to the provi- sion of services that are important for their patients. In organi- zations in which guidelines for care have been established, it may be necessary for a physician to explain to administrators the specific needs and problems of individual patients—some- times over and over again, because laypersons may be less apt to recognize that guidelines for clinical practice must remain just guidelines. Because more and more physicians are salaried and thus bound to the needs of populations of patients, physi- cians face the problem of balancing the needs of individual pa- tients with the expectations of the employer. This is a delicate and, in some places, even fragile balance. To serve both pa- tients and the employer well, a physician must develop good judgment in managing patient care under conditions in which the allocation of resources is conservative.
The increasing organization of health care on a for-profit ba- sis has raised new issues. The physician's obligation to put the patient first, the thoroughness inculcated in physicians throughout their training, and the increasing costs of diagnos- tic tests and therapies can collide head-on with health care management's attempts to protect earnings for investors. Pro- fessional responsibility to patients and the public good is clear and at times poses difficult challenges for the physician.
A profession is defined by a specialized body of knowledge requiring advanced training and by the dedication of its practi- tioners to the public good over their own enrichment. In ex- change, professionals are granted considerable autonomy in setting standards and in the conduct of their work. Circum- stances within the medical profession have changed. The pub- lic in general and patients in particular have much more
knowledge of medicine than at any time in the past, and the modern organization of medicine has severely restricted the autonomy of physicians. But delivery of expert medical care and the welfare of the patient remain central to the physician's professional responsibility. Maintaining professionalism as the ground moves under us is more important than ever.
The weight of all these responsibilities may suggest that it is impossible, or nearly impossible, to be a good physician. Quite the contrary, persons with vastly different personalities, inter- ests, and intellects have become and are becoming good physi- cians and are deeply satisfied in this role. The information nec- essary for practicing medicine is now more accessible than ever before. The skills the physician needs can be learned through experience, sharpened through practice, and focused through specialization. The ethical requirements of physicians are not onerous. They are, in fact, expectations of all good citizens, re- gardless of their careers. Being a physician is both exciting and satisfying; it provides a unique opportunity to combine mod- ern scientific knowledge with the traditions of an ancient and honored profession in serving and helping one's fellow man.
ACP Medicine is written and edited by physicians to help other physicians meet the ideals enunciated in this introduc- tion. A principal goal of ACP Medicine is to be the most up-to- date textbook of medicine available. The section Clinical Es- sentials presents the contemporary skills and knowledge need- ed by all physicians to encourage and maintain good health, to analyze medical information, to deal compassionately with the end of life, and to understand issues of medical ethics. The other sections organize and summarize the most important in- formation on pathophysiology, diagnosis, and treatment for most problems encountered in practicing medicine for adults from general and specialty journals, as interpreted by experi- enced clinicians. The material is evidence-based, with exten- sive bibliographic citations that are updated regularly. Authors are selected who understand both the constraints of managed care and the quality of care that is possible with scientific ad- vances. In short, ACP Medicine is committed to conveying the information necessary for physicians to provide excellent care to their patients.
© 2005 WebMD, Inc. All rights reserved. October 2005 Update
ACP Medicine CE:I On Being a Physician–4
Christine K. Cassel, m.d., m.a.c.p. Ruth B. Purtilo, ph.d.
In the past, medical ethics was thought to refer solely to pro- scriptions against physicians advertising their services and fees or engaging in questionable economic arrangements such as fee-splitting. Within the past 20 years, however, medical ethics has evolved into a discipline in which clinicians (physicians, nurses, and other health professionals), philosophers, theolo- gians, and social scientists speak knowledgeably about value conflicts that arise in the practice of medicine.1,2 Physicians have come to recognize the need to be knowledgeable about com- plex and wide-ranging moral issues as the result of advances in biomedical science and technology; changes in the delivery of health care; changing worldwide demographic trends; epi- demics (e.g., the AIDS and severe acute respiratory syndrome epidemics) and new or reemerging infectious illnesses (e.g., avian influenza and Marburg viruses); and a growing under- standing of the interconnectedness of individual and public health concerns. The AIDS pandemic has brought awareness that global health threats and cross-cultural contacts can pre- sent clinical, epidemiologic, and ethical challenges. For exam- ple, what responsibility does the international community have to provide assistance to severely underprivileged, impov- erished countries experiencing an AIDS epidemic when treat- ment of the disease is readily available but out of reach of mil- lions of people who suffer from its ravages?
Ethical issues in the clinical setting persist, and physicians need to be aware of legal decisions and new technologies that affect clinical practice. The rapid, continuing advances of med- ical technology have raised a host of moral issues around such fundamental questions as when does life begin, when and how does life end, which services can patients require of physicians, and which requests can physicians legitimately refuse. These questions become even more complex in a society as diverse and multicultural as our own, where moral norms may con- flict. Respect for the personal values of our patients requires physicians to examine ethical dilemmas carefully and analyti- cally. Consider the following ethical dilemmas and the ques- tions that each one raises for physicians today:
A 90-year-old woman, totally disabled from several strokes, lives at home, where she receives 24-hour care. Her strokes have left her cognitively impaired and unable to communi- cate. She signed a living will 15 years ago, and her husband is her designated health care proxy. She was hospitalized be- cause she had stopped eating, and while in the hospital, she developed aspiration pneumonia. Four days into her hospi- talization, she developed a bleeding ulcer and hemorrhaged several units of blood. She had a cardiac arrest, was resusci- tated after 45 minutes of asystole, and is now unresponsive and ventilator dependent. Her husband insists that she be kept alive by whatever means possible. The hospital team is strongly divided about the morally appropriate course of ac- tion. Some agree with the patient’s husband and argue that the patient should receive life-sustaining treatment, even though she has virtually no chance of recovery. Others ar-
gue that it would be more respectful to discontinue intrusive medical care—an action consistent with her advance direc- tive—and allow her to die. What clinical and moral value considerations should govern their final decision?
A 58-year-old man living in Oregon is suffering from end- stage AIDS with lymphopenia, multiple refractory fungal in- fections, and Kaposi sarcoma. He has significant pain from mucosal lesions and skin breakdown and has sustained frac- tures, including one from a spinal metastasis that has led to paraplegia and urinary and fecal incontinence. He is cogni- tively intact and has given oral and written directives indi- cating that he does not want to be kept alive any longer. He has repeatedly asked his physician to give him an overdose of sedative so that he will die and be released from his in- tractable suffering. The physician is convinced that this pa- tient is competent, that he is well-informed about his condi- tion, and that his wish to die is made in good faith. The pa- tient’s companion of 15 years agrees with the patient’s decision. Both have known the physician for a long time and trust her judgment. Physician-assisted suicide is currently legal in Oregon. Should the physician comply with this patient’s wishes? If she cannot do so in good conscience, must she refer her patient to a physician who can? Why or why not?
Science allows physicians to transplant hearts, livers, kidneys, and other living organs, tissues, and cells. Overall, there are drastic shortages of donors. Hundreds, sometimes thousands, of people die each year before an organ match becomes avail- able. Currently in the United States, people who wish to do- nate organs are encouraged to indicate that wish on their dri- ver’s licenses. In the absence of such clear evidence of consent, physicians and other hospital staff are often reluctant to ask bereaved family members for donations because many peo- ple, understandably, cannot deal with such a request in a time of crisis. Should the United States adopt a policy—already practiced in other countries—of allowing hospitals to harvest organs upon the death of a patient unless that person has specified otherwise? Could one policy ever work to every- one’s benefit in a diverse society in which there may be differ- ing attitudes about treatment of the dead, the moral use of an- imals, and other culturally derived considerations? Would therapeutic cloning or xenotransplantation provide ethically preferable alternatives?
A woman whose family has a strong history of breast and ovarian cancer wants to be tested to determine whether she is a carrier of the BRCA family of genes, which confer high risk for these malignancies. She is between jobs and is about to apply for a position with a small, innovative firm that has a self-insured health care plan. She knows that the disclosure of this information would dramatically skew the insurance risk and insurance costs for this company, which is largely composed of young people who have relatively low health care costs. She might be denied the job for these reasons. The patient wants to undergo BRCA screening but asks you not to note the results in her medical record. You know that her fears are well founded. What should you do?
© 2005 WebMD, Inc. All rights reserved. October 2005 Update
ACP Medicine CE:II Contemporary Ethical and Social Issues in Medicine–1
I I C O N T E M P O R A R Y E T H I C A L A N D S O C I A L I S S U E S I N M E D I C I N E
These examples highlight the complexity of ethical dilem- mas and the need for a common language by which clinicians and society can openly deliberate about ethical issues. Often, there is not a single right answer to an ethical dilemma; in al- most all cases, there are competing values that need to be weighed against each other before a decision is made that most fully upholds the moral values by which physicians must guide their practice. As in many other areas of medicine, there may be a high degree of uncertainty. For that reason alone, it is useful to have a framework for ethical decision making.
A Context and Process for Ethical Decision Making
A conflict of values lies at the center of each ethical dilemma. Most medical ethicists agree that several fundamental ethical norms can be drawn from the overarching principle that pa- tients should be treated with respect. These ethical norms in- clude the responsibility to act in a way that benefits the patient (beneficence); the responsibility, whenever possible, to do no harm (nonmaleficence); the responsibility to acknowledge the autonomy of the patient and his or her right to self-determina- tion; and the responsibility to treat people fairly and equitably. Although it would be hard to argue against any of these values taken individually, they come into conflict with one another every day in medical practice. Three steps are useful for mak- ing decisions when ethical conflicts arise.
First, the clinician needs to gather all available relevant infor- mation regarding the patient. Inadequate information can re- sult in decisions that do not reflect the interests and desires of the patient. However, the clinician must be aware that cultural differences and language barriers may limit a patient’s under- standing of the choices that need to be addressed.3 Key infor- mation includes not only information about the medical condi- tion of the patient but also information about the patient’s val- ues and preferences, the family…