Title: Professionalism

Title: Professionalism

Learning Objectives:

1. Define the qualities of professionalism and what it means to be part of a profession.
2. Identify medical errors and how to handle them.
3. Understand the issues involved in “gaming” the system.
4. Recognize conflicts of interest and understand their implications.

Author:Rosemarie L. Conigliaro, MD

Associate Professor of Medicine

Associate Program Director, Internal Medicine Training Program

University of Kentucky

Kentucky Clinic K-518

740 South Limestone Street

Lexington, Kentucky 40536

859-323-6642

Case 1

You areseeing a 38 year old female patient that you have been following for severalyears. She comes to see you for complaints of fatigue, poor sleep, restlessness and mood irritability. After an appropriate history and physical, you both decide that she is probably depressed, and you prescribe an antidepressant medication that she is agreeable to take. She asks you, however, not to use the diagnosis of depression in her chart so that she does not carry that label. What do you do?

Case 1: Options

1. Agree, and use the diagnosis of “hypothyroidism” even though she had a normal TSH last year.

1. As #1, above, but then change the diagnosis to depression after the patient leaves the clinic.

1. Explain to the patient that this is the most likely diagnosis, that it is an acceptable medical diagnosis, and the most appropriate diagnosis for you to use in her chart.

1. Tell her that since she cannot accept you using “depression” as the correct diagnosis, you cannot give her the prescription for antidepressant medication.

Case 1: Answers

1. Incorrect.

Comment: Physicians have an obligation to be accurate in their chart documentation. Documenting incorrectly can have potential adverse consequences for the patient, as well as be misleading for any other health care provider who may care for that patient.

2. Incorrect.

Comment: This would not only be lying in the documentation, but also deceiving to the patient.

3. Correct.

Comment: This allows the physician to educate the patient about chart access, as well as identifies for the patient the issues surrounding being given a diagnosis of depression.

4. Incorrect.

Comment: This tactic abandons the patient and does not allow her to get the care that she needs.

Case 1: Explanation

Professionalism is the basis of medicine’s contract with society. The terms of this contract demand that the physician maintain standards of excellence in providing care to his/her patients. According to the ACP-ASIM Physician Charter on Professionalism , the first principle of professional behavior is the primacy of patient welfare. This means that we must serve the interest of our patients before our own. When we take the Hippocratic Oath we commit to honesty and integrity with our patients. Lying within the context of the doctor-patient relationship hurts not only our patients, but us, our colleagues and, indeed, the entire profession. Society as a whole and individual patients rely on a system in which they can trust their doctor to tell them the truth. Lack of commitment to honesty damages the integrity of the individual physician as well as the profession to which he belongs.

Patients should expect physicians to tell the truth in their medical record. Without a policy of truth telling in documentation, patients would not be able to trust their physicians or their records. This, in turn, would make it very difficult for physicians to advocate for their patients when necessary or appropriate. Worry about potential future issues in terms of access and stigma (for example, when applying for life insurance or employment) is never a reason to document anything other than what really occurred.

Case 2

You are a PGY-1 on a busy medical service. Your son is performing in a school play this afternoon and you planned on leaving early to attend the play. As you are finishing up your work and preparing to sign out, you get a call that one of your patients is becoming unstable. As the bedside, it is clear that he needs to go to the intensive care unit, and there are many issues that need to be taken care for that to happen. Your resident is in clinic. The night float intern is not due for several hours. What do you do?

Case 2: Options

1. Get the on call intern to stay with the patient until he is safely transferred to the MICU.

2. Call your resident and tell her that you need to leave and ask her what you should do.

3. Call the chief medical resident and tell them your situation and ask them for help.

4. Stay with the patient and do what needs to be done until he is safely transferred to intensive care or your resident returns from clinic, even if it means missing your son’s performance.

Case 2: Answers

1. Incorrect.

Comment: This is reneging on your responsibility to the patient.

2. Incorrect.

Comment: Although your resident has responsibility for this patient as well, it your primary responsibility to care for this patient. The resident’sprimarily responsible is to his clinic patients at this time.

3. Incorrect.

Comment: Although this is an option, it does not ascribe to the commitment to one’s professional responsibility and reliability towards patients.

4. Correct.

Comment: As a member of the medical profession, your obligation is to patient care over personal priorities and self-interest.

Case 2: Explanation

In real life, one is likely to do several of the options listed above, as there is often no single or right answer that will apply in every situation. All of the options listed allow for care of the patient without abandonment; the ideal resolution of this dilemma would ensure appropriate care for the patient, while potentially allowing for the fulfillment of family responsibilities as well.

A profession is a complex social structure that allows for the distribution of specialized and complex knowledge and services to individuals and society. Professionals enter into a contract whereby they agree to adhere to high ethical and moral standards, practice humanistic values of honesty, integrity and respect, exercise accountability for their behavior, and subordinate their own interests to the interests of others. Although there are many privileges which go along with being part of a profession, there are also many responsibilities.

The ABIM designates altruism as the essence of professionalism. Duty, another component of professionalism, entails being available and responsive when “on call”, and, at times, accepting inconvenience to meet the needs of one’s patients (From ABIM Project Professionalism at However, recently, work hour restrictions have been put into place for doctors-in-training in an effort to minimize sleep deprivation and improve the quality of patient care; this may also, additionally, improve the trainees’ quality of life.Physicians may find themselves struggling to maintain a balance between work and personal life, and between duty and duty-hour restrictions. Physicians as a profession are coming to an understanding of the importance of self-care. However, thistension between physicians’ commitment to fully care for their patients when on duty and their necessary attention to their personal life may continue to generate internal as well as situational conflicts.

Case 3

You are seeing one of your partner’s patients, as she is on a 2-week vacation. The patient is a 63 year old male complaining of several weeks of cough with wheezing, and occasional blood-tinged sputum. He had a similar episode about a year ago for which he saw his doctor, had a chest x-ray, and was given a course of antibiotics. Since he is a former smoker, and admits to a 10-pound weight loss, you decide to send him for a chest x-ray. You are called later by the radiologist regarding a RUL mass that is now larger than when seen on chest film one year ago. Puzzled, you look in the patient’s chart and discover that the chest x-ray report from the previous year was filed in the chart without being reviewed, and your partner’s note makes no mention of the findings. What should you do?

Case 3: Options

1. Give the patient appropriate treatment for his symptoms but wait until your partner comes back from vacation to have her tell the patient the x-ray results.

2. Tell the patient about the findings and arrange for work-up without mentioning the previous x-ray

results.

3. Tell the patient about the findings of this and the previous x-ray and arrange for work-up. Defer all questions about the previous x-ray to your partner, asking the patient to save this discussion until his doctor returns from vacation.

4. Admit the oversight to the patient. Explain the findings of both x-rays and the possible implications. Arrange for work-up. Allow the patient time to ask questions and explore the issues involved.

Case 3: Answers

1. Incorrect.

Comment: This will delay work-up as well as ignore the problem.

2. Incorrect.

Comment: The AMA’s “Code of Medical Ethics”< makes clear that physicians have an obligation to reveal medical errors and mistakes to patients.

3. Incorrect.

Comment: Per the AMA, physicians are ethically required to inform patients of all the facts necessary to ensure their understanding of their care.

4. Correct.

Comment: According to the ACP’s “Ethics Manual < this patient has both an ethical and legal right to information regarding errors made in his care.

Case 3: Explanation

Disclosure of errors in medical care is very difficult for many physicians. This is due to many factors including fear of liability, shame, and inadequate training in admitting to and discussing medical errors. Communicating quickly and honestly with patients about errors in their care will help to maintain patient trust in their physician and the medical system. Additionally, open communication allows for discussion of the emotional fallout that often follows a mistake including fears and anxiety, and helps to work toward restoring patient satisfaction and trust. The Institute of Medicine, in their 1999 report on medical errors and patient safety, concluded that most medical errors are systems related and not the result of individual neglect, malice, laziness or greed < This implies that system changes can decrease the number of medical errors. Reporting errors promptly and working through proper channels will expedite system changes.

In this case, you are obligated to reveal even someone else’s mistake to the patient. If you can reach your partner you can give her the option to tell the patient herself. Additional follow-up to this case requires review of the office’s practices regarding notification and filing of reports of diagnostic studies. System changes are likely to prevent errors like this one from happening again

Case 4

You are seeing a 50 year old male for follow upof hypertension. He asks you about colon cancer screening and you have a discussion of the various screening options. He would like to have a screening colonoscopy, but his insurance company will not pay if it is for screening purposes. Which of the following options should you chose?

Case 4: Options

1. Discuss other screening options with the patient, including how much they might cost the patient, and help the patient decide which option he could choose.

2. Write on the requisition that the patient is having GI bleeding to get the colonoscopy covered.

3. Tell the patient that he doesn’t need a colonoscopy

4. Tell the patient that you believe that colonoscopy is the best screening test and that you think he should have it done despite the cost.

.

Case 4: Answers

1. Correct.

Comment: This allows the doctor and the patient to make an informed decision together, and allows the patient to participate in shared decision making.

2. Incorrect.

Comment: It is unethical to lie on the requisition form, even though the intention, getting the patient an appropriate screening test, is well-meant.

3. Incorrect.

Comment: Telling the patient that he does not need a colonoscopy does not fulfill the physician’s obligation to provide optimal care to the patient.

4. Incorrect.

Comment: Insisting that the patient have the colonoscopy displays a paternalist attitude that doesn’t involve the patient in an informed decision-making process.

Case 4: Explanation

Physicians work in situations where third party payers and utilization review systems may seem to thwart physicians’ efforts to do the best for their patients. They may find themselves caught between contractual restrictions and their fiduciary role. Physicians can often find ways to get around these restrictions, while still appearing to work within the system. Many physicians report manipulating reimbursement rules in an effort to get services for their patients. However, minor “fudging” may inexorably lead to flagrant lying and fraud. “Gaming” the system can result in harm to that patient, other patients, and the system as a whole. Physicians have a responsibility to advise their patients regarding the economic constraints of the current health care system, and to help their patients take a more active role in health care choices. Physicians must also advocate for their patients (another component of professionalism) by working to change the health care system to secure health care more judiciously.

In this case, as in the first case, the documentation in the patient’s chart should reflect the true situation, as potential and unforeseeable harms may come as a result of falsifying information. Additionally, a stronger patient-physician relationship may come about as a result of working together to find the best test that suits each patient’s means and preferences. Lastly, the physician, alone or as part of a group (eg. local medical society), may petition the insurance company and work to make changes in the insurance plan’s coverage.

Case 5

You are seeing a patient who is complaining of low back pain, with pain and numbness down his leg. His exam is consistent with a herniated disc at L5-S1, and you are considering obtaining an MRI. However, he has no neurologic findings, and you have not yet tried conservative therapy. The patient lives near a diagnostic facility at which your wife works as a radiologist, and you have holdings in that company. You order the MRI, telling the patient that it will better help you manage his LBP.

Case 5: Options

Which one of the following statements are correct?

1. You have not done anything wrong, since the patient may eventually need an imaging study, and you are just being efficient by getting it now.

2. You are not harming the patient, since the study is non-invasive, so you and the patient come out ahead.

3. You are breaching your commitment to do the best for the patient by the use of referrals to an institution in which you have a financial interest.

4. There is no conflict of interest since you do not directly benefit from the patient’s MRI unless the facility is in the black at the end of the year.

Case 5: Answers

1. Incorrect.

Comment: If you are basing your decision on potential economic gains you may be more likely to make decisions that are not absolutely in the best interests of your patient.

2. Incorrect.

Comment: According to the AMA Council on Ethics and Judicial Affairs “physicians should not refer patients to a health care facility outside their office practice when they have an investment interest in the facility”.

3. Correct.

Comment: As professionals, physicians are obligated to avoid situations that benefit them personally via their ability to refer patients. This constitutes a conflict of interest.

4. Incorrect.

Comment: A conflict of interest occurs when a physician’s professional judgement is influenced by a secondary interest. In the case above, the potential for economic gain distorts the physician’s decision-making capacity, whether or not that gain is ever realized.

Case 5: Explanation

A conflict of interest is defined as a set of conditions in which professional judgement concerning a primary interest (patient welfare, research validity, educational integrity) is unduly influenced by a secondary interest (financial gain, publication, recognition). The physician’s primary interest is determined by his/her professional duties. Physicians are involved in activities of highest standards, as they are the fiduciaries of their patients. In this capacity, physicians hold the trust of their patients and society: even the appearance of impropriety may be damaging to that trust. Thus, even the failure to avoid a conflict of interest may have negative consequences, even if no secondary gain occurred.

The professional breach in this case is that, by referring to a facility in which you have a financial interest, you may order excessive or unnecessary tests, or send the patient to a less-than-optimal place or specialist for care. Physicians cannot allow personal gain to influence their judgement about what constitutes appropriate care for their patients.