Ethical and Professionalism Implications of Physician Employment and Health Care Business Practices: A Policy Paper From the American College of Physicians.

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.

[Previous experiences of Japanese children with parents who have a mental illness, and their consultation situation at school: A survey of grown-up children].

Objectives　The purpose of this study was to understand the experience of grown-up children with parents suffering from mental illness during their elementary, junior high, and high school years, and the consultation situations at their schools.Methods　A web-based questionnaire survey was conducted on 240 grown-up children who had participated in groups for children with parents suffering from mental illness. The analysis was a simple tabulation and compared the consultation history inside and outside the school environment, according to the respondent's age. Free-response descriptions were categorized according to the content.Results　A total of 120 respondents answered, ranging in age from 20 to over 50 years, with the majority being women (85.8%). Their mothers were the most likely parent to suffer from a mental illness (67.5%), and their estimated age at illness onset was before entering elementary school (73.1%).　During their elementary, junior high, and high school years, 57.8-61.5% of the respondents provided emotional care, and 29.7-32.1% did household chores. When they were in elementary school, most recognized adult fights (62.4%) and experienced attacks by parents (51.4%). Signs that others could have noticed included the fact that parents did not visit the school or talk to teachers, being bullied, forgetfulness, absenteeism, arriving late for school, and academic deterioration. Nearly half of the respondents (43.2-55.0%) hid their challenges during their elementary, junior high, and high school years. They were aware of teachers' prejudice towards mental illness, discriminatory behavior, and lack of consideration for privacy. At the same time, many respondents wanted teachers to be concerned about their circumstances and listen to their stories.　More than half of the respondents (62.7-80.7%) did not approach school staff, who did not notice their problems. When they were high school students, they had an inadequate consultation environment or were unprepared to consult. The easiest person to approach was the teacher in charge.Conclusion　Children with parents suffering from a mental illness were those most in need of support, while being the least connected to sources of support. Schools need to support children to become aware of their problems at home, and teachers need to pay more attention to their students, and listen to them carefully, including to what they may not say.

Emergency physician care of family members, friends, colleagues and self.

Emergency Physicians are frequently called upon to treat family members, friends, colleagues, subordinates or others with whom they have a personal relationship; or they may elect to treat themselves. This may occur in the Emergency Department (ED), outside of the ED, as an informal, or "curbside" consultation, long distance by telecommunication or even at home at any hour. In surveys, the vast majority of physicians report that they have provided some level of care to family members, friends, colleagues or themselves, sometime during their professional career. Despite being common, this practice raises ethical concerns and concern for the welfare of both the patient and the physician. This article suggests ethical and practical guidance for the emergency physician as to how to approach these situations.

Understanding Conscience as Integrity: Why Some Physicians Will Not Refer Patients for Ethically Controversial Practices.

The moral pluralism of Western democratic societies results in ethical differences among citizens and health professionals, due to contrasts between the foundational beliefs and values on which their ethical convictions rest. Some of these differences have challenging implications for the practice of medicine when a patient seeks access to a legal medical service that a conscientiously acting physician believes is unethical. Such disagreements raise pivotal questions about competing ethical values, the moral dynamic of shared decision-making, the meaning of conscience, and the extent to which society will accept ethical differences in professional practice. The act of referral is the focal point of this essay, because it appears to be at the front line of some current debates and legal contests about the extent to which society is willing to accommodate conscientious practice by physicians. Some see referrals as a way to balance respect for physician integrity with promotion of patient autonomy; others see referrals as a mistaken attempt at compromise that misunderstands the meaning of moral responsibility and participation. Understanding conscience as integrity helps explain the moral seriousness of conscientious practice and reinforces the need for professional and legal accommodations that respect it.

Reflective Capacity: An Antidote to Structural Racism Cultivated Through Mental Health Consultation.

Effecting a paradigm shift from "reproductive health" to "reproductive justice" within the perinatal field requires changes simultaneously at the levels of the individual healthcare provider and the system of care. The Infant-Parent Program at the University of California, San Francisco (UCSF) has extended its pioneering infant and early childhood mental health consultation to perinatal service systems applying an infant mental health approach to programs caring for expecting and new parents. In partnership with two nursing programs, UCSF consultants direct their efforts at supporting reflective practice capacities and use-of-self in patient-provider relationships. Both nursing programs serve vulnerable groups of expectant and new parents who grapple with challenges to health and well-being stemming from structural racism. As reflective capacities are supported within the consultation case conferences, providers spontaneously identify the need for tools to effectively address issues of race, class, and culture and to combat structural racism throughout the healthcare system. Policies and procedures that uphold structural racism cease to be tolerable to providers who bring their full selves to the work that they are trained to do. Using these nurse consultation partnerships as organizational case studies, this article describes a range of challenges that arise for providers and delineates steps to effective engagement toward reproductive justice.

Llevar a cabo un cambio de paradigma de "salud reproductiva" a "justicia reproductiva" dentro del campo perinatal requiere cambios simultáneamente al nivel individual del proveedor de cuidados de salud y el sistema de cuidado. El Programa Infante-Progenitor de la Universidad de California en San Francisco (UCSF) ha extendido su pionera consulta de salud mental infantil y la primera infancia a sistemas de servicio perinatal con la aplicación de un acercamiento de salud mental infantil a programas que les sirven a progenitores nuevos y que esperan un niño. En colaboración con dos programas de enfermería, los consultores de UCSF dirigen sus esfuerzos al apoyo de las capacidades de la práctica con reflexión y el uso de sí mismo en las relaciones entre proveedor y paciente. Ambos programas de enfermería les sirven a grupos vulnerables de padres nuevos y que esperan los cuales luchan con retos a la salud y el bienestar provenientes del racismo estructural. A medida que las capacidades de reflexión son apoyadas dentro de las conversaciones de casos consultados, los proveedores espontáneamente identifican la necesidad de herramientas para hablar con efectividad de asuntos de raza, clase social y cultura y combatir el racismo estructural dentro del sistema de cuidado de salud. Políticas y procedimientos que sostienen el racismo estructural dejan de ser tolerables para proveedores que se dan por completo al trabajo para el cual han sido entrenados. Por medio de usar estas colaboraciones de consulta con enfermeras como casos de estudio organizacionales, este artículo describe una gama de retos que surgen para los proveedores y delinean los pasos para un involucramiento eficaz hacia la justicia reproductiva.

Procéder à un déplacement de paradigme d'une "santé reproductive" vers une "justice reproductive" dans le domaine périnatal exige des changements à la fois au niveau du service de soin individuel et et du système de soins. Le programme Nourisson-Parent de l'Université de Californie à San Francisco (abrégée avec ses initiales UCSF) aux Etats-Unis a élargi sa consultation pionière de santé mentale du nourrisson et de la petite enfance aux systèmes de soins périnatals en appliquant une approche de santé mentale du nourrissons à des programmes s'occupant de parents attendant un enfant ou à de nouveaux parents. En partenatia avec deux programmes de soins infirmières, les consultants de l'UCSF dirigent leurs efforts vers le soutien de capacités de réflection sur la pratique et l'utilisation de soi dans la relation patient/prestataire. Ces deux programmes de soins infirmiers servent des groupes vulnérables de parents attentant un enfant ou de nouveaux parents qui rencontrent des difficultés et des défis à leur santé et bien-être du fait d'un racisme structural. Puisque les capacités de réflexion sont soutenues au sein des conférences discutant les cas de consultation, les prestataires identifient spontanément le besoin d'outils afin d'aborder de manière efficace les problèmes de race, de classe et de culture et afin de combattre le racisme structurel au sein du système de soins médicaux. Les mesures et les procédures qui maintiennent le racisme structurel cesse d'être tolérable pour les prestataires qui amènent au travail pour lequel ils ont été éduqués leur être tout entier. En utilisant ces partenariat de consultation avec les infirmières en tant qu'études de cas organisationnelles, cet article décrit un éventail de défis qui se posent aux prestataires et présente les étapes nécessaires pour un engagement efficace vers la justice reproductive.

Characteristics Associated with Confidential Consultation for Adolescents in Primary Care.

OBJECTIVE: To examine how provider report of confidential consultation in the electronic health record is associated with adolescent characteristics, health risk factors, and provider training. STUDY DESIGN: This prospective cohort study was conducted as part of a larger study implementing computerized clinical decision support in 2 urban primary care clinics. Adolescents used tablets to complete screening questions for specified risk factors in the waiting room. Adolescent-reported risk factors included sexual activity, substance use, and depressive symptoms. Providers were prompted on encounter forms to address identified risk factors and indicate whether confidential consultation was provided. Provider types included adolescent medicine board certified pediatrics and general pediatrics. Differences in proportions of adolescents reporting risk factors by provider type were assessed using χ2 tests. Associations between adolescent characteristics, risk factors, and provider-reported confidential consultation were examined using logistic regression analyses. RESULTS: The sample included 1233 English and Spanish-speaking adolescents 12-20 years of age (52% female; 60% black; 50% early adolescent). Patients seen by adolescent medicine board certified providers reported sexual activity, depressive symptoms, and substance use significantly more often than those seen by general pediatric providers. Among patients seen by board certified adolescent medicine providers, confidential consultation was provided to 90%. For those seen by general pediatric providers, confidential consultation was provided to 53%. Results of multiple logistic regression demonstrated that female sex, later adolescence, and clinic location were significantly associated with confidential consultation. CONCLUSIONS: Provider training is needed to reinforce the importance of confidential consultation for all adolescents.

Medical Overtreatment: Friend or Foe?

"Overtreatment" is a neologism coined some 15 years ago to denote medical and surgical interventions that are unnecessary. It is a topical term for an old concept. However, it has rapidly become a shibboleth for those inclined toward finger-pointing and blaming in matters of health policy. As such, it is a "foe" that heats up rather than modulates debate. But if one examines the notion in the context of the contemporary patient-physician dialogue, it is anything but a foe. Overtreatment and its fellow travelers, overutilization and overprescription, face off with contrary notions when a patient contends with the challenge of evaluating any clinical option.

Vulnerability in the clinic: case study of a transcultural consultation.

Discrimination and inequalities in healthcare can be experienced by many patients due to many characteristics ranging from the obviously visible to the more subtly noticeable, such as race and ethnicity, legal status, social class, linguistic fluency, health literacy, age, gender and weight. Discrimination can take a number of forms including overt racist statement, stereotyping or explicit and implicit attitudes and biases. This paper presents the case study of a complex transcultural clinical encounter between the mother of a young infant in a highly vulnerable social situation and a hospital healthcare team. In this clinical setting, both parties experienced difficulties, generating explicit and implicit negative attitudes that heightened into reciprocal mistrust, conflict and distress. The different factors influencing their conscious and unconscious biases will be analysed and discussed to offer understanding of the complicated nature of human interactions when faced with vulnerability in clinical practice. This case vignette also illustrates how, even in institutions with long-standing experience and many internal resources to address diversity and vulnerability, cultural competence remains a constant challenge.

Telemedicine and virtual consultation: The Indian perspective.

Telemedicine was considered futuristic and experimental some years ago, but it is a reality today. It is now emerging as an important tool for convenient as well as specialized healthcare, particularly for patients in remote locations with limited access to standardized healthcare services. However, there are multiple challenges to realizing its full potential. We focus on some key medicolegal and ethical issues such as doctor-patient relationship, informed consent, rights of the patient, malpractice, and principles of confidentiality relevant to the practice of telemedicine and virtual consultation. We explore the global as well as the Indian legal perspective pertaining to the application of telemedicine. The absence of specific laws for registration and practice of telemedicine and virtual consul-tation in India acts as a deterrent for medical practitioners to engage in its potential use. Hence, there is a need for specific legislation.

Patient-Driven Second Opinions in Oncology: A Systematic Review.

BACKGROUND: Although patient-driven second opinions are increasingly sought in oncology, the desirability of this trend remains unknown. Therefore, this systematic review assesses evidence on the motivation for and frequency of requests for second opinions and examines how they evolve and their consequences for oncological practice. MATERIALS AND METHODS: Relevant databases were sought using the terms "cancer," "second opinion," and "self-initiated." Included were peer-reviewed articles that reported on patient-initiated second opinions within oncology. Selection, data extraction, and quality assessment were performed and discussed by two researchers. RESULTS: Of the 25 included studies, the methodological designs were qualitative (n = 4), mixed (n = 1), or quantitative (n = 20). Study quality was rated high for 10 studies, moderate for eight, and low for seven studies. Reported rates of second opinion seeking ranged from 1%-88%. Higher education was most consistently related to seeking a second opinion. Patients' primary motivations were a perceived need for certainty or confirmation, a lack of trust, dissatisfaction with communication, and/or a need for more (personalized) information. Reported rates of diagnostic or therapeutic discrepancies between the first and second opinions ranged from 2%-51%. DISCUSSION: Additional studies are required to further examine the medical, practical, and psychological consequences of second opinions for patients and oncologists. Future studies could compare the potential advantages and disadvantages of second opinion seeking, and might offer guidance to patients and physicians to better facilitate the second opinion process. Some practical recommendations are provided for oncologists to optimally discuss and conduct second opinions with their patients. The Oncologist 2017;22:1197-1211 IMPLICATIONS FOR PRACTICE: Although cancer patients increasingly seek a second opinion, the benefits of this process remain unclear. Results of this systematic review suggest that the available studies on this topic are highly variable in both methodology and quality. Moreover, reported rates for a second opinion (1%-88%) as well as for disagreement between the first and second opinion (2%-51%) range widely. The primary motivations of patients are a need for certainty, lack of trust, dissatisfaction with communication, and/or a need for more (personalized) information. Additional research should evaluate how unnecessary second opinions might be avoided. Practical suggestions are provided for oncologists to optimize second opinions.

Conscientious objection in healthcare and the duty to refer.

Although some healthcare professionals have the legal right to conscientiously object to authorise or perform certain lawful medical services, they have an associated duty to provide the patient with enough information to seek out another professional willing to authorise or provide the service (the 'duty to refer'). Does the duty to refer morally undermine the professional's conscientious objection (CO)? I narrow my discussion to the National Health Service in Britain, and the case of a general practitioner (GP) being asked by a pregnant woman to authorise an abortion. I will be careful not to enter the debate about whether abortion should be legalised, or the debate about whether CO should be permitted-I will take both as given. I defend the objecting GP's duty to refer against those I call the 'conscience absolutists', who would claim that if a state is serious enough in permitting the GP's objection in the first place (as is the UK), then it has to recognise the right to withhold any information about abortion.

Conscientious objection in healthcare, referral and the military analogy.

An analogy is sometimes drawn between the proper treatment of conscientious objectors in healthcare and in military contexts. In this paper, I consider an aspect of this analogy that has not, to my knowledge, been considered in debates about conscientious objection in healthcare. In the USA and elsewhere, tribunals have been tasked with the responsibility of recommending particular forms of alternative service for conscientious objectors. Military conscripts who have a conscientious objection to active military service, and whose objections are deemed acceptable, are required either to serve the military in a non-combat role, or assigned some form of community service that does not contribute to the effectiveness of the military. I argue that consideration of the role that military tribunals have played in determining the appropriate form of alternative service for conscripts who are conscientious objectors can help us to understand how conscientious objectors in healthcare ought to be treated. Additionally, I show that it helps us to address the vexed issue of whether or not conscientious objectors who refuse to provide a service requested by a patient should be required to refer that patient to another healthcare professional.

Conscientious Objection and "Effective Referral".

Complicity in an immoral, and even criminal, activity, such as robbery or murder, is itself regarded as involving responsibility for those acts. What should the position be of health professionals who are expected to participate in actions that they believe are morally wrong? Professional responsibilities may clash with private conscience. Even referring a patient to someone else, when what is in question may be assisted suicide, or euthanasia, seems to involve some complicity. This is a live issue in Canada, but similar dilemmas occur elsewhere. Physicians and others should not be coerced into involvement of any kind in what they regard as wrong. Such coercion goes against the very principles of liberal democracy. Conscience matters. Reasonable accommodation should be given to those whose moral judgment may be at variance with prevailing professional norms. Moral questions should still be given weight within medicine, and disagreements respected. Dedication to the promotion of human welfare should be paramount, but it should be recognized that there may be different visions of what such welfare consists of.

Conscientious Objection, Complicity in Wrongdoing, and a Not-So-Moderate Approach.

This article analyzes the problem of complicity in wrongdoing in the case of healthcare practitioners (and in particular Roman Catholic ones) who refuse to perform abortions, but who are nonetheless required to facilitate abortions by informing their patients about this option and by referring them to a willing colleague. Although this solution is widely supported in the literature and is also widely represented in much legislation, the argument here is that it fails to both (1) safeguard the well-being of the patients, and (2) protect the moral integrity of healthcare practitioners. Finally, the article proposes a new solution to this problem that is based on a desirable ratio of conscientious objectors to non-conscientious objectors in a hospital or in a given geographic area.

Second Medical Opinions in End-of-Life Disputes in Critical Care: An Ethics-Based Approach.

Requests for a second medical opinion (SMO) by patients or substitute decision-makers (SDMs) can arise during end-of-life disputes in critical care. Such disagreements between patients or SDMs and physicians often pertain to specific elements of the decision-making process related to withholding or withdrawing of life-sustaining treatments. When these disputes occur in the critical care setting in Canada, practicalities and policy barriers prevent an SDM from obtaining an SMO without support from healthcare providers; moreover, in a majority of these cases the SDM will require the facilitation of a physician who is often the same individual with whom they are in conflict. Institutional and a national society's policy statements propose SMOs as an important component of a conflict resolution process for end-of-life disputes (Bosslet et al. 2015; Singer et al. 2001). However, these policies do not provide specific guidance to physicians on how to fairly consider SMO requests. Given the vulnerable position of patients and their SDMs in the critical care context and in order to promote fairness, physicians should apply consistent standards in deciding whether to facilitate a request for an SMO. To guide physicians' decision-making and inform future policy development, we propose three ethical principles for considering SDM requests for an SMO in critical care at the end of life.

Fiduciary disparity clarity: Ethics of divided allegiances.

An experienced senior vascular surgeon, Dr H. O. Nest, at a university medical center is asked to evaluate a patient with a rare complex vascular problem. The patient is a high-ranking university official, Mr N. Otable, well known to all in the university setting. Dr Nest has had very limited experience with the condition. He has viewed presentations about it but is aware of a world expert at another institution. He discusses transfer with the patient, who agrees on that approach. Later that day, when Dr Nest receives a visit from the Chief-of-Staff and the hospital CEO asking about Mr Otable, they are very concerned that transfer will reflect badly on the medical center's reputation. Dr Nest is strongly requested to reconsider his recommendation--almost at gunpoint. What should he do? A. If he believes that the outcome will be satisfactory, he should schedule the operation. B. He should explain the situation to the patient and let him choose where he wishes to have his surgery. C. He should continue with the plan to refer the patient to another center. D. He must understand his limits and base his decision accordingly. E. He should arrange a conference with the surgeons in the vascular division and the administrators.

The ethics of insurance limiting institutional medical care: It's all about the money.

Dr F. Inest practices surgery at a renowned medical center but is concerned because increasing numbers of medical insurers are excluding his institution from coverage. Many of his former referring physicians are beginning to send their patients elsewhere for this reason. The marketing people have been busy increasing their advertising buys and exploring new business models. There is even talk about reducing expensive clinical trials. However, regardless of his affiliation, he has little control over these and other organizational decisions that directly impact his practice clinically and fiscally. What should he do?

What kinds of cases do paediatricians refer to clinical ethics? Insights from 184 case referrals at an Australian paediatric hospital.

Clinical ethics has been developing in paediatric healthcare for several decades. However, information about how paediatricians use clinical ethics case consultation services is extremely limited. In this project, we analysed a large set of case records from the clinical ethics service of one paediatric hospital in Australia. We applied a paediatric-specific typology to the case referrals, based on the triadic doctor-patient-parent relationship. We reviewed the 184 cases referred to the service in the period 2005-2014, noting features including the type of case, the referring department(s) and the patient's age at referral. The two most common types of referral involved clinician uncertainty about the appropriate care pathway for the child (26% of total referrals) and situations where the child's parents disagreed with the doctors' recommendations for the child's care (22% of total referrals). Referrals came from 28 different departments. Cancer, cardiology/cardiac surgery and general medicine referred the highest numbers of cases. The most common patient age groups were children under 1, and 14-15 years old. For three controversial areas of paediatric healthcare, clinicians had initiated processes of routine review of cases by the clinical ethics service. These insights into the way in which one very active paediatric clinical ethics service is used further our understanding of the work of paediatric clinical ethics, particularly the kinds of ethically challenging cases that paediatricians view as appropriate to refer for clinical ethics support.

US primary care physicians' opinions about conscientious refusal: a national vignette experiment.

OBJECTIVE: Previous research has found that physicians are divided on whether they are obligated to provide a treatment to which they object and whether they should refer patients in such cases. The present study compares several possible scenarios in which a physician objects to a treatment that a patient requests, in order to better characterise physicians' beliefs about what responses are appropriate. DESIGN: We surveyed a nationally representative sample of 1504 US primary care physicians using an experimentally manipulated vignette in which a patient requests a clinical intervention to which the patient's physician objects. We used multivariate logistic regression models to determine how vignette and respondent characteristics affected respondent's judgements. RESULTS: Among eligible respondents, the response rate was 63% (896/1427). When faced with an objection to providing treatment, referring the patient was the action judged most appropriate (57% indicated it was appropriate), while few physicians thought it appropriate to provide treatment despite one's objection (15%). The most religious physicians were more likely than the least religious physicians to support refusing to accommodate the patient's request (38% vs 22%, OR=1.75; 95% CI 1.06 to 2.86). CONCLUSIONS: This study indicates that US physicians believe it is inappropriate to provide an intervention that violates one's personal or professional standards. Referring seems to be physicians' preferred way of responding to requests for interventions to which physicians object.

Accompanied consultations in occupational health.

BACKGROUND: Accompanied consultations are often reported as difficult by occupational physicians but have not been studied in the occupational health setting. AIMS: To collect information about accompanied consultations and the impact of the companion on the consultation. METHODS: We collected data on all accompanied consultations by two occupational physicians working in a private sector occupational health service over the course of 16 months. Accompanied consultations were matched to non-accompanied consultations for comparison. RESULTS: We collected data on 108 accompanied consultations. Accompanied consultations were more likely to be connected with ill health retirement (P < 0.01), have a neurological diagnosis or multiple diagnoses (P < 0.01), be rated as complex (P < 0.01) and take longer than 30 minutes (P < 0.01) than non-accompanied consultations. Over half of the companions (54%) were a spouse or partner. An impact by the companion was recorded in 81% of consultations but this was most frequently that they had provided information (56%) and in over a quarter the impact was recorded as helpful. Interruptions were recorded in 28% of accompanied consultations but only 6% of consultations had free text suggesting that the consultation or companion was difficult. CONCLUSIONS: Accompanied consultations are likely to be more challenging in terms of the reason for referral, the presenting medical problems, the complexity of the case and the duration of the consultation. However, the companion is more likely to be of benefit than cause difficulty. Occupational health practitioners may benefit from better understanding of accompanied consultations and guidance on their management.