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.

The Corporate Practice of Medicine: Ethical Implications of Orthopaedic Surgery Practice Ownership by Non-Physicians.

There has been an upsurge in the number of practices owned by non-physicians. With orthopaedic surgery as the next frontier in this market, orthopaedists need to consider the ethical consequences of such acquisitions. The history and trends of practice ownership are reviewed alongside how laws shifted to reflect a changing health-care climate. The 4 tenets of bioethics (beneficence, nonmaleficence, autonomy, and justice) are explored with regard to practice acquisition by non-physician entities. Although non-physician-owned corporations and private equity firms provide liquidity to the health-care sector, there are ethical concerns that may ultimately impact patient care. Orthopaedic surgeons must be cautious when engaging in acquisitions with non-physician-owned entities, as the goals of each party may not align. This may yield situations that infringe on the basic principles of bioethics for both physician and patient.

Adherencia a la dieta mediterránea en pacientes diabéticos con mal control / Adhesion to the Mediterranean diet in diabetic patients with poor control

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SCAI/ACVP expert consensus statement on cardiovascular catheterization laboratory economics: If the cath lab is your home you should understand its finances: This statement was endorsed by the Alliance of Cardiovascular Professionals (ACVP) in April 2019.

This article is intended for any physician, administrator, or cardiovascular catheterization laboratory (CCL) staff member who desires a fundamental understanding of finances and economics of CCLs in the United States. The authors' goal is to illuminate general economic principles of CCL operations and provide details that can be used immediately by CCL leaders. Any article on economics in medicine should start by acknowledging the primacy of the principles of medical ethics. While physicians have been trained to act in the best interests of their patients and avoid actions that would harm patients it is vitally important that all professionals in the CCL focus on patients' needs. Caregivers both at the bedside and in the office must consider how their actions will affect not only the patient they are treating at the time, but others as well. If the best interests of a patient were to conflict with any recommendation in this article, the former should prevail. KEY POINTS: To be successful and financially viable under current payment systems, CCL physicians, and managers must optimize the outcomes and efficiency of care by aligning CCL leadership, strategy, organization, processes, personnel, and culture. Optimizing a CCL's operating margin (profitability) requires maximizing revenues and minimizing expenses. CCL managers often focus on expense reduction; they should also pay attention to revenue generation. Expense reduction depends on efficiency (on-time starts, short turn-over time, smooth day-to-day schedules), identifying cost-effective materials, and negotiating their price downward. Revenue optimization requires accurate documentation and coding of procedures, comorbidities, and complications. In fee-for-service and bundled payment reimbursement systems, higher volumes of procedures yield higher revenues. New procedures that improve patient care but are expensive can usually be justified by negotiating with vendors for lower prices and including the "halo effect" of collateral services that accompany the new procedure. Fiscal considerations should never eclipse quality concerns. High quality CCL care that prevents complications, increases efficiency, reduces waste, and eliminates unnecessary procedures represents a win for patients, physicians, and CCL administrators.

La comunicación del error médico. Consecuencias éticas y médico-legales / Medical errors communication. Ethical and medicolegal issues

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La ètica de la ignorància (i de la incertesa) i la iatrogènia, un problema de salut pública / La ética de la ignorancia (y de la incertidumbre) y la iatrogenia, un problema de salud pública / The Ethics of Ignorance (and Uncertainty) and Iatrogenesis, a Public Health Problem

La iatrogènia és, actualment, un dels principals problemes de salut pública, que acostumem a atribuir exclusivament a errors i negligències, menyspreant l'exagerat intervencionisme sanitari a causa del consumisme i també negant la ignorància i amb poca tolerància de la incertesa. La consideració dels dubtes i de les equivocacions des d'una perspectiva ètica pot contribuir a la millor comprensió i prevenció dels danys associats a la pràctica mèdica i sanitària mitjançant la promoció de la prudència com a valor essencial de qui ha de prendre decisions sobre la salut i les malalties de les persones i les comunitats

La iatrogenia es actualmente uno de los principales problemas de salud pública, que acostumbramos a atribuir exclusivamente a errores y negligencias, menospreciando el exagerado intervencionismo sanitario promovido por el consumismo y también debido a la negación de la ignorancia y a la intolerancia de la incertidumbre. La consideración de las dudas y de las equivocaciones desde una perspectiva ética puede contribuir a la mejor comprensión y prevención de los daños asociados a la práctica médica y sanitaria mediante la promoción de la prudencia como valor esencial de quienes que han de tomar decisiones sobre la salud y las enfermedades de las personas y las comunidades

Iatrogenesis is now, one of the main public health problems, which we tend to attribute exclusively to errors and negligence, belittling the exaggerated health interventionism promoted by consumerism and also due to the denial of ignorance and the intolerance of uncertainty. The consideration of doubts and mistakes from an ethical perspective can contribute to the better understanding and prevention of the damages associated with medical and public health practice by promoting prudence as an essential value of those who have to make decisions on people's health

Nurturing the Virtues: Upholding Professionalism in the Midst of Busy Medical Practice.

Tom L. Beauchamp and James F. Childress' (B&C) book Principles of Biomedical Ethics is well known for its four-principle approach to biomedical ethics. However, the authors also emphasize the importance of the virtues of health care personnel. After a short overview of virtue ethics, the five "focal virtues" described by B&C are discussed and applied to a chronic pain example. The question of how virtues are learned in the health care setting is addressed, and it is argued that virtues such as the ones defended by B&C are acquired when health care personnel are socialized in an environment dedicated to the continuous upholding of practices that aim at the telos of medicine. Viewed from this perspective, professional isolation can be considered to be dangerous; the upholding of medical professionalism throughout a whole career largely presupposing the existence of a community where virtues relevant to the practice of medicine are embodied and kept alive. The concept of professional socialization is important in that respect. Finally, some potential general implications of this view for continuing professional development are proposed.

American College of Physicians Ethics Manual: Seventh Edition.

Medicine, law, and social values are not static. Reexamining the ethical tenets of medicine and their application in new circumstances is a necessary exercise. The seventh edition of the American College of Physicians (ACP) Ethics Manual covers emerging issues in medical ethics and revisits older ones that are still very pertinent. It reflects on many of the ethical tensions in medicine and attempts to shed light on how existing principles extend to emerging concerns. In addition, by reiterating ethical principles that have provided guidance in resolving past ethical problems, the Manual may help physicians avert future problems. The Manual is not a substitute for the experience and integrity of individual physicians, but it may serve as a reminder of the shared duties of the medical profession.

La atención al final de la vida: deliberando sobre hechos y valores / End of life care: deliberating on facts and values

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El internista como consultor de ética clínica: un antídoto contra "la barbarie delespecialismo" en la práctica hospitalaria / The internist as clinical ethics consultant: An antidote to "the barbarism of specialization" in hospital practice

El desarrollo de la ética clínica hospitalaria en España depende casi exclusivamente de los comités de ética asistencial. Estos han sido criticados por su falta de cercanía a la cabecera del paciente en los conflictos éticos cotidianos y por su escasa operatividad práctica, que se refleja en el escaso número de consultas que reciben. En el presente trabajo reflexionamos sobre la necesidad de modificar el modelo actual de atención en ética clínica para reactivarlo y llamar la atención sobre el papel primordial del internista como motor de dicho cambio. Para ello proponemos un modelo en que los comités de ética asistencial incorporen consultores de ética, mejor posicionados para la discusión de casos a la cabecera del enfermo. Seguidamente analizamos las características que dichos consultores deberían poseer

The development of hospital clinical ethics in Spain depends almost exclusively on the healthcare ethics committees, which have been criticized for a lack of proximity to the patient's bedside in day-to-day ethical conflicts and for their scarce practical operation, reflected in the low number of consultations they receive. In this study, we reflect on the need to change the current healthcare model in clinical ethics so as to reactivate it and call attention to the essential role of internists as the engine for this change. To this end, we propose a model in which the healthcare ethics committees incorporate ethics consultants, who are better positioned to discuss cases at the patient's bedside. We then analyse the characteristics that these consultants should have

Estressors ètics i atenció sanitària. Anàlisi d'estressors ètics en l'àmbit del CèAVOC (Comitè d'Ètica Assistencial del Vallès Oriental Central) Ethical stressors and healthcare / Análisis de estresores éticos en el ámbito del CèAVOC (Comité de Ética Asistencial del Vallés Oriental Central) / Analysis of ethical stressors within the CèAVOC (Healthcare Ethics Committee from Vallès Oriental Central) Estresores éticos y atención sanitaria

La pràctica mèdica i l'atenció al pacient poden estar associades a conflictes d'índole diversa: personals, professionals, ètics. Les polítiques d'austeritat derivades dels reajustaments econòmics arran de la crisi global han vingut a incrementar aquests conflictes. Amb intenció de detectar, definir i proposar solució a alguns d'ells, el CèAVOC va promoure un debat que va generar un treball de prospecció en l'entorn laboral dels seus membres, per esbrinar la realitat quotidiana i els principis ètics que aquesta vulnerava. Es van identificar múltiples factors estressors ètics. De l'anàlisi d'ells se'n desprèn un increment de sensació de vulnerabilitat personal i social. Es fa necessària una major implicació dels professionals de la salut en la gestió sanitària des de la visió de servei a les persones

La práctica médica y la atención al paciente pueden estar asociadas a conflictos de distinta índole: personales, profesionales, éticos. Las políticas de austeridad derivadas de los reajustes económicos a raíz de la crisis global han incrementado estos conflictos. Con intención detectar, definir y proponer solución a algunos de ellos, el CèAVOC promovió un debate que generó un trabajo de prospección en el entorno laboral de sus miembros, para averiguar la realidad cotidiana y los principios éticos que ésta vulneraba. Se identificaron múltiples factores estresores éticos. De su análisis se desprende un incremento de sensación de vulnerabilidad personal y social. Se hace necesaria una mayor implicación de los profesionales de la salud en la gestión sanitaria des de la visión de servicio a las personas

Medical practices and patient's care activities may be associated with conflicts of different nature, such as personal, professional, or ethical. These conflicts, furthermore, may have even increased due to the arrival of austerity policies devised to deal with the effects of the global economic crisis. With the purpose of detecting, defining and proposing solutions to some of these conflicts, CèAVOC encouraged a debate, which afterwards resulted in exploring its staffs' work environment, in examining their daily realities as well as the ethical principles that affected them. Multiple ethical stressor factors were identified, one of which reflected higher awareness of their personal and social vulnerability. It seems necessary that health professionals are deeper involved in the management of health by adopting a patient service approach

Dilemas éticos en la práctica de la medicina infantil / Ethical dilemmas in practice of medicine child

Tras revisar la bibliografía existente en los últimos 20 años se aprecia un déficit de información sobre los conflictos éticos que afectan a los pediatras en su práctica diaria lo que provoca cierto grado de incertidumbre en estos profesionales a la hora de resolver estos problemas. Por este motivo se realizó una búsqueda sistemática en las principales bases de datos encontrando más de 150 artículos relacionados con este asunto, de los que se seleccionaron 80 considerados como los más relevantes. Tras estudiarlos, se encontraron 40 dilemas éticos relacionados con algún principio de solución y que se describen en este artículo. Entre ellos destacan algunos dilemas éticos relacionados con incapacidades, o con cuidados paliativos en medicina infantil, o el dilema del consentimiento informado en este rango de edad

After reviewing the existing bibliography in the last 20 years, we concluded that there is a lack of information regarding the ethical conflicts that affect to pediatrics in their daily practice. It produces certain degree of uncertainty in these professionals at the time of solving these problems. We made a systematic search in the main data bases, finding more than 150 articles related, of which 80 were considered outstanding. After studying them, we have found 40 ethical dilemmas, related to some principle of solution and that we described in this article. Through them we can find such important dilemmas as those related to physical disability, palliative care or consent from children

THEY SAID WHAT? REPUTATION MATTERS.

What people say online about you and your practice is important. Harsh words and missed opportunities to strengthen your interactions can reflect on your leadership skills unless you take proactive measures.

Bioética del día a día: más allá de los expertos / Day to day bioethics: beyond the experts

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Giving Away the Keys to the Kingdom: Vendors and Your Website.

Certain third-party vendors are now offering to "assist" practices by placing ma- terial and links associated with their services on the practice's website. This offer requires the practice to provide access to its website's contents. Patient privacy, insurance coverage, ethical duties, and IT integrity are all reasons that a practice should not provide a vendor administrative access to its website. Vendors seek- ing to promote goods or services via the practice should never be given access to alter the practice's website content. In the event a practice needs website assistance, it should seek help only from a qualified and insured person or entity.

Deontología profesional y ejercicio médico en prisiones / Professional deontology and medical practices in prisons

Objetivo: Estudiar el conocimiento sobre la deontología profesional entre los médicos de prisiones. Material y Método: Estudio descriptivo, transversal y multicéntrico. Se recogieron variables laborales, colegiales, sociodemográficas y de cuestiones deontológicas. Se realizó un análisis descriptivo de las variables. Se hizo un análisis bivariante mediante modelos de regresión logística binaria con las odds ratio e intervalos de confianza al 95%. Los datos se procesaron con el programa SPSS v.20. Resultados: Contestaron 118 médicos. 68 hombres (57,6%), con mediana de edad de 51 años (50-53). Conocen qué es la Comisión Deontológica 100 (84,7%), pero sólo 77 (65,3%) conocen bien sus funciones. 42 (35,6%) conocen la existencia del Código de Deontología y 37 (31,3%) lo han leído y lo acatan. Los que definieron correctamente la Deontología profesional encuentran más problemas deontológicos en su ejercicio diario [23(46,9%) vs 18(26,1%); OR: 2,506; IC95%: 1,153-5,451; p=0,020] y denunciarían más a un colega ante su Colegio [40(81,6%) vs 42 (60,9%); OR: 2,857; IC95%: 1,197-6,819; p=0,018]. Los más antiguos conocen mejor las funciones de las Comisiones deontológicas [54(73%) vs 23(52,3%); OR: 2,465; IC95%: 1,127-5,394; p=0,024] y han denunciado situaciones ante su Colegio [27(36,5%) vs 5(11,4%); OR: 4,481; IC95%: 1,577-12,733; p=0,005], pero creen menos en la necesidad de un Comité ético asistencial propio de prisiones [57(77%) vs 42(95,5%); OR: 0,160; IC95%: 0,035-0,729; p=0,018].Conclusiones: Los médicos de prisiones conocen poco qué es la deontología profesional. Este conocimiento aumenta con la antigüedad en el ejercicio y se asocia a mayor percepción de problemas deontológicos en el ejercicio diario (AU)

Objective: To study knowledge of professional deontology amongst doctors in prisons. Materials and Method: Descriptive, transversal and multi-centre study. Labour, collegiate, social, demographic and deontological variables were collected. A descriptive analysis of the variables was performed. A bivariant analysis was made by binar y logistic regression models, attending to the odds ratio, and assuming a 95% confidence interval. Data is processed by SPSS v.20 software. Results: 118 doctors replied. 68 men (57.6%), average age 51 years (50-53). 100 know about the Deontology Commission (84.7%), but just 77 (65.3%) know its functions properly. 42 (35.6%) know about the existence of the Deontological Code, and 37 (31,3%) have read and apply it. Those who made a correct definition of deontology do find more deontological issues in theirdaily work [23(46.9%) vs 18(26.1%); OR: 2.506; IC95%: 1.153-5.451; p=0.020] and would denounce a colleague more often to the Medical Association [40(81.6%) vs 42 (60.9%); OR: 2.857; IC95%: 1.197-6.819; p=0.018]. Older ones know more about the deontology commissions’ functions [54(73%) vs 23(52.3%); OR: 2.465; IC95%: 1.127-5.394; p=0.024] and have already denounced situations to the Medical Association [27(36.5% vs 5(11.4%); OR: 4.481; IC95%: 1.577-12.733; p=0.005], but think that a different Care Ethics Committee is unnecessary [57(77%) vs 42(95.5%); OR: 0.160; IC95%: 0.035-0.729; p=0.018].Conclusions: Prison doctors know little about what professional deontology really is. This knowledge increases with age in the profession and is associated with increased perception of deontological issues in daily practice (AU)

Curricular priorities for business ethics in medical practice and research: recommendations from Delphi consensus panels.

BACKGROUND: No published curricula in the area of medical business ethics exist. This is surprising given that physicians wrestle daily with business decisions and that professional associations, the Institute of Medicine, Health and Human Services, Congress, and industry have issued related guidelines over the past 5 years. To fill this gap, the authors aimed (1) to identify the full range of medical business ethics topics that experts consider important to teach, and (2) to establish curricular priorities through expert consensus. METHODS: In spring 2012, the authors conducted an online Delphi survey with two heterogeneous panels of experts recruited in the United States. One panel focused on business ethics in medical practice (n = 14), and 1 focused on business ethics in medical research (n = 12). RESULTS: Panel 1 generated an initial list of 14 major topics related to business ethics in medical practice, and subsequently rated 6 topics as very important or essential to teach. Panel 2 generated an initial list of 10 major topics related to business ethics in medical research, and subsequently rated 5 as very important or essential. In both domains, the panel strongly recommended addressing problems that conflicts of interest can cause, legal guidelines, and the goals or ideals of the profession. CONCLUSIONS: The Bander Center for Medical Business Ethics at Saint Louis University will use the results of the Delphi panel to develop online curricular resources for each of the highest rated topics.