Reasons to volunteer outweigh discomforts
■ A column that answers questions on ethical issues in medical practice
The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA. Posted June 6, 2005.
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Physicians often don't volunteer within America's health care "safety net" system because of real and perceived barriers. How can barriers be overcome and what are the compelling reasons for physicians to provide free medical care?
Most of America's 45 million uninsured rely on the overburdened safety net of charity hospitals, community health centers and free medical clinics. The care they receive there is far better than none, but most of the thousands of doctors, medical students, nurses, and others who work within this system recognize that the best care they can provide is neither as timely nor of the same quality as the care that insured patients get.
Few of those practicing within the safety net would be unhappy if the United States were to create a health care financing system that provided for all Americans and put free clinics out of business.
Until that day arrives, however, physicians must act both individually and collectively to bolster safety net institutions. Specifically, more physicians must volunteer within that system to expand the scope and quantity of care for the uninsured.
The medical profession has a long tradition of providing charity care. The AMA Code of Medical Ethics states that physicians have "an obligation to share in providing care to the indigent," by offering, for example, free health care in their own office settings or through volunteering their services at free clinics typically situated in poorer communities.
Recently, though, several factors have contributed to a reduction in the number of physicians who volunteer. These include concerns about medical liability, the quality of care provided in free clinic settings and the general state of medical practice (e.g., increased corporate oversight and dissatisfaction with the profession's limited role in forming health policy).
Our response to these concerns is frank: We won't "sugar coat" volunteer medical practice, and we understand that most physicians confront real barriers and discomforts when they donate their time and expertise. But we hope to dispel myths and convince doctors that the reasons why they should volunteer outweigh the discomforts.
Good Samaritan laws
Concerning medical liability for physicians acting in volunteer capacity, the risk is probably more perceived than real. First, most states have "Good Samaritan" laws that offer legal protections to physicians who provide care without compensation; sometimes these statutes confer full freedom from liability (as long as gross negligence isn't found).
Second, for states that do not provide such protections, the federal government has established a liability program for physicians working in free clinics, legally recognizing qualified physicians as employees of the U.S. Public Health Service and thereby limiting their liability risk.
Finally, many insurers offer additional coverage for charity services at a nominal cost (in Illinois, this article's physician-author pays $60 annually). This low premium, barely covering the administrative cost of underwriting the policy, probably reflects actuarial evidence that patients who receive free health care rarely sue the physicians who provide it.
Many physicians are troubled by the quality of care they will be able to offer in a free clinic. This is a real and nontrivial concern. Because most charity health care organizations have limited funding, the medical supplies, lab work and medications that most physicians take for granted are rationed. Examination rooms can be cramped, disorganized, and supplied with decades-old diagnostic equipment. Moreover, after working with a full health care team in a private clinic or hospital, physicians can be shocked at suddenly having to perform duties -- administering vaccinations, drawing blood, offering social work counseling -- usually provided by other staff.
Better than going thirsty
But focusing on these barriers is viewing the health care safety net as a glass half-empty. True, it's not a full glass, but it's better than going thirsty, so to speak.
At the heart of a physician's promise to heal, there is no qualifier that it be done with the newest equipment in the cleanest, most well-ordered office settings. Rather, physicians have a duty to deliver medical care wherever there is a need.
Sometimes that means caring for patients in a free clinic that is chaotic and dingy, with limited and undertrained staff and substandard medical supplies and equipment. Meeting the obligation to recognize need and to give care, regardless of surroundings or tools, is the foundation of the physician's volunteer experience.
The obvious fact is that the greater the number of physicians who volunteer, the greater the number of uninsured who can receive care; those who are sick have a better chance of getting well, and those who aren't acutely ill have a better chance of staying well through preventive care, thus reducing the numbers of uninsured who must seek last-minute, critical care in overcrowded emergency departments around the country.
A beneficial by-product of physician volunteerism is the phenomenon that those who offer unpaid services often become more active in related aspects of civic life, including advocating for patients beyond the confines of an examination room. Such civic participation fulfills their professional obligations to public life outlined in the AMA's "Principles of Medical Ethics."
Promoting positive values
Concerns about the state of the U.S. medical profession -- high corporate and government oversight over daily practice, increasing constraints on time, and a general dissatisfaction with the influence of the profession on social policy -- turn some doctors away from volunteering.
Volunteering will just bring more of the same frustrations, they reason; and they wonder how individual volunteerism can improve the state of medicine.
We suggest that increased physician volunteerism may promote the positive values of the medical profession. For those who feel disconnected from the ideals that initially attracted them to the profession -- altruism, individual decision-making, active service, constant learning -- giving medical care without financial interests and the constraints of administrative oversight can be invigorating.
Volunteering can reconnect disillusioned physicians to their original vision of the profession. Further, there is power in numbers; as a widespread effort, physician volunteerism would collectively improve morale and satisfaction among members of the profession.
The access-to-care crisis not only threatens the well-being of individuals, it undermines the status of the medical profession, which has been entrusted with securing and maintaining our nation's health.
The AMA Code of Medical Ethics urges that physicians "devote their energy, knowledge, and prestige to designing and lobbying at all levels for better programs to provide care for the poor." Activating large numbers of physician volunteers, particularly in an organized, nationwide effort, would go far toward reinforcing the public's image of physicians as caretakers of the public's health. With more hands-on clinical volunteers who truly understand the plight of the uninsured, the medical profession would have more clout in influencing long-term decision-making on access to care and other policy areas.
Encouragingly, volunteerism has become a significant part of the curriculum of many medical schools and residency programs, providing more direct clinical experience earlier than in the past. It has also created a more ecumenical atmosphere, with graduates who are in tune with broader issues in social policy as it relates to health care. Hence, volunteerism can serve as a form of continuing medical education for experienced physicians, exposing them to situations they might not see in their daily practices.
A final barrier to volunteerism is the poor dissemination of information about how and where physicians can volunteer their time.
The Robert Wood Johnson Foundation estimates that 375,000 physicians volunteer each year. This high a number suggests that few of the reported volunteer experiences are long-term commitments. Further surveys and long-term studies are needed to give the profession a clearer picture of where the deficits lie. Where are volunteer physicians needed? How often? For what kinds of medical services?
There is a concurrent need for a comprehensive volunteer resource center -- a clearinghouse for information on why, how and where to volunteer. Such an initiative could be created either through a central organization or through a consortium of several interested groups.
The American Medical Association is working on such an effort, but it needs the help of state and specialty medical societies. Some societies have volunteer assistance programs and are encouraged to expand them.
We urge state and specialty societies that do not yet have such programs to create initiatives that make it easy for physicians to tap into volunteer opportunities.
The more individual physicians recognize the need for improving the state of volunteerism in the medical profession, the more quickly our society can realize better health care for its neediest citizens and spur more work in finding long-term solutions to this growing crisis.
Audiey C. Kao, MD, PhD, vice president, Ethics Group, American Medical Association
Christian J. Krautkramer, research assistant, Ethics Group, American Medical Association
The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA.