AMA House of Delegates

AMA meeting: Delegates explore on-call coverage, at-home genetic tests

A shortage of specialists taking call at hospitals sparks debate at CEJA forum.

By — Posted July 7, 2008

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Most hospitals are struggling to find specialists to provide emergency on-call coverage, and many are paying a stipend to attract them.

But are physicians obligated to take call? Is it OK for hospitals to mandate medical staff to do so? Should hospitals compensate some doctors for taking call but not others?

These are some of the questions delegates examined at the Council on Ethical and Judicial Affairs open forum at the AMA's Annual Meeting in June. Delegates also discussed the need for guidance from CEJA on ethical issues related to the explosion of direct-to-consumer genetic testing.

Nearly three-quarters of hospitals say they have inadequate on-call coverage, according to a 2006 American College of Emergency Physicians report. Neurosurgeons, orthopedic surgeons, trauma surgeons, ob-gyns, ophthalmologists and dermatologists are some of the specialists hospitals have trouble getting to take call. More than a third of hospitals now pay specialists, usually surgeons, to provide on-call coverage, ACEP says.

Constance Powell, MD, a Portland, Ore., psychiatrist and alternate delegate for the American Psychiatric Assn., said many physicians used to feel compelled to take call by the unwritten social contract between doctors and society. In exchange for working strenuous hours, physicians were rewarded with excellent pay and high social esteem, Dr. Powell said.

"Now, society has changed the social contract with physicians," she said. "We feel ambivalent about asking for money for giving care, as though there is something wrong with that."

Some delegates told CEJA that hospitals often lack the equipment required to provide specialized care, making it a burden to be on call. Others said that increasing specialization makes them uncomfortable taking call for other surgical areas, especially given higher liability risks associated with emergency care.

Even when doctors taking call get paid, it is often not enough to make up for the sleepless nights, said Marvin S. Kaplan, MD, a Newport Beach, Calif., general surgeon and alternate delegate for the California Medical Assn. The stipend for physicians in his area turned out to be less than that for on-call nurses. "Many younger physicians don't feel automatically obliged to be on call for emergencies and volunteer their services," Dr. Kaplan said."I know when I address physicians on this subject their minds are made up."

Delegates also examined the ethical implications of direct-to-consumer mail-order kits that can determine paternity or tell patients whether their DNA puts them at increased risk of certain diseases.

"Does this constitute a dangerous disturbance of the patient-physician relationship?" asked Kavita Shah, a medical student member of CEJA. "On one hand, patients get knowledge. On the other hand, will patients turn to pamphlets for information rather than their physicians?"

Many delegates said genetic testing often can be misleading and should be offered only within the context of physician-patient relationships, and when clinical or family history warrants testing.

The open forum issues CEJA chooses to pursue could be studied for as long as 18 months before the council issues a report on the topic to the House of Delegates.

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Meeting notes: Medical ethics

Issue: To better halt the spread of chlamydia and gonorrhea, the Centers for Disease Control and Prevention recommends expedited partner therapy, in which doctors give patients antimicrobials for their sex partners. The practice, while effective, may undermine informed consent and continuity of care, and violate state laws.

Proposed action: New ethical policy saying doctors should only use EPT if they believe a patient's partner would otherwise not seek treatment. [ Adopted ]

Issue: Some hospitals have asked medical staff members to provide personal financial information as part of conflict-of-interest policies apparently aimed at shutting out doctors who work for competitors.

Proposed action: A Board of Trustees report recommending that only physicians seeking to serve in a hospital leadership position be required to disclose employment, ownership or financial interests, or leadership positions at another hospital. Also, the information requested should be no different from that requested of nonphysicians. [ Adopted ]

Issue: Treating peer physicians poses special challenges to clinical objectivity and confidentiality.

Proposed action: New policy saying doctors should not hesitate to treat peers in emergencies, but should beware of the risk of biased treatment recommendations, take care to respect privacy, and share decision-making as they would with other patients. [ Adopted ]

Issue: Drug- and device-maker funding of graduate and continuing medical education may undermine physicians' professional integrity and subtly bias doctors' practice patterns in ways that are not in patients' best interest.

Proposed action: A new ethical opinion calling on doctors, medical schools and organized medicine groups to end industry funding of residency positions and clinical fellowships, educational programs and physician speakers' bureaus -- except when new diagnostic or therapeutic devices and techniques are introduced, as industry representatives may be the only experts available to teach doctors about them. [ Referred ]

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