AMA House of Delegates

Doctors are "doing everything they can to keep the malpractice costs down," says John A. Seibel, MD.

AMA meeting: Are doctors responsible for controlling health care costs?

A CEJA open forum explored the role of physicians in an age of ever-rising medical spending.

By Kevin B. O’Reilly — Posted Nov. 23, 2009

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In the debate over health insurance reform, proposals to control rising costs have focused on systemic changes such as redesigning the payment system, prioritizing primary care and comparing the effectiveness of medical interventions.

But what obligation does the individual physician have to appropriately use scarce medical dollars? And how can that responsibility be squared with doctors' duty to advocate for the welfare of their patients?

These were some of the questions delegates explored at the Council on Ethical and Judicial Affairs open forum held at the AMA's Interim Meeting in November.

Health care costs account for 16% of U.S. gross domestic product. That level of spending "represents an enormous burden for individuals, employers and other payers at the state and federal levels," said CEJA member Susan D. Goold, MD, an Ann Arbor, Mich., internist. She said it is critical for doctors to examine what part they play in rising costs.

"The physician's pen is the most expensive medical device out there," Dr. Goold said. "Our orders pretty much control what happens to patients. We have a big role in what happens to health care spending."

Some delegates said the fear of medical liability lawsuits drives doctors to order costly interventions.


"The physician's pen is the most expensive medical device out there," said CEJA member Susan D. Goold, MD, an internist from Ann Arbor, Mich.

"Until we end up with a solution to the malpractice problem so that patients can be adequately compensated when they are injured without throwing all kinds of blame or harassment on physicians, we're going to have overutilization," said John A. Seibel, MD, an Albuquerque, N.M., endocrinologist and a delegate for the American Assn. of Clinical Endocrinologists.

Shifting responsibilities

Others challenged the notion that rising medical spending is a baleful trend.

"Increased spending on health care is good for this country," said Leon Reinstein, MD, a Baltimore physical medicine and rehabilitation specialist and a delegate for American Academy of Physical Medicine and Rehabilitation. "Two-thirds of health care spending goes into wages. These people don't put their money into mattresses. They buy houses, they buy cars, they spend money. You can't say the sky is falling just because we're spending more money on health care; the question is how to spend that money wisely."

Others said they want ethical guidance on how to balance obligations to individual patients and to society.

"I'm troubled by the ethical policy that says the responsibility is only to the patient in front of you," said Neil H. Brooks, MD, a Vernon Rockville, Conn., family physician and a delegate for the American Academy of Family Physicians. "Every moment I am with a patient, I'm also responsible to other patients. When I'm with the family with a mom who has cancer and they want one more CT scan, I somehow have to be involved in these decisions about the use of resources. I don't think it's ethical for me not to."

Delegates also discussed "never events" -- serious preventable adverse outcomes such as wrong-site surgery. Medicare recently stopped paying for some of these mistakes, joining a growing number of health plans. Many hospitals also have stopped billing for these errors, and 27 states require organizations to report when never events happen.

But many delegates asked CEJA to distinguish in its deliberations on ethics policy between true never events and complications, such as urinary tract infections, that are not always preventable despite the best efforts to adhere to evidence-based guidelines.

CEJA could present ethical opinions on these topics for delegates' consideration within the next 12 to 18 months.

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Meeting notes: Medical ethics

Issue: Industry funding of continuing medical education and CME faculty with financial conflicts may inappropriately influence educational content.

Proposed action: Develop ethical guidance advising that commercial support should be avoided when possible. Lay out principles for how to minimize financial conflicts and reduce the potential for bias. [Referred]

Issue: Kidney transplant chains have become more prevalent in recent years, raising questions about their propriety.

Proposed action: Examine the scientific feasibility and ethical implications of these new practices. [Adopted]

Issue: Some medical students and doctors post unprofessional content online.

Proposed action: Write ethical standards for physician professionalism online and incorporate them into the modernized AMA Code of Medical Ethics. [Adopted]

Issue: Illegal immigrants sometimes are discharged from American hospitals and repatriated to their home countries, where they get little or no medical care.

Proposed action: Develop ethical guidance advising doctors to refuse to sign discharge orders that would repatriate such patients involuntarily. [Referred]

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