AMA House of Delegates

Delegates ask AMA council how to just say no to patients

■ It's not always easy to turn down requests for unnecessary drugs or surgeries, delegates tell a CEJA forum.

By Kevin B. O’Reilly — Posted July 4, 2011

Chicago -- Managed care, patient satisfaction surveys and direct-to-consumer advertising are among the factors making it more difficult for physicians to refuse unsuitable medical requests from patients, said delegates testifying during the Council on Ethical and Judicial Affairs open forum at the AMA Annual Meeting.

"We're taught to listen to patients and really meet the patient's needs. That's what makes us tick -- we get gratification from helping patients," said Michael M. Miller, MD, a Wisconsin Medical Society delegate and addiction medicine specialist from Oconomowoc. "The problem is, what about the situation where the best help you can give the patient is to frustrate their desires? They ask you for something and you say you don't think that's the best course of action. It's tougher now to say no because of the many implications of saying no. ... You could pay a price for saying no."

Poor patient satisfaction ratings can harm a physician's standing with administrators and even affect compensation, said Dr. Miller and other delegates. And, they added, shorter office visits mean less time to talk with patients about alternatives to the unsuitable care they are requesting, such as unnecessary drugs or surgery with a poor likelihood of success.

Delegates said patients frequently ask for inappropriate medications they see advertised on TV or elsewhere.

"From an ethical standpoint, we need to look at the whole picture," said John O. Cletcher Jr., MD, a delegate for the American Academy of Orthopaedic Surgeons from Berthoud, Colo. "Some pharmaceutical companies spend more on direct-to-consumer advertising than they do on research."

Michael M. Miller, MD, a Wisconsin Medical Society delegate and addiction medicine specialist from Oconomowoc. Photo by Peter Wynn Thompson

Other delegates said the difficulty of saying no also is present in end-of-life care situations, when physicians recommend that families withdraw life support for patients with no chance of surviving.

"[Families] will persist in insisting that the care be given," said Arthur E. Palamara, MD, a vascular surgeon and Florida Medical Assn. delegate from Hollywood, Fla. "Then the family will go to administrators and say they are not getting the care they require. We find ourselves being challenged with threats of recrimination from the administration or with litigation."

Delegates asked the council for practical ethical guidance to help them refuse inappropriate requests while maintaining positive relationships with patients. 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.

Updating the ethics code

CEJA already is at work on a project to "modernize" the AMA Code of Medical Ethics to make it clearer, more consistent and easier to use. In addition to a new chapter structure, the updated code will revise ethical opinions that no longer reflect current science. The AMA Council on Constitution and Bylaws will review editorial changes to ensure they do not change the meaning of the opinions.

Ethics policies that require substantive revisions will be presented to the house for consideration according to its usual democratic protocols, said Sharon P. Douglas, MD, a Madison, Miss., pulmonologist and vice chair of CEJA. The code "is an invaluable resource, hopefully, to all of us, and one that needs to be user-friendly and organized in a way so that you can put your finger on what you need, when you need it," she said.

In a related action, the house voted to direct the AMA to publicize the Code of Medical Ethics among physicians and create educational programs involving the code.

ADDITIONAL INFORMATION

Meeting notes: Medical ethics

Issue: Patients who provide samples of blood, cells, tissue and DNA may not fully understand that their biological materials may be pooled and stored for future research. Would the development of a universal consent form for research that involves stored biological materials be the best approach to ensure consent?

Proposed action: The Council on Ethical and Judicial Affairs said a universal consent form is not needed, as AMA policy already appropriately addresses informed consent as it relates to biobanking. The council proposed reaffirming several existing policies in reference to this issue. [Adopted]

Issue: Two resolutions asked the AMA to support specific positions on stem cell research and research involving human cloning.

Proposed action: CEJA said existing AMA policy must be updated to reflect the state of research. This means doctors who do stem cell research should adhere to institutional review board requirements. Doctors also should ensure that research is carried out with appropriate oversight and informed consent. [Adopted]

Issue: Studies say terminally ill hospice patients have an extended lifespan and improved quality of life compared with other terminally ill patients. But political discussions and media portrayals depict end-of-life issues in a bad light.

Proposed action: The AMA should meet with stakeholders to lead and direct the national discussion on end-of-life issues. [Adopted]

Issue: A museum exhibit in Michigan showcasing human bodies has raised questions about the cadavers' origins and whether consent was received from their families.

Proposed action: The AMA should request that federal or international authorities investigate if the bodies in the Premier Exhibition Inc.'s Bodies Revealed exhibits were obtained through approved international human rights measures. [Adopted]