Health reform puts doctors' professionalism on the line
■ A message to all physicians from David O. Barbe, MD, MHA, chair of the AMA Board of Trustees, on the ethical and professional challenges facing physicians in this time of health reform.
Many of my patients think I know everything and can fix anything. Others, of course, disagree, but I have spent my life trying to live up to the standards that my patients set for me and the standards of our profession.
Today, probably more than ever, our professionalism is on the line. As health reform moves our system to try out new payment and delivery models, it also forces us to face questions of ethics and professionalism with respect to how we treat our patients and in how we conduct ourselves.
As a family physician, I began my career in a solo practice in a small Missouri town. I knew my patients, their parents and their children. In 1997, after 15 years of solo and small-group practice, I merged with a large integrated health system based 65 miles away. At that time, the group consisted of about 300 physicians. Since then, my Southwest Missouri group has grown to 650 physicians and is part of a health system with a four-state footprint that encompasses southwest Missouri, northwest Arkansas, southeast Kansas and northeast Oklahoma — including Moore, the town devastated by a tornado in May.
Because I've seen solo practice, large group practice and everything in between, I believe I have a pretty good idea about the issues that physicians are facing.
It is clear that the changes we're seeing in the system are going to require a lot from all of us. I grieve that the “business of medicine” threatens to eat up time better devoted to medical care and clinical issues.
The legislators and bureaucrats in Washington don't understand or even think about physicians' needs from this perspective. Helping them understand is one reason we need the AMA, and a reason I feel privileged to serve as your chair during the coming year. As a former chair of the Council on Medical Service, I participated in developing a lot of the AMA policy related to reforming our health care system, Medicare and health insurance markets. It has been gratifying to see so much AMA policy incorporated into legislation, rules and regulations. However, there is much, much more to be done. In my new role as board chair, I will work even harder on behalf of physicians and our patients to shape policy that enhances health care delivery, the health of our patients, and the standing of our profession.
As the nation focuses on lowering health care costs and improving quality, it will be up to each of us in our daily practices to do what we can to be part of the solution and find ways to practice cost-effective, high-quality medicine. When done correctly, this aligns perfectly with our professional ethics and role as patient advocates. If done incorrectly, it can put us in conflict with those same professional standards. Getting it right is challenging and open to differing opinions as to what constitutes appropriate versus inappropriate approaches to incentivize efficiency and quality.
For many of us, finding our way to a better future state won't be easy. Fortunately, we have resources in the AMA and the Code of Medical Ethics to provide support and guidance as we go forward. In this context, I especially commend to you this section in the Code of Medical Ethics, 8.00 — Opinions on Practice Matters. Let me just touch on a few of the challenges to our professionalism that are already out there.
We've all heard a lot about the pros and cons of employment. Of particular concern to me are situations in which employment contracts contain financial incentives or administrative conditions that may compromise our professional judgment on a particular case or cases. These provisions have the potential to undermine our ethical obligations to advocate for our patients.
Another potential conflict occurs in situations in which we are faced with a fixed payment per patient per unit of time or episode of care. While this can be part of a model that leads to more efficient, cost-effective and higher-quality medical care, there is also the potential for conflicts involving use of health care resources and pressure from insurance companies, employers or other third-party payers to limit even necessary care. Opinion 8.054 in the Code of Medical Ethics cautions that physicians should “ensure that the quality of patient care is not compromised by unrealistic expectations for utilization or by placing that physician's payments for care at excessive risk.”
There is no question that wise stewardship of limited health resources is an ethical obligation for physicians or that there are unexplained variations in use of medical resources in some instances and locations. Yet regardless of what kind of pressures we face, we must never lose sight of the fact that what is best for the patient is our overriding professional responsibility. Our knowledge of the efficacy of treatments, tests and procedures; an understanding of each patient's unique needs; and an awareness of the cost impact of our treatment recommendations is one way we bring value as physicians and as a profession to our patients and the rapidly changing health care system.
There is also no question that in our changing health care system, physicians are particularly visible and an easy target of criticism or even blame. We can expect the scrutiny of our profession to increase, because the physician's pen still controls the majority of health care — utilization, quality and cost. How we participate in this unfolding evolution of health care delivery will determine the outcome.
As I said at the beginning of this column, we are practicing in a time that challenges us as never before to live up to our standards of ethics and professionalism. However, this also offers us a unique opportunity to lead by example and shape the future of medicine into what it needs to be for physicians and our patients. I ask you to join me in this cause.
You can read more about the AMA and medical ethics and see the Code of Medical Ethics online (link).