OUTPATIENT ETHICS FOR THE INTERNIST:

NEGLECTED PROFESSIONAL DILEMMAS

Cynthia M.A. Geppert, MD, MA, PhD, MPH, MSBE

Chief Consultation Psychiatry & Ethics New Mexico Veterans Affairs Health Care System

Professor of Psychiatry and Director of Ethics Education University of New Mexico School of

Medicine

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cute crises

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nvolves technology

E

nd-of-life

D

ramatic

W

ithholding care

T

ransient MD-PT relationship

C

hronic disease

I

nvolves psychosocial

P

reventive

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outine

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nappropriate care

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ngoing MD-PT relationship

DIFFERENCES IN OUTPATIENT & INPATIENT ETHOS

Inpatient Outpatient

FREQUENCY & TYPE OF OUTPATIENT ETHICAL PROBLEMS

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ittle research compared to inpatient dilemmas and much of it outdated or

conducted in Europe.

1

988 study of 562 IM office visits.

E

thical problems defined as conflicts between other ethical issues and

physician’s moral obligation of beneficence.

E

thical problems were present in 30% of encounters 84/280 patients and in

21% of office visits.

C

osts of care (11%)

P

sychological factors influencing

patient preferences (9.6%)

C

ompetence & capacity to choose

(7.1%)

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efusal of treatment (6.4%)

MOST COMMON ETHICAL PROBLEMS

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nformed consent (5.7%)

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onfidentiality (3.2%)

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ore frequently encountered in

patients over 60.

(

Connelly JE, DalleMura S. Ethical problems in the

medical office. JAMA 1989; 260:812-5.)

1. Impaired drivers

2. Third-party information

3. HIPAA and privacy

4. Adolescent

confidentiality

5. Life-threatening non-

adherence

6. Demands for inappropriate

treatment

7. Lying for patients

8. Discharging Difficult patients

TOP 10 ETHICS ISSUES IN PRIMARY CARE

Confidentiality-Consent Physician-Patient Relationship

Professionalism

9. PCP versus Consultant

10. Impaired physician

# 1 IMPAIRED DRIVERS

C

ase: Mr. F is a 75-year old widower with mild dementia,

BPH, DJD and CAD who presents to your office for an ER

follow up visit. Mr. F was involved in an MVA and sustained

some minor lacerations and contusions. Mr. F wears

hearing aids and his vision was recently checked. MMSE

performed in the office is 19. Mr. F lives independently in

an apartment in town but has no family in the state.

DRIVING, CONTINUED

W

hen you suggest he might no longer be safe to drive, he is

indignant, citing his safe driving record. “If I can’t drive, I

might as well be dead.” He does agree to limit his driving

to daytime hours and short trips. One month later his

daughter calls from out of state and tells you he has hit a

parked car and it is time for you to “make him give up his

license.” Can you do that? Is it legal? Is it ethical?

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hysician/medical reporting

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mmunity

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egal protection

D

MV follow-up

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ther reporting

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ot anonymous or confidential

REPORTING PROCEDURES NEW MEXICO

D

river is informed by mail that his/her

license will be cancelled in 30 days

unless he/she submits a medical

report stating that he/she is

medically fit to drive. If a report is

not submitted, the license will be

cancelled.

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ill accept information from courts,

other DMVs, police, and family

members.

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utonomy of patient versus do no

harm to the public.

C

onfidentiality versus truth-telling.

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equires medical assessment for

possible reversible causes.

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ust fail least restrictive

alternative.

ETHICAL ISSUES

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ork with family to secure

keys/cars.

S

ocial services for alternative

modes of transportation.

B

e transparent with patient and

permit voluntary surrender of

license.

# 2 THIRD-PARTY INFORMATION

M

rs. C calls and leaves the following message with your

nurse: “My husband is not telling you that he is drinking

again even with the pain medications the doctor

prescribed. He is verbally abusive to me when he is drunk.

Please don’t tell my husband I called but I wanted the

doctor to know that my husband doesn’t tell the truth to

him.” You didn’t ask but now do you tell?

CONFIDENTIALITY

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CP Ethics Manual (6th ed, p. 76) states that the “physician is not

obliged to keep secrets from the patient.”

M

D should recommend the wife encourage her husband to tell the MD

about the drinking and offer to facilitate a conversation.

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linical judgment regarding disclosing the information and its source

depends on what is best for the patient, not the wife.

You just hired a new office

manager who likes to read

technical manuals for fun.

She says several routine

office practices are violations

of HIPAA and could result in

fines or worse. Is she right or

just annoying?

#3 HIPAA IN THE OFFICE

1. You call patients by name in

the waiting room.

2. Your receptionist leaves

appointment reminders on

patients’ answering machines.

3. Your nurse regularly

communicates health

information to patient’s

spouses.

HIPAA THE HIPPO

She is wrong. Physicians’ offices can use patient sign-up sheets

or call out patients’ names so long as the information disclosed

is appropriately limited e.g., no medical diagnoses.

These are both what is technically called “incidental

disclosure,” when other patients hear or see another patient’s

name

Disclosures are only permitted if other reasonable safeguards

and the minimum necessary standard has been met.

MESSAGES ON MACHINES

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IPAA permits a physician’s office staff to leave a message on a

patient’s answering machine so long as the message limits the

information to the appointment time reminder or request for a

call back.

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nless the patient has previously requested confidential contact,

such as by mail to the patient’s office rather then his home.

COMMUNICATING TO FAMILY

H

IPAA allows physicians to communicate information to family members

or significant others about the patient’s care even if the patient is NOT

present or has not given explicit permission for the physician to

disclose health information, IF:

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n her professional judgment the physician believes such disclosure is

in the patient’s best interest.

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OT if the patient has explicitly instructed the physician not to disclose

any health information to specific family members or friends.

#4 ADOLESCENT CONFIDENTIALITY

M

iss R is a 17-year-old high school junior whose mother has been

in your practice for years. Miss R comes to the office requesting

birth control because she is sexually active with her long-time

boyfriend and doesn’t want to “get pregnant and mess up the

college thing.” She asks that you not tell her parents she

requested contraception because as you know they are strong

Christians and would not approve of her sexual activity. Do you

give the pill?

THE LAW: CONFIDENTIAL SERVICES FOR MINORS IN NEW MEXICO

§ 24-8-5 NMSA 1978 … Contraception

N

either the state… nor any health facility furnishing family

planning services shall subject any person to any standard or

requirement as a prerequisite for receipt of any requested family

planning service…[exceptions do not address age of client].

THE ETHICS

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dolescent privacy and autonomy versus the rights of parents to

decide what is best for their children.

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ry to persuade the adolescent to tell their parents and offer to

mediate meeting.

S

uggest a public health clinic so that the parents do not get the

insurance bill but the adolescent gets the contraception.

#5 LIFE-THREATENING NON-COMPLIANCE

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rs. S is a 64-year-old woman with alcohol dependence and

a personality disorder, who is on coumadin for a DVT and

PE 6 months ago. She has been erratic in her adherence to

coumadin monitoring and is now admitted to the hospital

with an INR of 7 thought secondary to heavy alcohol use

and overtaking her coumadin when intoxicated. Do you

continue coumadin?

STEPS PRIOR TO STOPPING

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ssess decisional capacity

S

trongly counsel substance use treatment including anti-craving

medication.

C

onsider a coumadin agreement with the patient so you an document a trial

before discontinuation.

E

nlist family or friends to help her monitor her coumadin at home.

DISCONTINUATION

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re there any other anticoagulation options to minimize the danger?

C

onduct an evidence-based assessment of the risk/benefit profile of continuing

coumadin.

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btain a consultation from a colleague.

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xtensively document the informed consent discussion with patient.

A

dvise of warning signs and symptoms of thrombosis or bleeding.

#8 DEMANDS FOR INAPPROPRIATE TREATMENT

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iss A is a 37-year-old unmarried woman with BMI of 26,

requesting thyroid medication. She has seen TV advertisements

for thyroid hormone clinics but none of them are on her

insurance plan. She denies constipation, cold intolerance,

skin/hair changes, and other symptoms, aside from inability to

lose weight. Her physical examination is normal and TSH is 1

U/ml. Why does she want the thyroid and do you prescribe it?

STANDARD OF CARE

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CP Ethics Manual (6th edition, p. 75-76) “Although

the physician must address the patient’s concerns,

he or she is not required to violate fundamental

personal values, standards of medical care or ethical

practice or the law.”

REFUSING INAPPROPRIATE REQUESTS ETHICALLY

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ry to understand the patient’s needs and beliefs – here Miss S clearly

wants to lose weight the easy way.

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ducate patients regarding the risks of inappropriate treatments such as

osteoporosis with thyroid replacement.

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ttempt to come to a mutually acceptable resolution.

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f you cannot agree, then offer to refer.

#7 LYING FOR PATIENTS

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r. K is a 38-year-old father of 3 whose wife, also in your practice,

has lupus. Mr. K was recently laid off from his warehouse job.

He comes asking if you can fill out workman’s compensation

forms indicating his knee was injured on the job. This will give

him time to go back to school in information technology. Your

records show that on his initial visit 2 years ago Mr. K reported

he injured his knee playing high school soccer. Do you fill out

the forms?

5

7% for cardiac bypass

5

6.2% for arterial vascularization

4

7.5% for intravenous pain medication and

nutrition

3

4.8% for screening mammography

3

2.1% for emergent psychiatric referral

2

.5% cosmetic rhinoplasty

169 board certified internists

surveyed on whether they

would use deception in 6

clinical scenarios.

More likely to use deception if

less time in practice, clinical

situation more severe, managed

care penetration higher

Freeman VG et al. Lying for patients. Arch

Intern Med. 1999;159:2263-70.

PHYSICIAN DECEPTION OF THIRD PARTIES

DOES USING DECEPTION SOLVE ETHICAL PROBLEMS

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epresents a conflict between traditional patient advocacy and newer

professional obligations of just resource allocation.

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ying for patients can have unintended and opposite effects of

compromising physician integrity and diminishing public trust in the

profession.

R

eflects burdens and unfairness of reimbursement systems best

addressed through policy reform.

ACP ON DISABILITY

“

Physicians may see a patient whose problems do not fit

standard definitions of disability, but who nevertheless seem

deserving of assistance. Physicians should not distort medical

information or misrepresent the patient’s functional status in an

attempt to help patients. Doing so jeopardizes the

trustworthiness of the physician as well as his or her ability to

advocate for patients who truly meet disability or exemption

criteria.” (p.80)

#8 DISCHARGING DIFFICULT PATIENTS

M

iss Y is a 31-year-old with fibromyalgia, migraine headache, and

benzodiazepine dependence, who has repeatedly no-showed

scheduled appointments and then demanded urgent visits. She calls

the office multiple times a day and when staff cannot immediately

attend to her needs becomes abusive. She has refused to follow an

exercise plan or accept referrals for mental health care and

threatens to sue if she is not given alprazolam. Can she be

legitimately discharged from the practice or is this patient

abandonment of a challenging patient?

ABANDONING A PATIENT

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either ethical nor legal when:

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here is an urgent or emergency situation.

N

o other clinician can provide a necessary service in the area/setting.

W

ould compromise the patient’s health.

Y

ou do not follow appropriate steps.

DISCHARGING A PATIENT

Y

ou can ethically and legally discharge a patient, IF you:

H

ave documented attempts to resolve conflicts.

T

ransfer records and care to another provider.

C

opies of all records: information belongs to patient; record to the

practice.

#9 CONSULTANT VERSUS PCP

D

r. S practices in Rio Rancho. He has been treating Mr. C for many years

for chronic pain from severe spinal stenosis, most recently with

oxycodone 10 mg QID, with only modest relief.

D

r. S sends Mr. C to a local pain specialist, Dr. I, for further work up and

treatment recommendations. Dr. I documents in his consultation that

the patient is receiving a dangerous amount of short-acting opioids and

recommends immediate and complete taper off opioids.

I

s Dr. S ethically or legally obliged to follow the consultant’s

recommendations?

PCP RULES

A

CP Ethics Manual (6th edition, p. 92)

“

The physician who does not agree with the consultant’s

recommendations is free to call in another consultant. The interests

of the patient should remain paramount in this process.”

“

Unless authority has been formally transferred elsewhere, the

responsibility for the patient’s care lies with the principal physician.”

#10 IMPAIRED PHYSICIAN

Y

ou work in a small group primary care practice. Dr. Z is 52 with

well-controlled diabetes and been a good partner for 10 years.

Over the last few months he has been showing up late for work,

not reachable on call, and your nurse has complained he is

irritable and tremulous at work. You have told him you are

worried about him, but he denies there is any problem, saying he

is just having trouble with his blood sugar. Where do you go from

here with your concerns?

ETHICAL OBLIGATION

A

CP Ethics Manual (6th ed. P. 92) “Every physician is

responsible for protecting patients from an impaired

physician and for assisting an impaired colleague.

Fear of mistake, embarrassment or possible

litigation should not deter or delay identification of

an impaired colleague.”

REPORTING A COLLEAGUE

F

irst try informal intervention, perhaps with the entire group or a trusted

colleague.

O

ffer to assist in referring to treatment, including monitored physician

treatment program.

C

onsult legal counsel, hospital chief of staff, or clinic administrator on process.

L

et the physician know you will have to report him if he does not take

preventive action.

PRIMARY CARE ETHICS

“

Because primary care is characterized by many repeated

episodes of relatively mundane events instead of a few

sharply defined crises requiring instant decisions, the way in

which these ethical issues arise and the peculiar flavor they

develop in a primary care setting may be more difficult to

discern than the way in which ethical issues crop up in

intensive care unit.” (

Brody H, Tomlinson T. Ethics in primary care: setting aside common misunderstandings.1989;

Primary Care 1986;13:225-240.)

RESOURCES FOR ANSWERS

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merican Board of Internal Medicine Advancing Professionalism to Improve Health

Care http://www.abimfoundation.org

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MA Virtual Mentor for Ethics and Professionalism http

://www.ama-assn.org/ama/pub/physician-resources/medical-ethics.page?

A

merican College of Physicians Center for Ethics and Professionalism

http://www.acponline.org/running_practice/ethics/

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niversity of Washington Ethics in Medicine

http://depts.washington.edu/bioethx/index.html