Outpatient Ethics for the Internist: Neglected Professional Dilemmas

1. 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

2. Differences in Outpatient & Inpatient ETHOS Outpatient Inpatient • Acute crises • Involves technology • End-of-life • Dramatic • Withholding care • Transient MD-PT relationship • Chronic disease • Involves psychosocial • Preventive • Routine • Inappropriate care • Ongoing MD-PT relationship

3. Frequency & Type of Outpatient Ethical Problems • Little research compared to inpatient dilemmas and much of it outdated or conducted in Europe. • 1988 study of 562 IM office visits. • Ethical problems defined as conflicts between other ethical issues and physician’s moral obligation of beneficence. • Ethical problems were present in 30% of encounters 84/280 patients and in 21% of office visits.

4. Most Common Ethical Problems • Costs of care (11%) • Psychological factors influencing patient preferences (9.6%) • Competence & capacity to choose (7.1%) • Refusal of treatment (6.4%) • Informed consent (5.7%) • Confidentiality (3.2%) • More frequently encountered in patients over 60. (Connelly JE, DalleMura S. Ethical problems in the medical office. JAMA 1989; 260:812-5.)

5. Top 10 Ethics Issues in Primary Care Physician-Patient Relationship Confidentiality-Consent • Impaired drivers • Third-party information • HIPAA and privacy • Adolescent confidentiality • Life-threatening non-adherence • Demands for inappropriate treatment • Lying for patients • Discharging Difficult patients Professionalism • PCP versus Consultant • Impaired physician

6. # 1 Impaired Drivers • Case: 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.

7. Driving, Continued • When 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?

8. Reporting Procedures New Mexico • Physician/medical reporting • Immunity • Legal protection • DMV follow-up • Other reporting • Not anonymous or confidential • Driver 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. • Will accept information from courts, other DMVs, police, and family members.

9. Ethical Issues • Autonomy of patient versus do no harm to the public. • Confidentiality versus truth-telling. • Requires medical assessment for possible reversible causes. • Must fail least restrictive alternative. • Work with family to secure keys/cars. • Social services for alternative modes of transportation. • Be transparent with patient and permit voluntary surrender of license.

10. # 2 Third-Party Information • Mrs. 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?

11. Confidentiality • ACP Ethics Manual (6th ed, p. 76) states that the “physician is not obliged to keep secrets from the patient.” • MD should recommend the wife encourage her husband to tell the MD about the drinking and offer to facilitate a conversation. • Clinical judgment regarding disclosing the information and its source depends on what is best for the patient, not the wife.

12. #3 HIPAA in the Office 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? • You call patients by name in the waiting room. • Your receptionist leaves appointment reminders on patients’ answering machines. • Your nurse regularly communicates health information to patient’s spouses.

13. 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.

14. Messages on Machines • HIPAA 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. • Unless the patient has previously requested confidential contact, such as by mail to the patient’s office rather then his home.

15. Communicating to Family • HIPAA 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: • In her professional judgment the physician believes such disclosure is in the patient’s best interest. • NOT if the patient has explicitly instructed the physician not to disclose any health information to specific family members or friends.

16. #4 Adolescent Confidentiality • Miss 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?

17. The Law: Confidential Services for Minors in New Mexico • § 24-8-5 NMSA 1978 … Contraception • Neither the state… noranyhealthfacilityfurnishingfamily planning services shallsubjectanyperson to any standard or requirement as a prerequisite for receipt of anyrequestedfamily planning service…[exceptions do not addressage of client].

18. The Ethics • Adolescent privacy and autonomy versus the rights of parents to decide what is best for their children. • Try to persuade the adolescent to tell their parents and offer to mediate meeting. • Suggest a public health clinic so that the parents do not get the insurance bill but the adolescent gets the contraception.

19. #5 Life-threatening Non-Compliance • Mrs. 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?

20. Steps Prior to Stopping • Assess decisional capacity • Strongly counsel substance use treatment including anti-craving medication. • Consider a coumadin agreement with the patient so you an document a trial before discontinuation. • Enlist family or friends to help her monitor her coumadin at home.

21. Discontinuation • Are there any other anticoagulation options to minimize the danger? • Conduct an evidence-based assessment of the risk/benefit profile of continuing coumadin. • Obtain a consultation from a colleague. • Extensively document the informed consent discussion with patient. • Advise of warning signs and symptoms of thrombosis or bleeding.

22. #8 Demands for Inappropriate Treatment • Miss 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?

23. Standard of Care • ACP 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.”

24. Refusing Inappropriate Requests Ethically • Try to understand the patient’s needs and beliefs – here Miss S clearly wants to lose weight the easy way. • Educate patients regarding the risks of inappropriate treatments such as osteoporosis with thyroid replacement. • Attempt to come to a mutually acceptable resolution. • If you cannot agree, then offer to refer.

25. #7 Lying for Patients • Mr. 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?

26. Physician Deception of Third Parties • 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. • 57% for cardiac bypass • 56.2% for arterial vascularization • 47.5% for intravenous pain medication and nutrition • 34.8% for screening mammography • 32.1% for emergent psychiatric referral • 2.5% cosmetic rhinoplasty

27. Does Using Deception Solve Ethical Problems • Represents a conflict between traditional patient advocacy and newer professional obligations of just resource allocation. • Lying for patients can have unintended and opposite effects of compromising physician integrity and diminishing public trust in the profession. • Reflects burdens and unfairness of reimbursement systems best addressed through policy reform.

28. 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)

29. #8 Discharging Difficult Patients • Miss 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 planor 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?

30. Abandoning A Patient • Neither ethical nor legalwhen: • There is an urgent or emergency situation. • No other clinician can provide a necessary service in the area/setting. • Would compromise the patient’s health. • You do not follow appropriate steps.

31. Discharging a Patient • You can ethically and legally discharge a patient, IF you: • Have documented attempts to resolve conflicts. • Transfer records and care to another provider. • Copies of all records: information belongs to patient; record to the practice.

32. #9 Consultant Versus PCP • Dr. 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. • Dr. 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. • Is Dr. S ethically or legally obliged to follow the consultant’s recommendations?

33. PCP Rules • ACP 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.”

34. #10 Impaired Physician • You 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?

35. Ethical Obligation • ACP 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.”

36. Reporting a Colleague • First try informal intervention, perhaps with the entire group or a trusted colleague. • Offer to assist in referring to treatment, including monitored physician treatment program. • Consult legal counsel, hospital chief of staff, or clinic administrator on process. • Let the physician know you will have to report him if he does not take preventive action.

37. 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.)

39. Resources for Answers • American Board of Internal Medicine Advancing Professionalism to Improve Health Care http://www.abimfoundation.org • AMA Virtual Mentor for Ethics and Professionalismhttp://www.ama-assn.org/ama/pub/physician-resources/medical-ethics.page? • American College of Physicians Center for Ethics and Professionalism http://www.acponline.org/running_practice/ethics/ • University of Washington Ethics in Medicine http://depts.washington.edu/bioethx/index.html