CHAPTER 2
Principles of Patient Care
KEY POINTS
1 Professionalism is the foundation of patient care and is as much an ongoing
educational endeavor as is learning new procedures or techniques.
2 The right to privacy prohibits a physician from revealing information regarding the
patient unless the patient waives that privilege.
3 Informed consent is a process whereby the physician educates the patient about the
medical condition, associated risks and benefits of treatment, explains reasonable
medical alternatives, and explores her values in this context.
4 The concept of autonomy does not allow a patient’s wishes to take precedence over
good medical judgment.
5 For children, parents are the surrogate decision makers, except in circumstances in
which their decision is life threatening and might not be the choice a child would
make later, when individual adult beliefs and values are formed.
6 Creating a highly professional environment of safe culture, lack of harassment, high
professional behavior standards, and disclosure of unexpected outcomes benefit
patients and health professionals.
7 Prevention of burnout and maintenance of physician wellness are ethical
responsibilities of the health care system and are vital to the fiduciary relationship
between a physician and their patients.
The practice of gynecology, as with all branches of medicine, is based on ethical
principles that guide patient care. These principles and concepts create a
framework for ethical decision making that applies to all aspects of practice:
Autonomy: a person’s right to self-rule, to establish personal norms of
conduct, and to choose a course of action based on a set of personal
values and principles derived from these concepts
Confidentiality: a person’s right to autonomy in deciding how and to
whom personal medical information will be communicated
Beneficence: the obligation to promote the well-being of others or, in
medicine, to act in the best interest of the patient, defined by meeting a
goal of medicine through the care offered
Covenant: an agreement or commitment between two or more parties
for the performance of some action
Fiduciary relationship: a relationship founded on faith and trust and
the obligation to act in a trustworthy manner
Informed consent: the patient’s acceptance of a medical intervention
after adequate discussion and consideration of the nature of the
79procedure, its risks, benefits, and alternatives
Justice: medical resources should be distributed fairly and individuals
or groups have the right to claim what is due to them based on certain
personal properties or characteristics
Nonmaleficence: obliges health professionals to avoid doing harm,
assuring that benefits of interventions outweigh the potential harms of
intervention
PATIENT AND PHYSICIAN: PROFESSIONALISM
Health care providers fulfill a basic need—to preserve and advance the
health of human beings. Despite the challenges imposed by the commercial
aspects of the medical environment, for most physicians, the practice of
medicine remains very much a “calling,” a giving of oneself to the greater
good. The behavior of health professionals is evaluated in accordance with
these ethical principles and concepts by other professionals and the public
who share the belief in the “calling” of medicine. There are examples of
unprofessional behaviors that mar this professional image. They are demonstrably
easier to see in others than ourselves, including unprofessional behavior in
shouting at or mistreating others, lack of recognition of conflicts of interest that
could affect patient care, or inappropriate interactions with students, patients, or
colleagues. These behaviors, such as boundary violations or learner abuse, erode
the professional standing of the physician. Lapses do not always represent
inherent flaws in professionals, “most lapses represent deficiencies in judgment
and skill. They occur when the physician in question fails to recognize the
presence of a challenge to professionalism or lacks the skill to handle a challenge
at the time it occurs” (1). As Lucey and Souba note, [1] the solution to
unprofessional behavior is not recrimination but development of a set of skills
that allow professionals to recognize and address these professional challenges—
and those skills need to be developed and reinforced by individuals and by the
whole community of practicing physicians throughout their professional careers
(1). Professionalism is as much an ongoing educational endeavor as is learning
new procedures or techniques, and “we should assume that our peers want to be
professional and that they will welcome interventions from a trusted colleague
when circumstances suggest that a lapse is imminent” (1). [6] Creating an
environment where we can help one another in this way improves the quality and
safety of the care for our patients by preventing unprofessional behavior. An
environment without fear of recrimination, harassment, or unprofessional
behavior fosters ease in speaking up for patients’ interests and promotes
safer environments for everyone. This is a fundamental principle of
80excellence in patient care (2).
Professionalism has to balance the differences between fiduciary and
contractual relationships between physician and patient: “The kind of
minimalism that a contractualist understanding of the professional relationship
encourages produces a professional too grudging, too calculating, too lacking in
spontaneity, too quickly exhausted to go the second mile with his patients along
the road of their distress” (3). There is a relationship between physician and
patient that extends beyond a contract and assumes the elements of a fiduciary
relationship—a covenant between parties. The physician, having knowledge
about the elements of health care, assumes a trust relationship with the
patient where her interests are held paramount. Both the patient and the
physician have rights and responsibilities in this relationship, and both are
rewarded when those rights and responsibilities are upheld. Honesty,
disclosure, confidentiality, and informed consent are expressions of that trust
or covenantal relationship. This cannot be accomplished without some selfawareness on the physicians’ part. Health care systems and the governing
bodies of medicine have a similar obligation to patients in maintaining
physician health through the identification and prevention of provider
burnout or dysfunction.
Disclosing Medical Errors and Unanticipated Outcomes
[6] In creating a trustworthy and safe environment, the timely and
appropriate disclosure of unanticipated outcomes improves the trust patients
have in their health care team and, with complete documentation and
reporting, ensures that all medical errors or near misses are used to improve
the environment of care. If we are obligated as professionals by our trust
relationship with our patients, then patients should expect truthfulness, including
being made aware of individual or systemic errors, which, as Kohn et al. noted in
To Err Is Human, are inevitable in the delivery of health care (4). [6] A climate
that supports a no-fault discussion of errors creates an environment
conducive to restructuring the systems or procedures that make it possible
for errors to occur and is critical in the development of a safety culture.
Medical errors can create a keen sense of shame, humiliation, and failed
responsibility in health professionals, and efforts have begun to identify and
develop the skills and methods for disclosing and learning from them. Support for
individuals facing these feelings and preparing to disclose is critical in this
development. [6] Skills that seem common to disclosure are explaining
medical facts with honesty and truthfulness (responsibility and answering
questions), empathy (and apology), stating how future errors will be
prevented, and using good communication skills (5). These are skills that
81require training and development and should not be taken for granted. Many
institutions have risk management groups or other support groups that can be
helpful in development of skills and can accompany or lead such a discussion in
the absence of those skills. Disclosure and apology cause apprehension for
physicians—particularly in the discipline of obstetrics and gynecology where
litigation has adversely affected practice patterns (defensive medicine) and
heightened a reluctance to disclose medical errors for fear of litigation (6,7).
Apology raises particular anxiety about implying culpability and inciting
litigation, so help with framing an apology is always appropriate. The obligation
of trust (fiduciary relationship) that we have with our patients is an
important part of healing—and we owe it to our patients and ourselves to
develop the robust curricula and support at all levels of medical care to make
disclosure the step toward solution and healing that it can be for physician
and patient.
Confidentiality
The patient seeking assistance from a health professional has the right to
assurance that the information exchanged during that interaction is kept private.
[2] Privacy is essential to the trust relationship between doctor and patient.
Discussions are privileged information. The right to privacy prohibits a
physician from revealing information regarding the patient unless the
patient waives that privilege. Privileged information belongs to the patient
except when it impinges on the legal and ethical rights of institutions and society
at large, regardless of the setting. In a court situation, for example, physicians
cannot reveal information about their patients unless the patient waives that
privilege. If privilege is waived, the physician may not withhold such testimony.
[2] A physician applying the principle of autonomy will respect a patient’s
privacy and maintain a process that protects confidentiality. The right of
privacy must be maintained even when it does not seem intrinsically obvious.
A patient’s family, friend, or spiritual guide, for example, has no right to
medical information regarding the patient unless the patient specifically
approves it, except when the patient is unable to provide that guidance
because of their medical circumstance. In that circumstance, health providers
must exercise their judgment based on their assessment of the involvement of that
particular person with the patient’s health. This may seem obvious, but often can
be overlooked, such as when a health care giver receives a call from a concerned
relative inquiring about the status of a patient. The response may be a natural
attempt to reassure and inform a caring individual about the patient’s status.
However, for her own reasons, the patient may not want certain individuals
informed of her medical condition. Thus, confidentiality can unintentionally be
82breached. It is wise to ask patients about who may be involved in decision making
and who may be informed about their status. [2] If a health care giver is unclear
of the patient’s wishes regarding the person requesting information, the
reply should indicate that the patient’s permission is necessary before
discussing her status. When trying to contact patients for follow-up of
medical findings, it is never appropriate to reveal the reason for contact to an
individual other than the patient.
Record Keeping
Health care professionals are a part of record-keeping organizations. Those
records are used for multiple purposes in medicine and are a valuable tool in
patient care. There is an increasing tendency for ancillary organizations to collect,
maintain, and disclose information about individuals with whom they have no
direct connection. Health care professionals must be aware of this practice and its
ramifications. Patients sign a document, often without understanding its meaning,
upon registering with a health care institution or insurance plan. That document
waives the patient’s privilege to suppress access and gives insurers, and often
other health care providers who request it, access to the medical record. The
consequences of such disclosure for patients can be significant in terms of
insurance coverage and potential job discrimination. Even with health care reform
and improved attention to pre-existing conditions as part of that reform (8), this
continues to be a concern because individuals may have shifts in the pools of
insurance available to them and their costs may vary. This concern must be
weighed against the need for all health care providers involved with an individual
to be informed about past or present diseases or activities that may interfere with
or complicate management. The use of illegal drugs, a positive HIV test result,
genetic testing results, and even a history of cancer or psychiatric illness are all
exceptionally important to health care providers in evaluating individual patients.
When revealed to outside institutions, these factors may affect the patient’s ability
to obtain medical care, insurance, or even credit. Everything that is written in a
patient’s record should be important to the medical care of that patient, and
extrinsic information should be avoided. It is appropriate for physicians to
discuss with patients the nature of medical records and their release to other
parties so that patients can make an informed choice about such release.
The Health Insurance Portability and Accountability Act (HIPAA) was enacted
in 1996 and effective compliance of the “privacy rule” was instituted in April
2003. This rule imposed additional requirements for access to patient records for
clinical research and guidelines for protecting electronic medical records.
Although the intent of the act was laudable, the extent to which privacy is
improved is still unknown. The potential harm to the public from
83misunderstanding of HIPAA requirements or the cost of those requirements that
may inhibit critical research is also unknown. Exceptions from the requirement to
obtain patient authorization to share health information include areas such as
patient treatment, payment, operations (quality improvement, quality assurance,
and education), disclosure to public health officials and health oversight agencies,
and legal requirements (9). It is important that researchers understand the
influence of these rules in all settings; preplanning for clinical database research
to include consent for research database efforts when the patient first enters the
office or institution will make this critical research possible. The security of
medical records is a concern for individual patients and physicians and for
health systems and researchers.
Legal Considerations
The patient’s privilege to keep their records or medical information private
can be superseded by the needs of society, but only in rare circumstances.
The classic legal decision quoted for the needs of others superseding individual
patient rights is that of Tarasoff v. Regents of the University of California (10).
That decision establishes that the special relationship between a patient and doctor
may support affirmative duties for the benefit of third persons. It requires
disclosure if “necessary to avert danger to others” but still in a fashion “that
would preserve the privacy of the patient to the fullest extent compatible with the
prevention of the threatened danger.” This principle is compatible with the
various codes of ethics that allow physicians to reveal information to protect the
welfare of the individual or the community. In other words, “the protective
privilege ends where the public peril begins” (11).
Legislation can override individual privilege. The most frequent example is
the recording of births and deaths, which is the responsibility of physicians.
Various diseases are required to be reported depending on state law (e.g., HIV
status may or may not be reportable in individual states, whereas AIDS is
reportable in all states). Reporting any injuries caused by lethal weapons, rapes,
and battering (e.g., elder and child abuse) is mandatory in some states and not
others. The regulations for the reporting of these conditions are codified by law
and can be obtained from the state health department. [4] These laws are designed
to protect the individual’s privacy as much as possible while still serving the
public’s interest. Particularly in the realm of abuse, physicians have a
complex ethical role regardless of the law. Victims of abuse must feel
supported and assured that the violent act they survived will not have an
adverse effect on how they are treated as people. Their sense of vulnerability
and their actual vulnerability may be so great that reporting an incident may
increase their risk for medical harm.
84Informed Consent
[3] Informed consent is a process that involves an exchange of information
directed toward reaching mutual understanding and informed decision
making. Ideally, informed consent should be the practical manifestation of
respect for individual patient preferences and autonomy (12). An act of
informed consent is often misunderstood to be getting a signature on a document.
The intent of the individual involved in the consent process is often the protection
of the physician from liability. Nothing could be further from either the legal or
ethical meaning of this concept.
[3] Informed consent begins with a conversation between physician and
patient that teaches the patient about the medical condition, explores her
values, and informs her about the reasonable medical alternatives. Informed
consent is an interactive discussion in which one participant has greater
knowledge about medical information and the other participant has greater
knowledge about that individual’s value system and circumstances affected by the
information. This process does not require an arduous lecture on the medical
condition or extensive examination of the patient’s psyche. It does require
adjustment of the information to the educational level of the patient and respectful
elicitation of concerns and questions. Fear that the information may frighten
patients, fear of hearing the information by the patient, a lack of ability to
comprehend technical information, the accuracy of the information given, and an
inability to express that lack are among the many barriers facing physicians and
patients engaging in this conversation (13). [1] Communication skills are part
of the art of medicine, and observation of good role models, practices, and
positive motivation can help to instill this ability in physicians.
Autonomy
[4] Informed consent arises from the principle of autonomy. Pellegrino
defines an autonomous person as “one who, in his thoughts, work, and actions, is
able to follow those norms he chooses as his own without external constraints or
coercion by others” (14). This definition contains the essence of what health care
providers must consider as informed consent. The choice to receive or refuse
medical care must be in concert with the patient’s values and be freely chosen,
and the options must be considered in light of the patient’s values.
[4] Autonomy is not respect for a patient’s wishes against good medical
judgment. Consider the example of a patient with inoperable, advanced-stage
cervical cancer who demands surgery and refuses radiation therapy. [4] The
physician’s ethical obligation is to seek the best for the patient’s survival
(beneficence) and avoid the harm (nonmaleficence) of surgery, even if that is
what the patient wishes. Physicians are not obligated to offer treatment that is of
85no benefit, and the patient has the right to refuse treatment that does not fit into
her values. Thus, this patient could refuse treatment for her cervical cancer, but
she does not have the right to be given any treatment she wishes, which in this
case is a treatment that would cause harm and no benefit.
Surrogate Decision Makers
[5] If the ability to make choices is diminished by extreme youth, mental
processing difficulties, extreme medical illness, or loss of awareness,
surrogate decision making may be required. In all circumstances, the
surrogate must make every attempt to act as the patient would have acted
(15). The hierarchy of surrogate decision makers is specified by statutory law in
each state and differs slightly from state to state. For adults, the first surrogate
decision maker in the hierarchy is usually a court-appointed guardian if one exists
and second is a durable power of attorney for health care if it exists, followed by
relatives by degree of presumed familiarity (e.g., spouse, adult children, parents).
For lesbian couples, this presents issues in some states even with changes in
federal law that make marriage for same-sex couples legal. In this situation, the
creation of a durable power of attorney can address this issue proactively.
Physicians should make sure their patients are aware of the need to have
clear instructions about who they would want to speak for them if they are
not able—in some cases it is not the person specified by the state guidelines.
For example, elderly women may not want their elderly (and slightly senile)
spouse making decisions and prefer a friend or children—and should have a
durable power of attorney for health care that ensures that will be the case.
[5] For children, parents are the surrogate decision makers, except in
circumstances in which the decision is life threatening and might not be the
choice a child would make later, when individual adult beliefs and values are
formed. The classic example of this is the Jehovah’s Witness parents who refuse
life-saving transfusions for their child (16). Although this case is the extreme, it
illustrates that the basic principle outlined for surrogate decision making should
apply to parents. Bias that influences decision making (in protection of parental
social status, income, or systems of beliefs) needs to be considered by physicians
because the potential conflict may lead parents to decisions that are not in the best
interest of the child. If there is a conflicting bias that does not allow decisions to
be made in the best interest of the child or that involves a medical threat to a
child, legal action to establish guardianship (normally through a child protective
agency by the courts) may be necessary. This action can destroy the patient
(child)–physician relationship and the parent–physician relationship. It may affect
the long-term health and well-being of the child, who must return to the care of
the parents. Such decisions should be made only after all attempts to educate,
86clarify, and find alternatives are exhausted.
[5] The legal age at which adolescents may make their own decisions
regarding their health care varies by state and national laws. There is a
growing trend to increase the participation of adolescents who are capable of
decision making for their own health care. Because minors often have developed
a value system and the capacity to make informed choices, their ability to be
involved in decisions should be assessed individually rather than relying solely on
the age criteria of the law and their parents’ views (17).
A unique area for consideration of informed consent is providing care or
conducting clinical research in foreign settings or caring for individuals from
other countries who have differing viewpoints regarding individual
autonomy. For example, if the prevailing standard for decision making by a
woman is that her closest male relative makes it for her, how is that standard
accommodated within our present autonomy-based system? In international
research, these issues presented major concerns when women were assigned to
placebo or treatment groups and consent was accepted from male relatives (18).
The potential of coercion when no other access to health care is available creates
real questions about the validity and freedom of choice for participants in entering
clinical research studies in order to access health care in under-resourced areas
(19). When caring for patients from different cultures and countries in daily
practice, it is important to recognize that these issues exist in a microcosm.
Ensuring that the patient can make the choice herself or that she freely
chooses to have a relative make it for her remains an important element of
informed consent.
Beneficence and Nonmaleficence
[1] The principles of beneficence and nonmaleficence are the basis of medical
care—the “to do good and no harm” of Hippocrates. These issues can be
clouded by other decision makers, consultants, family members, and sometimes
financial constraints or conflicts of interest. Of all the principles of good medical
care, benefit is the one that continually must be reassessed. Simple questions can
help clarify choices. What is the medical indication? How does the proposed
therapy address this issue? How much will this treatment benefit the patient? How
much will it extend the patient’s life? Does it meet a goal of medicine, such as
curing a disease, ameliorating symptoms, reducing suffering, or educating about a
disease? When confronted with multiple medical problems and consultants,
physicians should ask how much treatment will be of benefit given all the
patient’s problems (e.g., failing kidneys, progressive cardiomyopathy, HIVpositive status, and respiratory failure) rather than considering treatment of one
problem without acknowledging that the overall benefit is limited by the presence
87of all the other problems.
An additional area of balancing beneficence and nonmaleficence is
ensuring that the medicine we practice is the safest and of the highest quality
relative to medical evidence. The safety and quality agenda in medicine is
growing and necessitates consideration of the role of experience (number of
procedures, simulation for ongoing maintenance of skills and development of
skills, team training) in ensuring that our patients have access to the highest
quality of care. When evidence shows improved outcomes for specific
interventions—for example, with timing difference in preoperative antibiotics—
health care professionals must participate in and embrace efforts to achieve those
metrics on behalf of their patients as part of their fiduciary duty and their
obligation to seek the benefit of their patients. Steps specific to this in obstetrics
and gynecology are listed by the American College of Obstetricians and
Gynecologists as developing the commitment to encourage a culture of
patient safety, implementing safe medication practices, reducing the
likelihood of surgical errors, improving communication with health care
providers and patients, and working with patients to improve safety (20).
The benefit or futility of the treatment, along with quality-of-life
considerations, should be evaluated for all aspects of patient care. It is best to
weigh all of the relevant issues in a systematic fashion. Some systematic
approaches depend on a sequential gathering of all the pertinent information in
four domains: medical indications (benefit and harm), patient preferences
(autonomy), quality of life, and contextual issues (justice) (11). Other approaches
identify decision makers, followed by facts, and then ethical principles. It is
important for physicians to select an ethical model of analysis under which to
practice, one that will provide sufficient experience with an ethics-based
analytic system in order to help clarify the issues when confronting troubling
and complex decisions.
Medical Futility
The essence of good medical care in sometimes challenging situations is to
attempt to be as clear as possible about the outcomes of the proposed
interventions. If the proposed intervention (e.g., continued respiratory support or
initiating support) has a slight or highly unlikely chance of success, intervention
might be considered futile. Physicians have no obligation to continue or
initiate therapies that are not of benefit (21). The decision to withdraw or
withhold care is one that must be accompanied by an effort to ensure that the
patient or her surrogate decision maker is educated about the decision and agrees
with it. Other issues, such as family concerns, can and should modify decisions if
the overall well-being of the patient and of the family is best served. For example,
88waiting (within reason) to withdraw life support may be appropriate to allow a
family to reach consensus or a distant family member to see the patient for the last
time.
Quality of Life
Quality of life is a much used, often unclear, term. In the care of patients,
quality of life is the effect of therapy on the patient’s experience of living
based on her perspective. It is perilous to assume that health care givers
know what quality of life represents for a particular patient (11). It is
instructive to attempt to understand what is important to an individual patient’s
quality of life and seek the patient’s perspective. The results may be surprising.
For example, when offered a new drug for ovarian cancer, a patient might prefer
to decline the treatment because the side effects may not be acceptable, even
when there may be a reasonable chance that her life may be slightly prolonged.
Conversely, the physician may believe that further treatment offers little benefit
but the patient finds joy and fulfillment in entering a phase I clinical trial because
it adds meaning to her life to give information to others about the possibilities of a
new treatment. Informing patients of the experiences of others who have faced
these choices may help in decision making, but it is never a substitute for the
choice of the individual patient.
PROFESSIONAL RELATIONS
Conflict of Interest
All professionals have multiple interests that affect their decisions.
Contractual and covenantal relationships between physician and patient are
intertwined and complicated by health care payers and colleagues, which
create considerable pressure. The conflict with financial considerations
directly influences patients’ lives, often without their consent. Rennie
described that pressure eloquently: “Instead of receiving more respect (for more
responsibility), physicians feel they are being increasingly questioned,
challenged, and sued. Looking after a patient seems less and less a compact
between two people and more a match in which increasing numbers of spectators
claim the right to interfere and referee” (22). One response to this environment is
for the physician to attempt to protect his or her efforts by assuming that the
physician–patient relationship is only contractual in nature. For example, a preexisting contract, insurance, a relationship with a particular hospital system, or a
managed care plan may discourage referral to a specialist, removing the
physician’s responsibility. All health care professionals will experience this
tension between a covenantal or contractual relationship. However, the ethical
89requirement to put the patient’s best interests forward and to provide trustworthy
information about options remains.
Health Care Payers
An insurance coverage plan may demand that physicians assume the role of
gatekeeper and administrator. Patients can be penalized for a lack of knowledge
about their future desires or needs and the lack of alternatives to address the
changes in those needs. Patients are equally penalized when they develop costly
medical conditions that would not be covered if they moved from plan to plan.
These situations often place the physician in the position of being the arbiter of
patients’ coverage rather than acting as an advocate and adviser. It is an untenable
position for physicians because often they cannot change the conditions or
structure of the plan but are forced to be the administrators of it.
In an effort to improve physician interest in and compliance with
decreasing costs, intense financial conflicts of interest can be brought to bear
on physicians by health care plans or health care systems. If a physician’s
profile on costs or referral is too high, he or she might be excluded from the plan,
thus decreasing his or her ability to earn a living or to provide care to certain
patients with whom a relationship has developed. Conversely, a physician may
receive a greater salary or bonus if their management of patients causes the plan
or the health system to be more profitable.
These conflicts are substantially different from those of fee-for-service plans,
although the ultimate effect on the patient can be the same. In fee-for-service
plans, financial gain conflicts of interest have the potential to result in failure to
refer a patient or to restrict referral to those cases in which the financial gain is
derived by return referral of other patients (23). Patients who have poor insurance
coverage may be referred differently from those who have better coverage.
Patients may be unaware of these underlying conflicts of interest, a situation that
elevates conflict of interest to an ethical problem. A patient has a right to know
what her plan covers, to whom she is being referred and why, and the credentials
of those to whom she is referred. The reality is that health care providers make
many decisions under the pressure of multiple conflicts of interest. Physicians can
be caught between self-interest and professional integrity. Failure to recognize
and address conflicts of interest that impact decision making harm the relationship
of individuals and society to health care providers. [6] Focusing clearly on the
priority of the patient’s best interest and responsibly rejecting choices that
compromise the patient’s needs are ethical requirements.
Legal Problems
[6] Abuses of the system (e.g., referral for financial gain) led to proposals and
90legislation, often referred to as Stark I and II, affecting physicians’ ability to
send patients to local laboratories and facilities in which they have a
potential for financial gain. There were clearly documented abuses, but the same
legislation would negatively affect rural clinics and laboratories whose sole
source of financial support is rural physicians. States vary on the statutory
legislation regarding this issue. Regardless of the laws, it is ethically required that
financial conflicts of interest are revealed to patients (24–26).
Another abuse of the physician–patient relationship caused by financial
conflicts of interest is fraudulent Medicare and Medicaid billings. This
activity resulted in the Fraud and Abuse Act of 1987 (42 U.S.C. at 1320a–7b),
which prohibits any individual or entity making false claims or soliciting or
receiving any remuneration in cash or any kind, directly or indirectly, overtly or
covertly, to induce a referral. Indictments under these laws are felonies, with
potential fines, jail sentences, and loss of the license to practice medicine.
Physicians should be aware of the legal ramifications of their referral and billing
practices.
Harassment
The goal of medicine is excellence in the care of patients and, often, research
and education that will advance the practice of medicine. Everyone involved
in the process should be able to pursue the common goal on equal footing and
without harassment that interferes with employees’, learners’, or colleagues’
ability to work or be promoted equally in that environment. Every office and
institution should have an assessment strategy to ensure that the work
environment is conducive to focusing on work and learning and not hostile to
individuals.
Every office and institution must have written policies on discrimination
and sexual harassment that detail inappropriate behavior and state-specific
steps to be taken to correct an inappropriate situation and make sure they
are widely accessible and available. The goal is to ensure appropriate reporting
and procedures for taking appropriate action and protecting victims, educating or
rehabilitating an offender, and preventing the reoccurrence of the behavior.
In the United States, the legal support for this right is encoded in both statutory
law through the Civil Rights Act of 1964 (42 U.S.C.A. at 2000e–2000e–17 [West
1981 and Supp. 1988]) and reinforced with judicial action (case or precedent law)
by state and U.S. Supreme Court decisions. Charges of sexual harassment can be
raised as a result of unwelcome sexual conduct or a hostile workplace. Employees
are not the only ones to experience sexual or other harassment; learners such as
medical students or nursing students can experience it and have a high reported
prevalence of it. Sexual or other harassment for students can interfere with the
91educational process and trigger federal discrimination liability, including loss of
federal funds encoded in Title IX protections (27).
Stress Management, Burnout and Prevention
[7] In addition to the acknowledged stress of the time pressures and
responsibility of a career in medicine, the health care environment is
associated with an increasing incidence of physician burnout, a serious threat
to physician wellness and the safety and quality of care that their workforce
provides. Addressing this problem is a shared responsibility of the physicians
themselves and the health care systems where they work. Individual physician
responsibility should include awareness and education about this issue, addressing
professional priorities, and having a plan for work–life balance that includes selfcare and wellness.
Burnout is a work-related syndrome characterized by emotional exhaustion,
depersonalization, and feelings of low personal accomplishment. Practitioners
who are burned out have been found to have higher rates of depression, alcohol
abuse, and suicidal ideation and are more likely to have experienced medical
errors in their practice (28–30). Physician burnout is associated with absenteeism,
lapses in professionalism, and early retirement. There is a widening gap in
satisfaction with work–life balance and increase in burnout among US physicians,
with burnout in obstetrician–gynecologists measured over 50%, second only to
emergency medicine physicians (31). This level of distress puts the field of
obstetrics and gynecology at risk for depletion of qualified providers, with
physicians and others retiring early or leaving medicine entirely.
Addressing burnout in our specialty requires support for physicians through
focus on the workplace drivers of this problem, of which there are many. Time
spent directly with patients is an important source of reward for physicians and
this time is limited by organizational and regulatory demands that are
compounded by market forces. Loss of physician autonomy and resultant
excessive administrative tasks consume already limited time, distancing
physicians from the meaning and value of their work, thereby diminishing the
rewards associated with work. In a study of obstetrics and gynecology providers
done in collaboration with the AMA, the strongest single predictor of emotional
resilience and sense of accomplishment for individual physicians was control over
schedule and hours worked (32).
[6] Alignment of values between the worker and the [7] workplace, enhancing
communication, establishing a culture of respect, mutual support, and expressing
appreciation, have all been shown to improve efficiency, reduce errors, and
improve workflow in physician practices and are most effective when supported
by leadership. High-quality leaders prioritize improvement of workplace culture
92and creation of community along with nurturing support for flexibility and
physician work–life balance. Strength in leadership, measured by composite
leadership scores, is strongly correlated with decrease in burnout (33,34). The
personal experience of burnout frequently involves loss of meaning and joy in
one’s work, isolation, and lack of community. For busy clinicians, isolation has
become an occupational hazard and mindfulness or reflective practice in groups
can be a very effective outlet. Some data reflect that getting physicians together
for a meeting or a meal improves camaraderie and decreases burnout (34,35).
[7] All physicians should develop personal awareness and a commitment to a plan
for self-care. Various strategies have been advocated and studied to prevent
burnout, and there is no uniform approach that will be successful for every
physician. Definition of values or what is most important in life can clarify
priorities and facilitate setting limits, establishing time away from work, and
planning time for relationships or other revitalizing activities. Many preventative
measures and interventions involve wellness practices, stress reduction, and
reconnection with the meaning of work and the reasons why physicians entered
medical careers. Contemplative practices including mindfulness meditation,
cultivation of awareness, and narrative medicine are interventions that have been
studied in prevention or amelioration of physician burnout (36). Writing a mission
statement reflecting why the physician chose medicine has been recommended as
a simple strategy to refocus on the meaning of work.
Though formal mindfulness practice is not for everyone, focusing on the
moment, the self, or the breath can allow for regrouping and improve one’s sense
of being grounded and more in control. Small actionable steps such as improving
sleep and exercise and setting boundaries on work time can help. Specific
wellness practices and their relationship to burnout have been studied in US
surgeons. Incorporating a strategy that prioritized work–life balance, focusing on
what is most important in life, and finding meaning in one’s work were all found
to be helpful in reducing burnout (37). General health habits such as exercise and
attending primary care visits have also been found to be important.
Women’s health care providers have a significant risk for burnout and face
poorer personal, mental, and physical health; increased medical errors;
disengagement; and resultant early retirement. Professional well-being is
important for our patients and for the career, personal, and family life of the
individual physician.
SOCIETY AND MEDICINE
Justice
[1] Some of the ethical and legal problems in the practice of gynecology relate to
93the fair and equitable distribution of burdens and benefits. How benefits are
distributed is a matter of great debate. There are various methods of proposed
distribution:
Equal shares (everyone has the same number of health care dollars per
year)
Need (only those people who need health care get the dollars)
Queuing (the first in line for a transplant gets it)
Merit (those with more serious illnesses receive special benefits)
Contribution (those who have paid more into their health care fund get
more health care)
Each of these principles could be appropriate as a measure of just allocation of
health care dollars, but each will affect individual patients in different ways. Just
distribution has become a major issue in health care. The principles of justice
apply only when the resource is desired or beneficial and to some extent scarce
(38).
The traditional approach to medicine was for practitioners to accept the intense
focus on the individual patient. Changes in medicine will alter the focus from the
patient to a population: “in the emerging medicine, the presenting patient, more
than ever before, will be a representative of a class, and the science that makes
possible the care of the patient will refer prominently to the population from
which that patient comes” (39). Physicians increasingly have accumulating
outcomes data (population statistics) to modify the treatment of an individual in
view of the larger population statistics. If, for example, the outcome of radical
ovarian cancer debulking is only 20% successful in a patient with a certain set of
medical problems, that debulking may be offered instead to someone who has an
85% chance of success. Theoretically, the former individual might have a
successful debulking and the procedure might fail in the latter, but population
statistics were used to allocate this scarce resource. The benefit was measured by
statistics that predict success, not by other forms of justice allocation by need,
queuing, merit, or contribution. This approach represents a major change in the
traditional dedication of health care solely to the benefits, however small, of
individual patients. With scarce resources, the overall benefits for all patients are
considered in conjunction with the individual benefits for one patient.
There was always inequity in the distribution of health care access and
resources. This inequity is not seen by those health care providers who do not
care for the patients who are unable to gain access, such as those who lack
transportation, live in rural areas, or where limits are imposed by lack of health
care providers, time, and financial resources. Social discrimination leads to
94inequity in the distribution of health care. Racial and ethnic minorities are less
likely to see private physicians or specialists, with clear impacts on outcomes of
care, regardless of their income or source of health care funding (40). Thus, health
care is rationed by default.
To reform the health care system requires judicial, legislative, business
mandates, and attention to the other social components that can pose obstacles to
the efforts to expand health care beyond a focus on individual patients.
Health Care Reform
The tension between understanding health as an inherently individual matter
(in which the receipt of health care is critical to individual well-being) and as
a communal resource (in which distribution of well-being throughout society
is the goal) underpins much of the political and social debate surrounding
health care reform (41). The questions of health care reform are twofold: (1)
What is the proper balance between individual and collective good? and (2) Who
will pay for basic health care? Because much of health care reform requires
balancing competing goals, legislation to achieve reform should specifically
address how this balance can be achieved. The role of government can be:
Regulating access of individuals to health care
Regulating potential harms to the public health (e.g., smoking, pollution,
drug use)
Promoting health practices of benefit to large populations (e.g.,
immunization, fluoridation of water)
Even with the changes in health care structure in the United States, health care
payers, not individual providers, often make decisions regarding the distribution
of and access to coverage and resources. The health insurance industry determines
what are “reasonable and customary” charges and what will be covered. The
government decides (often with intense special-interest pressure) what Medicare
and Medicaid will cover. These decisions directly affect patient care. For that
reason, health care providers cannot ethically remain silent when the health and
well-being of their individual patients and their communities are adversely
affected by health care reform decisions.
Research on the outcomes of care provided by gynecologists or affected
adversely by systems for financing health care (financial aspects, safety,
quality-of-life measures, survival, morbidity, and mortality) will allow the
discipline to have a voice in determining choices for women’s health care.
This is an ethically important responsibility for all women’s health care
preference
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