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Published on Wednesday, July 09, 2014

A moral authority

By Raymond Christensen, M.D.

Every time I read about some new kind of technology that is designed to help patient care, I wonder how useful it will actually be to our profession, as well as the cost physically and financially to the patient. The most important factor is, and always will be, the relationship between physicians and their patients and no technology, no matter how sophisticated, will supplant that.

Reports on the latest new gadget often cause me to turn to an old article from the Annals of Internal Medicine. The article brings me peace because it focuses on medical professionalism and helps guide me on where we need to go. Here’s a link to the full article, but I will provide you with a brief summary.

First and foremost, the article reminds us that our patients come first. That’s why we joined this profession - to help people. We need to provide our patients with our best knowledge, based on proven science, and guide them so that they can make the best decisions regarding their health.

We must provide this knowledge and guidance to all patients regardless of their race, gender, socioeconomic background, religious beliefs, sexual preference, etc. All patients must have access if we are truly doing our jobs.

In addition, we must be dedicated to the ever-improving quality of health care, whether that’s ensuring that we continue to educate ourselves, provide data so that others can learn from what we are doing or make sure that all of our colleagues remain competent and act professionally.

Unfortunately, these points are often obscured when we get into political discussions. In my opinion, we need to stand together on these principles as a profession. In fact, I’d argue that because of who we are and what we do, we have a moral obligation to do so. We have the education, the experience, and the authority to make a difference for our patients, our profession, our communities and the health of the nation as a whole.

One of the best ways to do this is by becoming more active in organized medicine. Join an MMA committee or task force, become politically active through MEDPAC or volunteer to testify before the Legislature. Get active in the AMA. Join your specialty society if you haven’t already. Together, we can increase our sphere of influence.

The world doesn’t need quiet physicians. The world needs physicians who are willing to boldly lead - for the better health of their patients, for their communities, for the nation, for everyone.

Raymond Christensen, M.D., is associate dean of the University of Minnesota’s Duluth School of Medicine. He is also an AMA delegate for the MMA.

Comments (13)Number of views (3423)

Author: Mary Canada

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13 comments on article "A moral authority"

Greg Peterson

7/11/2014 8:07 AM

Great commentary on the real role of a physician in our technology based society. I find it frightening that many medical students no longer have any idea of how to use a stethescope, opting for ultrasound instead of auscultation.

Good job, Ray.


jeff taber

7/11/2014 8:46 AM

TELL US WHAT YOU THINK....

Ok, here's a thought:

Physicians/medical associations....should ban together and resist the ICD-10 system. It does nothing for patients, it's financially wasteful, it's burdensome to private practice (smaller) clinics, it's going to put some physicians out of practice.

Then there's the "meaningful use" yoke....and the quality measures ball and chain....and the pay for performance hoax.....and PCMHs tale.....and the "affordable care act" mess,....all unnecessary burdens placed upon physicians and clinics. All top down, government mandated and driven programs to effect their directives and controls from the outside in...

Ah, but who cares anymore? Our medical profession's gone the way of big business / organized medicine / "providers and clients"...

"Patients come first...." Really?

When, with all of the above burdens, mandates and pressures do our patients truly come first?

We need to take back medicine, renew our professional vows as physicians, and truly put patients and their care FIRST.

Respectfully


Philip Fallt MD

7/11/2014 8:47 AM

Unfortunately the AMA does not represent my views. This happens more than not. There is an arrogance in opinion that offends many. They seem to have an agenda that many do not share.


Loree Kalliainen

7/11/2014 9:21 AM

Thank you, Dr. Christensen, for posting this thought-provoking article. Though I agree with each element of professionalism, the societal application becomes extraordinarily complex very quickly. How do we balance each element: Venn diagram or pyramid? Given that some very good treatments may be obscenely expensive, how do we balance distributive justice with quality and access? How do we best acquire strong and neutral scientific evidence if the research dollars are coming from corporations rather than universities? Conflicts of interest are not just based on money but on prestige, and on interest in caring for one's particular patient "type" rather than giving up some of the pot to go toward the greater good. As a subspecialist, I don't see this happening in a meaningful way yet, but I remain hopeful. We need to have ongoing, complex, and measured discussions to try to find a balance between competing forces. We need to be willing to make major changes in 1) how we pay for medical education, 2) how we reimburse physicians, and 3) how we engage patients to take greater control of their lives and need us less.


William Jacott

7/11/2014 10:05 AM

Amen Ray, well done. The nay-sayers don't do their homework. Bill


Dr. Douglas Smith

7/11/2014 10:05 AM

Given the AMA/MMA abdication of representing the professionalism of physicians, I find Dr. Christensen's article extremely hypocritical.

The MMA has contributed to the change for medicine from a profession to an occupation. When and if the MMA starts representing those of us that still believe in the autonomy and professionalism of physicians, then this article will ring more true.


Nate Scheiner

7/11/2014 10:12 AM

I must respectfully disagree with Dr. Christensen.

First, I have to point out that Dr. Christensen asserts that technology supplants the physician-patient relationship without much discussion on the actual effects we see of technological advances in that interaction. I see no prima facie reason why this is so. In fact, as a student at Dr. Christensen's sister school in Minneapolis, I am encouraged by my standardized patients to practice integrating note taking and charting into my history taking so it is neither surprising nor awkward when I reach the clinic and must do this on a computer on the fly. I am taught the benefits of ultrasound, and, importantly, when it is and is not indicated. But I am also taught that "patient first" means "patient's CHOICE," not that a probe in my hand placed on my patient's skin obscures autonomy. In fact, one big take away from my first experience in the emergency room was that ultrasound can provide the information to diagnose or rule out an inflamed gallbladder without the adverse effects of the CT that the patient requested.

Second, he points to the Charter on Medical Professionalism, and (notwithstanding the problematic western-centric view of the charter) this document actually supports the use of technology to foster physician-patient relationships. Take the advent of MyChart as an example: for those patients who travel long distances to see their physicians, this can be an essential tool to communicate with one's provider, thus improving access to care as set out by the charter. Technology gives us new ways for our patients to communicate with us and can prevent an undue burden on the patient.

In summary, I agree that our patients should come first but not that technology supplants this. New technology can help us interact with, diagnose, and treat our patients in ways that were not available to physicians before.


Richard Morris, M.D.

7/11/2014 10:12 AM

I echo Dr. Taber's impassioned comments. Organized medicine, in the form of the AMA and MMA, has lost its commitment to our profession in favor of going along with the social engineering and financing fads of the day. Consolidation, insurance company hegemony, government dictates, spurious expensive "quality" measures, ICD-10, etc. MMA stripped moral and legal authority from member physicians when it abolished the House of Delegates. MMA is a top-down organization that doesn't represent or defend the patient-physician relationship. Dr. Christensen is right, we DO need to stand together on these principles as a profession. We DON"T need quiet physicians. We DON'T need government or MN Community Measurement in the exam room. We DO need a more active, representative, democratic MMA that will go to bat against the forces that interfere with patient care and our profession.


Lee Beecher, MD

7/11/2014 12:35 PM

Clearly, attention to doctor-patient relationships and Hippocratic Ethics is an admirable message from Dr. Christensen. But, there very little from the perspective of solo or small group independent practices to recommend or justify membership in the AMA or MMA in 2014 -- given wholesale 2010 AMA advocacy for the ACA, a neutered MMA Task Force on Indpendent Practice a few years ago (chaired by the MMA CEO), and dissolution of the MMA House of Delegates in 2013.

So, the key question for the MMA and AMA is: Why should everyday doctors spend their time and money on the MMA or AMA given the dynamics of practicing medicine as employees in large clinic or hospital organizations?


Lisa Erickson, MD

7/11/2014 1:38 PM

"MMA Priorities

When we develop the questionnaire for our candidate interviews we try to focus on the priority issues of the MMA. While the reproductive rights issue is important to many members, it has not been a priority issue for the MMA. "

I will need to understand why this is not a priority to the MMA. These issues deal with the basics of the privacy of the patient physician relationship.


jeff taber

7/11/2014 2:26 PM

Valuable comments being made..... but, how are we as physicians to move from typing to changing things?

I just reviewed one of my young healthy male patient's medical record. He was apparently seen last week at an ER nearby and diagnosed with "pneumonia". The sum of the evaluation event was he ended up being "treated and streeted" (not admitted).

As I have been MANY TIMES in the past, ...I was once again irritated by the EMR. Yes, the EMR, for it produces and/or encourages fraudulent records. Templates, defaults, clicks of mice....and voo wah lah! A very lenthy and complex physician's note.

I mean, this note (for a young healthy, non smoker, non asthmatic, athletic male pneumonia case) had on BOTH THE admit exam...as well as discharge exam... things like, but certainly not limited to: cranial nerves, finger to nose, heel to shin, funduscopic, pelvic (yes, pelvic), etc.etc.etc.. exam components! I mean, really?!?

EMR.... a "tool" pushed upon us and twisted around us by things like "meaningful use"...excessive coding intricacies and detail...and billing systems,....is expensive, poor medical record, more time consuming than ever admitted to, and a fraud fertilizer.

Who are we? How have we gotten to where we are? Where are we going?

Patients first? How....?


jeff taber

7/11/2014 2:34 PM

Dr. Beecher..... I could not agree more. As a rural solo FP of 23 years I find virtually little to no assistance from our "supporting organizations". I receive their encouragements to join, but their activities and messages are all too often "out there" in terms of really being focused on better patient care....and supporting private practice physicians. Our profession's all but sold out to big business/corporate medicine...run by the protocols of the CDC and federal/state governments.

I love what I do, when referring to caring for patients, but I loath what I do, when referring to my having to jump through the hundreds of regulation and requirement hoops put in front of me by outside influences ( the "meaningful use" yoke....and the quality measures ball and chain....and the pay for performance hoax.....and PCMHs tale.....and the "affordable care act" mess ).

Patients first? How?


RW Geist MD

7/17/2014 7:47 PM

Dear Ray Christensen,

7-17-14

I have long admired your devotion to the medical profession and was thus interested in your recent editorial on professional morality or maybe more precisely, about professional ethics. I have always found our colleagues with rare exceptions to be moral and their actions professional, albeit, their understanding of medical ethics has too often been lacking. The lack has left them open to attacks on their integrity, which they find baffling and therefore difficult to answer. More on that later.

I also do not see technology per se, especially EHRs, as a moral or ethical problem except that EHRs are mandated. Mandated means unnecessary expense of equipment, software, data entry for 3rd parties, and all the serious problems it has brought too many of our colleagues. If purveyors of EHRs had to sell their products without aid of a police state club ready to beat up “buyers”, they might create more useful tools.

Your emphasis is correct: a physician’s loyalty must always first be to the patient’s interests. You sense that this ethic is under duress, but you did not touch on population “ethics” and how this ‘ethic’ threatens over 2000 years of medical ethics or how the threats are being implemented. Unfortunately, the implementation of population ethics to override professional medical ethics is with the tacit approval of the AMA and MMA.

I published an article in MN Medicine in 2013. It dealt with how the profession’s ethic and business of medical practice became threatened by two transitions in the medical market place. First, from a professional to a commercial dominated system after 1973, and second from a commercial to a cartel controlled system after 2010. These transitions were prompted by futile political attempts to control politically driven “free” care demand inflation, an unrelenting inflation which literally did not exist until after 1965.

When the second transition failed, HMO corporate gatekeeping role is being transferred to clinicians at the bedside. To explain previous managed care [HMO] gatekeeper failure and to sell implementation of PPACA “payment reforms” for clinic bedside gatekeepers, Government and Corporation “payers” make three specious evidence-free claims:

“First that medical inflation is due to “poor quality” and profligate care by culprit clinicians driven to ignoble avarice by an “evil” fee-for-service system. Second, that costs would be contained by transfer of the “payer” gatekeeping role to “culprit” providers by capitation payments for servicing “payer” populations (“payment reform”). Third, that physician gatekeepers could gain redemption, when their avarice is enlisted at the bedside in the more noble cause of conserving society’s “scarce resources”—and by no co-incidence, “payer” treasure.”

Thus is created a legalized financial conflict of interest between patient and gatekeeping doctor, whose pay is contingent on restricting care under the sophistry of “stewardship”. The moral position that we doctors assure access is not compatible with doctors being paid to restrict access—something that is immoral.

Is it any wonder that physicians are troubled amidst the turmoil? They run too fast trying to keep up with ballooning patient demand and medical knowledge. They have been demonized and assaulted by political hostility and blunt regulations. They are told that their moral path to salvation is to be “payer” gatekeepers of patient access—another rationing of supply scheme, this time at the bedside.

The pretext of a social good (cost control) is touted to justify questionable means (gatekeeping doctors). This is how professionals and professional medical organizations can lose their claim to patient and public loyalty, the very soul of medicine. It is a story of how patients can lose the protection of law and professionalism.

Amidst the turmoil of wrecked private practices, corporate employment, and mandated EHRs for 3rd party trolling for culprit patients and clinicians, physicians sense that an authoritarian rationing panaceas for medicine’s cost ailment is stalking the medical profession and professional practice of medicine. But they ask, what can we do? There are alternatives to authoritarian rationing panaceas for medicine’s cost ailment—alternatives that would return power to patients and foster affordable medical insurance.

This is where the MMA ought to lead.

Best wishes,

Bob Geist

RW Geist MD

North Oaks, MN

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