The star-spangled banner can make for an impressive trellis when dangled between a physician and his or her patients. A recent paper released by the American College of Physicians (ACP) describes just how dense the fabric of federal and state government intervention can be when draped over healthcare and the patient-physician relationship, and ultimately suggests a score of principles to be considered by government bodies to halt further imposition on medical professionalism.
“The physician’s first and primary duty is to put the patient first,” David L. Bronson, MD, FACP, president of ACP, said on the topic of doctor duties in a news release. “To accomplish this duty, physicians and the medical profession have been granted by government a privileged position in society.”
But whereas government has bestowed upon physicians certain honors, current and upcoming legislation is doing quite the opposite by “inappropriately infring[ing] on clinical medical practice and patient-physician relationships, crossing traditional boundaries and intruding into the realm of medical professionalism,” Bronson noted.
Essentially, the new laws form a practice picket fence — a lattice that may have been erected under a well-meant aesthetic, yet serves more to bar physicians from their patients and professional pledge than it helps in finessing the bigger picture for primary care.
Using key points in the ACP paper — developed by the organization’s Health and Public Policy unit with aid from the Ethics, Professionalism and Human Rights Committee — as support for his comments, Bronson conveyed his concern about the clinical practice interference promoted by select government motions.
- The act of prohibiting a physician from having conversations with patients about risk factors possibly affecting personal health or family health — discussions recommended by the evidence-based guidelines of care no less — puts patient health in jeopardy as well as professional ethics, Bronson and the ACP contend. “Physicians should not be prohibited by law or regulation from discussing with or asking their patients about risk factors, or disclosing information to the patient, which may affect their health, the health of their families, sexual partners and others who may be in contact with the patient,” the ACP paper states.
- If physicians are required by law to discuss specific methods of care that are not adherent to the doctor’s best clinical judgment for a particular patient’s case, a crisis of ability and trust can occur between the doctor and the government. Also, individualized care is put at risk, and thus, so is the patient. Therefore “laws and regulations should not mandate the content of what physicians may or may not say to patients or mandate the provision or withholding of information or care that, in the physician’s clinical judgment and based on clinical evidence and the norms of the profession, are not necessary or appropriate for a particular patient at the time of a patient encounter.”
- If legislation demands that physicians provide diagnostic tests or medical interventions that are not backed by evidence or clinical relevance, the patient-physician relationship is once again put on the line as well as patient lives.
- When the information that physicians are allowed to disclose to their patients is limited, patients are not receiving the full benefits of healthcare they should be and physicians cannot practice to the rightful extent of their occupation.
To discourage these restrictions from taking root and permeating in the future, the ACP paper provided the following seven questions which should be posed by lawmakers and industry experts to ensure that the patient-physician relationship won’t be compromised by any given bill.
- Is the content and information or care consistent with the best available medical evidence on clinical effectiveness and appropriateness and professional standards of care?
- Is the proposed law or regulation necessary to achieve public health objectives that directly affect the health of the individual patient, as well as population health, as supported by scientific evidence, and if so, are there no other reasonable ways to achieve the same objectives?
- Could the presumed basis for a governmental role be better addressed through advisory clinical guidelines developed by professional societies?
- Does the content and information or care allow for flexibility based on individual patient circumstances and on the most appropriate time, setting and means of delivering such information or care?
- Is the proposed law or regulation required to achieve a public policy goal – such as protecting public health or encouraging access to needed medical care – without preventing physicians from addressing the healthcare needs of individual patients during specific clinical encounters based on the patient’s own circumstances, and with minimal interference to patient-physician relationships?
- Does the content and information to be provided facilitate shared decision-making between patients and their physicians, based on the best medical evidence, the physician's knowledge and clinical judgment, and patient values (beliefs and preferences), or would it undermine shared decision-making by specifying content that is forced upon patients and physicians without regard to the best medical evidence, the physician’s clinical judgment and the patient’s wishes?
- Is there a process for appeal to accommodate individual patients’ circumstances?
By asking the right questions, the ACP and Bronson agree healthcare laws that “can cause grave damage to the patient-physician relationship and medical professionalism and undermine the quality of care” will be easier to avoid.
In a subset of care that must always maintain a balance between the helper and the helped, the ACP finds there isn’t room for fences no matter how neatly they fit into the American dream.