A basic concept in the clinical ethics of managed care: physicians and institutions as economically disciplined moral co-fiduciaries of populations of patients

Managed care employs two business tools of managed practice that raise important ethical issues: paying physicians in ways that impose conflicts of interest on them; and regulating physicians' clinical judgment, decision making, and behavior. The literature on the clinical ethics of managed care has begun to develop rapidly in the past several years. Professional organizations of physicians have made important contributions to this literature. The statements on ethical issues in managed care of four such organizations are considered here, the American Medical Association, the American College of Physicians, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics. Three themes common to these statements are identified and critically assessed: the primacy of meeting the medical needs of each individual patient; disclosure of conflicts of interest in how physicians are paid; and opposition to gag orders. The paper concludes with an argument for a basic concept in the clinical ethics of managed care: physicians and institutions as economically disciplined moral co-fiduciaries of populations of patients.     

The case for managed care: reappraising medical and socio-political ideals

The arguments against managed care can be divided into two general clusters. One cluster concerns the way managed care undermines the ethical ideals of medical professionalism. Since those ideals largely focus on the physician-patient relation, the first cluster comes under the rubric of micro-ethics; namely, the ethics of individual-individual relations. The second cluster of criticisms focuses on macro-ethical issues, primarily on issues of justice and policy. By reviewing these arguments, it becomes clear that managed care does not easily fit within traditional modes of ethical analysis. It poses a radical challenge to current medical and socio-political norms, and even resists the distinction between micro- and macro-ethical domains, a distinction that reflects the private/public distinction. Managed care organizations call for a third way, an inter-ethic for middle level organizations. The essays in this Journal provide a first step in this radical reassessment, laying the foundation for an organizational ethic that is responsive to the realities and promise of managed care.     

Biotechnology and ethics in medical education of the new millennium: physician roles and responsibilities

Although the medical education curriculum varies internationally, we suggest that it is desirable for medical educators to share a universal responsibility to prepare physicians to perform three distinct, yet interrelated professional roles. The first is that of a clinician who has the knowledge and technical skills to care for individual patients, as well as the public. The second role can be viewed as that of an educator, a teacher, or a consultant who has the interpersonal skills and personal qualities to teach, advise and counsel patients and the public about their health and illness, risk factors and healthy lifestyle. The third role is that of a resource manager to enable physicians to care for patients and serve the public not only by drawing on available material assets but also by prudent use of the resources for better serving the most number of people at the least expense without compromising the quality of care. The very nature of the medical profession also obligates medical educators through the world to sensitize medical students and physicians to the ethical responsibilities that are implicit to each of the three aforementioned roles. Although the basic ethical responsibilities of do no harm and confidentiality are universal, certain global changes, such as rapid advancements in biotechnology and resource allocation, are now reshaping medical ethics on every continent. Spawned by the rapid advances in the biomedical sciences, biotechnology is revolutionizing human reproduction, sustaining human life, cloning human beings, and mapping the entire human genetic terrain. These advances imply changes in medical education and formal preparation of physicians in performing their roles as clinicians, educators and resource managers. These biotechnological developments, coupled with the increasing cost of healthcare and maldistribution of resources worldwide, present unprecedented ethical-social challenges that need to be addressed in the education of the physician in the new millennium.     

Medical education in the public versus the private setting: a qualitative study of medical students' attitudes

Public hospitals serve as primary training sites for medical students. Public patients may therefore bear a disproportionate burden of medical student education. The purpose of this study was to critically examine the ethics of medical education in the public setting. Attitudes of first- and fourth-year students towards the role of public patients in medical education were elicited in focus groups. Inductive qualitative analysis was utilized to organize data into conceptual groups, which were then analyzed within an ethical framework. All patients have an equal obligation to participate in medical education. Students identified modifying factors that could affect a patient's obligation to educate future physicians. Available data highlight a concern that public teaching hospitals may provide a lower quality of care. If true, then the public teaching setting is creating an unfair burden upon that patient population who would then have a weakened obligation to participate in medical education.     

"I have learnt ... a different way of looking at people's health": an evaluation of a prevocational medical training program in public health medicine and primary health care in remote Australia

The purpose of this study was to gain insight into what prevocational medical practitioners (PMPs) learnt during a six-month public health medicine and primary health care training program (the Program) in remote Aboriginal Australia in 2001-2002. The Program's curriculum objectives included clinical and public health management of sexually transmitted infections, immunization, clinical audit and quality improvement, primary health care in remote Aboriginal communities, and working as part of an interdisciplinary team with health and non-health professionals, and lay people. The mode and location of delivery of these objectives was determined by the healthcare needs of the Kimberley population, and availability of safe, supported workplaces. Qualitative data from a variety of sources, including PMPs' reflective journals, were examined in the context of the Program's curriculum objectives and by conducting a content analysis of journal notes. Findings are presented using the curriculum objectives and other comments that emerged while examining the data. Preliminary data indicated that PMPs gained knowledge and practical experience in clinical and public health management of sexually transmitted infections, immunization and primary health care in poorly resourced remote Aboriginal settings. Deeper understandings of health and illness in a cross-cultural setting also developed, along with professional and personal growth, as illustrated by the following quotations from PMPs: "I have learnt ... a different way of looking at people's health ... I was encouraged to think more deeply than before about the whys and wherefores of medical practice, and thus consider the most effective ways of influencing patients' behaviours for the better." "I was encouraged to examine the thought processes behind the ways ... healthcare was provided ... [after leaving the Kimberley] I am constantly questioning the reason why we are practising medicine in a certain way in the big city hospitals-much to the consternation of my colleagues ... ." The Program was successful in teaching its first four PMPs the basic tools of public health medicine and remote area primary health care.     

Poland: biomedical ethics in a socialist state

In one of a Hastings Center Report series of four country reports, a professor of ethics discusses the Polish approach to ethical issues in health care. Szawarski begins by outlining five factors that influence the practice of medicine in Poland: a socialist form of government, the influence of the Roman Catholic Church, an ongoing economic crisis, the legacy of the Nazi death camps, and a lack of formal instruction in biomedical ethics. He then discusses three current ethical concerns of physicians, patients, and the public: regulation of physician conduct, abortion, and in vitro fertilization. There is little formal public debate of the issues, however, and physicians seem committed to upholding traditional medical codes of ethics without analyzing underlying moral principles and justifications.     

Twelve tips for setting up an ambulatory care (outpatient) teaching centre

The ambulatory care setting is becoming an increasingly important environment for clinical teaching. This reflects the changing focus of healthcare delivery with more procedures and patient treatment being delivered in this setting. Maximizing learning opportunities for students without compromising patient care has never provided a greater challenge. This paper shares 12 educational tips for developing an ambulatory care teaching centre where both students and patients benefit from a protected yet realistic clinical setting.     

In Uruguay, an ethic of care for the dying

The ethics of care for the terminally ill in Uruguay spring from deeply rooted attitudes which invest the physician with sole power to determine the course of treatment, even to prescribe painkilling drugs and to hasten death actively or passively, without collaboration from the patient's family. The paternal function attributed to the physician has not been questioned by any systematic reflection on biomedical ethics. However, conscientious physicians are interested in these issues and are well informed about the concerns of their foreign colleagues.     

Critical care in the Philippines: the "Robin Hood Principle" vs. Kagandahang loob

Practical medical decisions are closely integrated with ethical and religious beliefs in the Philippines. This is shown in a survey of Filipino physicians' attitudes towards severely compromised neonates. This is also the reason why the ethical analysis of critical care practices must be situated within the context of local culture. Kagandahang loob and kusang loob are indigenous Filipino ethical concepts that provide a framework for the analysis of several critical care practices. The practice of taking-from-the-rich-to-give-to-the-poor in public hospitals is not compatible with these concepts. The legislated definition of death and other aspects of the Philippine Law on Organ Transplants also fail to be compatible with these concepts. Many ethical issues that arise in a critical care setting have their roots outside the seemingly isolated clinical setting. Critical care need not apply only to individuals in a serious clinical condition. Vulnerable populations require critical attention because potent threats to their lives exist in the water that they drink and the air that they breathe. We cannot ignore these threats even as we move inevitably towards a technologically dependent, highly commercialized approach to health management.     

The role of medical education in the recruitment and retention of rural physicians

In many countries the sustainability of rural healthcare systems is being challenged by a shortage of rural physicians and difficulties in recruiting and retaining physicians in rural practice. There are numerous factors that influence efforts in rural physician recruitment and retention, many of which are beyond the scope of the academic medical centre and medical education. Nevertheless, there are strategies that medical schools can adopt to contribute to efforts to recruit and retain physicians in rural communities. Rural student recruitment, admissions policies, rural-oriented medical curriculum, rural practice learning experiences, faculty values and attitudes, and advanced procedural skills training are areas which the medical school has direct control of and which have been shown to influence the likelihood of medical students entering rural primary care practice. The purpose of this paper is to elaborate on some of the key strategies that have been identified in the literature.     

Humans and machines: Moving towards a more symbiotic approach to learning clinical reasoning

Abstract

Artificial intelligence is a growing phenomenon that is driving major changes to how we deliver healthcare. One of its most significant and challenging contributions is likely to be in diagnosis. Artificial intelligence is challenging the physician’s exclusive role in diagnosis and in some areas, its diagnostic accuracy exceeds that of humans. We argue that we urgently need to consider how we will incorporate AI into our teaching of clinical reasoning in the undergraduate curriculum; students need to successfully navigate the benefits and potential issues of new and developing approaches to AI in clinical diagnosis. We offer a pedagogical framework for this challenging change to our curriculum.     

Microburst Teaching and Learning

Amidst changes in the health care field with requirements for increased efficiency and limited time for teaching, there is a need for a teaching-learning model which maximizes the learning process and is exciting, fun, and motivating for both teacher and learner. Microburst Teaching and Learning is one strategy for combining various teaching styles and methods in 'bursts' with different learning styles to enhance the learning process.The model accommodates adult learning theory, adult attention span, learner motivation, the variety of learning styles found in learners, and the need for efficiency. Preliminary reactions to the Microburst Model indicate its appeal and motivating nature as a useful teaching-learning model.The next steps are to more critically evaluate the efficacy of the model for a broader range of clinical preceptors and to examine the variety of specific teaching strategies to determine which methods work best in specific settings. Because there are many potential teaching methods and teaching styles from which medical teachers can choose, a companion article outlining these specific methods and styles is currently in preparation.Weanticipate the article's publication within the next year.     

Improvement in undergraduate medical education: a 10-year follow-up in Finland

Several studies have revealed that undergraduate medical education does not adequately prepare students for their work as physicians. There have been attempts to solve this problem in curriculum reforms in medical faculties. In this article, Finnish physicians' opinions on their undergraduate medical education are analysed. In 1988, a postal questionnaire was mailed to 2632 physicians registered during 1977-86, and altogether 1745 questionnaires were returned (66.3%). A follow-up study was done in 1998, and a questionnaire was sent to 2529 physicians who graduated between 1987 and 1996; 1822 questionnaires were returned (73.1%). Half of the respondents considered undergraduate education to correspond well with the requisite diagnostic skills and hospital doctors' work in general. In older and more traditional medical faculties (Helsinki, Oulu and Turku) education in primary healthcare work was considered insufficient. Also, more than 80% of the respondents felt they received too little teaching in administrative work. They reported that both traditional and younger, community-oriented faculties (Kuopio and Tampere) had considerably improved their education, especially in primary healthcare, during the 10-year follow-up. However, there were still clear differences between the education in the respective types of faculty as evaluated by their graduates. There is still room for improvements in undergraduate medical education, the better to meet the real needs of practising physicians in different fields of health care.     

Bluffing, puffing and spinning in managed-care organizations

I argue that because bluffing, puffing, and spinning are features of corporate life, they are likely to characterize the doctor-patient relationship in managed care medicine. I show that managed-care organizations (MCOs) and the physicians who contract with them make liberal use of puffing and spinning. In this way, they create a context in which it is likely that patients will also use deceptive mechanisms. Unfortunately, patients risk their health when they deceive their doctors. Using the warranty theory of truth I argue that although bluffing may be ethical in business because all participants agree to it and business has not warranted truth-telling, it is not ethical in a medical context because physicians and MCOs have warranted truth-telling and the quality of medical care depends on it.     

AMEE Guide No 26: clinical teaching in ambulatory care settings: making the most of learning opportunities with outpatients

Increasing student numbers and changes in healthcare delivery are making inpatient settings less ideal for teaching undergraduate students. As the focus of healthcare provision shifts towards ambulatory care, increasing attention must now be given to developing opportunities for clinical teaching in this setting. This Education Guide describes the opportunities to be made available by introducing clinical teaching into ambulatory care venues not usually used for undergraduate teaching as well as different models for maximizing student/patient interaction in traditional outpatient clinics. In general there has been only a limited development of teaching initiatives in such ambulatory care areas as accident and emergency departments, clinical investigation units, radiology and imaging suites or the departments of professions allied to medicine. Each of these venues provides different resources suitable for clinical teaching and has its own advantages and disadvantages. A variety of models for facilitating student groups in these venues can be used. Practical advice is provided for the clinical tutor about to supervise clinical teaching in any of these ambulatory care settings. In contrast the development of a dedicated Ambulatory Care Teaching Centre allows the use of specific instructional strategies and can focus teaching on specific body systems illustrated by clinical volunteers invited to attend from a 'bank' of previous patients with stable clinical conditions. Finally, a teaching programme based on the day surgery unit is described as a way of achieving a variety of educational objectives in a busy resource that may not previously have been used for teaching.     

A survey of medical ethics: from truthtelling to AID

Southern Illinois University's School of Medicine sent a questionnaire to Illinois physicians asking them to estimate how frequently they encountered 25 ethical issues. The 800 respondents ranked truthtelling first, followed by informed consent, pain control, confidentiality, and professional etiquette. They ranked lowest such issues as therapeutic experimentation, organ transplantation, hemodialysis selection, euthanasia, and artificial insemination. The doctors also added some items to the list, including children's rights and unnecessary surgery.     

Developing and evaluating ambulatory care: problem-based learning cases

Medical educators have raised concerns about the quality of teaching and learning in busy ambulatory care settings. Problem-based learning (PBL), which allows students to learn to diagnose and manage common ambulatory care problems as they discuss patients away from the clinical setting, is one possible solution for addressing these concerns. This article describes a process for developing realistic and well-written PBL cases for an ambulatory care clerkship. The process details specific steps for writing and evaluating cases to ensure they contain relevant learning issues students often encounter in outpatient training sites. Faculty at other institutions can adapt this process to develop and evaluate PBL cases reflecting the common presenting problems and patient issues at their sites.     

Twelve tips for just in time teaching of communication skills for difficult conversations in the clinical setting

The ability to communicate well with patients and other members of the healthcare team is a vital skill for physicians to have, but one that is often not emphasized in medical education. Learners of all levels can obtain and develop good communication skills regardless of their natural ability in this area, and the clinical setting represents an underutilized resource to accomplish this task. With this in mind, we have reviewed the growing body of literature on the subject and organized our findings into twelve tips to help educators capitalize on these missed opportunities. While our emphasis is helping learners with difficult discussions, these tips can be easily adapted to any other clinical encounter requiring clear communication. Teaching effective communication skills in the clinical setting requires some extra time, but the steps outlined should not take more than a few minutes to complete. Taking the time to develop these skills in our learners will make a significant difference not only their lives but also their patients and their families.