Originally published September 2012
It might be an understatement to say the practice of medicine is not what it used to be.
The healthcare environment is changing, largely influenced by fiscal constraints, human resource issues, alternative models of healthcare delivery, and a growing malaise about the long-term sustainability of the healthcare system. Concurrently, new technologies and medical advancements are generating impressive treatment options that can cure illness or prolong life to an extent unimaginable only a decade ago.
While these changes are affecting the practice of medicine, physicians continue to address the clinical, administrative, research, teaching, and policy dimensions of healthcare delivery. With a common conviction in the importance of quality patient care, physicians are eager to embrace progress, while also mindful of the emerging risk management considerations implicit in change.
One area of medicine which has changed considerably is the relationship between patients and physicians. Today, patients are highly engaged in their care.
Patients as partners in care
Patient-centred care is now a recognized model of healthcare delivery.
Several studies have confirmed the benefits of this model, stating that "patient-centered practice is associated with improved health status (less discomfort, less concern, and better mental health) and increased efficiency of care (fewer diagnostic tests and referrals)."1
For some physicians, patient empowerment may be viewed as a significant departure from an earlier model in which medicine was largely physician-centred. In this new paradigm, patients' beliefs, values, and knowledge are important elements in the discussion about the care plan. The CMPA has published articles on physician-patient communications, emphasizing the importance of active listening. The ability to listen and to understand a patient's viewpoint, given the hectic pace of healthcare delivery, is not easily achieved. For additional strategies related to effective physician-patient communications, members may wish to read the CMPA article, "Physician-patient communication: Making it better."
Beyond making the final decision on their care, patients are also seeking diverse opinions and perspectives on their medical conditions and therapeutic options. With information so readily available, patients may challenge recommended treatment plans. This exchange between physician and patient is part of the consent dialogue. Physicians should avoid what may be perceived as a paternalistic approach in language, tone, and body positioning and engage fully with patients. Active and responsive engagement with patients is an important part of a quality healthcare experience.
Patient empowerment may also drive patients towards stronger consumer behaviour. This may include participating in physician rating websites and sharing healthcare experiences on social media sites. While most patients will provide a fair assessment of their experience, others may resort to these websites to convey dissatisfaction with the care received. It is understandable that rating websites may cause discomfort to physicians. While it may be tempting to ask patients to refrain from using such websites, this approach will likely invoke the opposite reaction. Ignoring these sites is also not advisable. Physicians should monitor what is being said about them. To encourage open and direct communication, physicians and their staff should encourage patients to discuss issues in person so any problems can be resolved instead of being allowed to escalate.
- Physicians should promote patient involvement in all aspects of care.
- Physicians may explore communication techniques that facilitate the active engagement of patients in decision-making.
- Recognizing that some patients will want to voice their viewpoints on the care received, physicians may consider implementing a feedback system in their practice.
Restraint in the healthcare system
There are very few areas of healthcare that are not confronted with some form of fiscal restraint.
As demands for healthcare services continue to outpace resources in some areas, physicians are tasked with managing their wait-time lists and, on occasion, with prioritizing patient procedures. These decisions carry medico-legal implications and mitigating these risks will benefit physicians and patients.
Physicians have a duty of care to patients. This duty may extend to resource allocation, and ensuring patient care is not compromised. In an environment of constrained resources, or when faced with an unexpected shortage of medication or supplies, physicians should engage with hospital officials or health authorities to request resources to meet patient needs. This advocacy work, if not handled professionally, may be interpreted as a challenge to the leadership of the hospital or health authority. To avoid this perception, physicians should work with the hospital administration and channel requests for resources in writing, using a professional tone and providing the facts to support the allocation of necessary resources.
To reduce medico-legal exposure, physicians should ensure that they meet the standard of care of a reasonably competent physician in similar circumstances. While the courts are willing to consider the resources available to physicians when assessing whether the standard of care was met, physicians are still expected to do the best they can within resource constraints.
Similarly, fiscal realities cannot supersede medical judgment. Physicians should acknowledge the financial pressures confronting the facilities and hospitals in which they practise. However, medical judgment should not be compromised by cost considerations. For example, when considering diagnostic tests, physicians may consider alternative tests that would cost less but still give the information needed to diagnose or treat the patient.
Beyond direct patient care, physicians may also be engaged in cost containment reviews to identify short- or long-term solutions to fiscal pressures. Physicians in leadership positions (chief of staff, division, or department) are regularly asked to contribute or to lead these program reviews. In this capacity, physicians become advocates for the societal good. This dual responsibility, to an individual patient and to society, may cause conflicting imperatives for physicians.
Many Colleges have advanced codes of ethics which provide direction to physicians in this regard. For example, the College of Physicians and Surgeons of New Brunswick acknowledges these responsibilities, advancing that "the physician should consider the well-being of other patients, of society and of colleagues, as well as his/her own well-being, but that of the patient being treated at the time must be the physician's primary concern."2
- When faced with resource constraints that impact patient care, physicians should work collaboratively with administrators and health authorities to identify solutions.
- Physicians should consider the fiscal environment in which they practise, but cost considerations should not supersede medical judgment.
- When confronted with a dilemma between patient and societal good, a physician's primary duty remains the well-being of the patient.
Technology and medical advancements
Despite the fiscal environment, the pace of technological advancements in the 21st century is unprecedented.
Medical advancements are no exception and new treatment options are continually being developed to address patients' medical conditions. As new studies emerge regularly on the efficacy of diagnostics, treatments, and medications, keeping up to date on clinical practice guidelines and accepted practices can prove challenging for physicians.
The obligations placed on physicians to keep abreast of new medical advancements can be daunting. However, a physician holds a duty to patients to provide care in accordance with recognized and accepted practice. When considering new procedures or technologies, it is prudent to be familiar with how and when these should be employed, and be satisfied that they are recognized by a respected body of peers. If a physician feels the care required by a patient extends beyond his or her clinical competence or experience, it is prudent to refer the patient to another physician who can provide the necessary care.
Physicians are also faced with keeping current with rapidly evolving clinical technology relevant to their practice. The use of technology may give rise to patient safety concerns, so effective technology management plans are required to mitigate risk. Whether in a clinic or hospital setting, physicians are encouraged to develop or to be aware of the patient safety initiatives directly related to technology.
Responsibility and accountability for clinical technology will generally rest with the hospital, or in the case of a physician-owned clinic, with the physician owner(s). Irrespective of the setting, a physician who relies on technology for treatment and care should be knowledgeable and experienced in its use.
Patients may also seek to leverage medical advancements. Armed with information acquired through the Internet or other sources, patients may request treatment options or procedures that extend beyond the accepted standard of care. Physicians are not obligated to comply with a patient's request of this nature. If a physician believes the requested treatment may not be beneficial, or could even cause harm, it is important to share this information with the patient. Doctors can also explain their obligation to provide care that is supported by current clinical evidence. The patient's request and the ensuing discussion regarding treatment options should be noted in the patient's medical record.
- If the required treatment extends beyond a physician's clinical competence or experience, the physician should refer the patient to another doctor.
- Physicians considering new procedures should be satisfied that these procedures are recognized by a respected body of peers.
- Physicians may counsel patients not to pursue treatments which may be harmful, and decline to perform treatments that are not supported by current clinical evidence.
Expectations of physicians
As technology promotes rapidity, it also conjures new expectations of healthcare delivery.
Physicians are regularly confronted with scheduling conflicts between clinic hours, operating room time, on-call duties, clinical rounds, ongoing professional development, and administrative responsibilities. The stresses and demands of medical care give rise to physician fatigue and associated medico-legal risks.
Colleges generally expect physicians to be aware of their capacity to provide competent clinical care and to ensure they are clinically fit to provide treatment or care. Likewise, courts have ruled that physicians should know whether they are capable of providing the necessary care. Hospitals also have a duty to patients, and this includes meeting the provision of competent personnel and adequate facilities to meet the needs of the community.
If a physician is unable to properly care for a patient due to scheduling conflicts or pressures, it is advisable to notify the administration of the hospital as promptly as possible. Since the hospital shares a responsibility to patients, a collaborative examination of resource and personnel allocation will benefit all involved.
Physicians often put aside their own well-being to respond to a patient's urgent or emergent clinical needs. Physicians also acquiesce to hospital or clinic requests to take on additional shifts or on-call duties. From a medico-legal perspective, physicians are independent professionals who are usually responsible for their own acts and omissions. It is the individual physician's responsibility to ensure that working conditions do not compromise his or her ability to meet the requisite standard of care.
As physicians and other professionals examine the issue of fatigue and work schedules, the numerous factors influencing medical care, such as technological advancements and patient-centred care, will render this examination challenging. The medico-legal considerations for physicians centre on the ethical duty to act in the best interests of their patients. This may mean that if a physician feels that his or her on-call schedule endangers patient care, reasonable steps are taken to ensure patients do not suffer as a result and that the physician is able to continue providing an adequate level of care for patients.
- Physicians should consider their level of fatigue and if they are clinically fit to provide treatment or care.
- Physicians may work with hospitals or health authorities to establish the appropriate schedules and level of human resources to meet the community's needs.
- A physician's schedule should ensure the provision of safe medical care, recognizing his or her ethical duty to act in the best interest of patients.
A final word
Change has become a constant for Canadian physicians who are adapting to a healthcare environment which continuously strives for high-quality patient care. As the boundaries of medical practice evolve, physicians are encouraged to embrace new realities, while considering the medico-legal implications of change.
The CMPA is available to assist members who may have questions regarding their professional and medico-legal obligations in this constantly evolving medical environment.
- Stewart, Moira, Brown, Judith Belle, Donner, Allan, McWhinney, Ian R., Oates, Julian, Weston, W.Wayne, Jordan, John, "The impact of family-centered care on outcomes," The Journal of Family Practice (September 2000) Vol. 49, no.9. Retrieved on May 1, 2012 from: http://www.ucdmc.ucdavis.edu/ome/mcrtp/docs/Kravitz%20The%20impact%20of%20patient-centered%20care%20on%20outcomes..pdf
- College of Physicians and Surgeons of New Brunswick, Code of Ethics. Retrieved on May 1, 2012 from: http://www.cpsnb.org/english/code-of-ethics.html