According to Piaget, by age 12 most children rely upon internal efforts to avoid self-recrimination triggered by guilt and are able to take account of situational contexts within which a given moral choice is being evaluated. Given that an individual's moral standards are so well developed by this young age, I consider it unlikely that including medical ethics in the medical school curriculum would have any impact on the ethical character of medical school graduates. ("Is there an ethical doctor in the house?" October ACP Observer, p. 2.)
I suggest, therefore, that the value of medical ethics training may be found in three other areas: knowledge base, communication skills and professional practice protection.
In terms of a physician's knowledge base, training in medical ethics can help make difficult clinical decisions about issues such as futile care. A framework for how to approach such ethical questions can also help physicians address emerging ethical issues such as the application of new technologies like genetic engineering.
Second, the transition of the physician from an authority figure to a partner with patients has resulted in patients making demands of their physicians that in the past would have been considered presumptuous. Many patients question the character and motivations of their physicians; as a result of uninhibited behavior, many ask their physicians to engage in unethical behavior. If physicians are familiar with the language of medical ethics, they can better negotiate with patients or family members who ask physicians to engage in unethical behavior.
Finally, medical ethics training might prove most useful to practicing physicians if it could help them recognize and protect themselves from the unethical activities of colleagues. Consider the value of being able to spot the unethical motivations of a physician proposing a professional business relationship. Compared to this, deciding whether to order an unnecessary diagnostic study or minimize care for personal financial gain is ethical child's play.
Gary M. Stewart, ACP Member
Computerized medical records
The headline "Doctors are the main barrier to computerizing medical records" (November ACP Observer, 1997, p. 8.) is not consistent with ACP's scientific, evidence-based tradition.
From programs such as the Clinical Efficacy Assessment Project (CEAP) to publications that promote evidence-based medicine such as ACP Journal Club and Evidence Based Medicine, ACP leadership has shown its commitment to an evidence-based approach. New tests, treatments and procedures are always promoted on the basis of beliefs about their expected benefits, but an evidence-based approach requires that they withstand the scrutiny of well-designed trials before they can be widely recommended or adapted.
Information technologies must be subjected to this same scientific scrutiny before they can be recommended. The same standard of high quality evidence that we require to adopt inexpensive screening tests such as a urinalysis must be applied before we adopt information systems, which can cost tens of millions of dollars.
At present, little evidence is available that using electronic medical records will benefit patient outcomes, health professionals or even health systems. Until that changes, doctors must continue to approach electronic medical record technology with the same healthy skepticism that they appropriately apply to any costly and unproven medical technology.
Paul Gorman, FACP
It is unfortunate that ACP Observer promoted the interests of commercial electronic medical records vendors, self-appointed experts and hospital administrators at the expense of physicians practicing medicine.
As a member of the American Medical Informatics Association with 20 years of experience in medical computing and endocrinology/internal medicine, I refer you to a recent review article, "The Barriers to Electronic Medical Record Systems and How to Overcome Them," by Clement J. McDonald, FACP, in the May/June 1997 issue of the Journal of the American Medical Informatics Association.
Dr. McDonald clearly points out that the main obstacle to implementation of electronic medical records is the lack of agreement among the various interests promoting proprietary systems, coupled with the insistence by vendors and administrators that physicians use their systems whether they work or not. The difficult task of enhancing physician productivity with medical records software is generally ignored. Instead, extraordinary efforts are demanded from physicians for system implementation. Dr. McDonald's observations certainly match my experiences.
Eric S. Lichtenstein, FACP
For those of us in the trenches, what we need from medical record software is speed. You just cannot see 30 internal medicine patients a day and spend a lot of time working at a computer.
Many of the newer programs have features like links to formulary databases, provider panels, drug information and disease information. Physicians are finally getting "lookup information" quickly. Add good quality voice recognition software, which should be available in about a year, and most of us will be ready to computerize our practices.
If most software producers knew what the marketplace was demanding, they'd quickly enhance their functionality to remain a contender for new sales of their products.
Steven D. Atwood, FACP
We definitely need to reform the medical malpractice system. ("Medical malpractice reform: finding a better way," November ACP Observer, p. 7.) Many injured patients have to wait two to three years before getting any compensation, while many doctors have to endure what are often frivolous lawsuits.
One option is to establish a committee at a county level to hear medical malpractice cases. The committee would consist of two doctors, two lawyers, one nurse, one lab technician and two laypeople. The committee would hear from both the plaintiff and defendant; the case would then be reviewed by two experts in that field. Based on all the facts, the committee would make a decision, and any award to the plaintiff would be made on a no-fault system. Each member on the committee would serve for two to three years, and expenses would be paid by malpractice insurance companies, health insurers and hospitals.
This option would reduce litigation time considerably, and because both parties would not have to go through an exhaustive lawyer-operated system, it would also reduce the cost of litigation.
Arvind Kamthan, FACP
Charleston, W. Va.
Before we extol the benefits of certification, recertification, accreditation, proficiency testing and any other "tests," we need to ask ourselves a simple question: Are we creating these tests to appease the forces of managed care, or do we really believe that they are necessary to improve health care delivery? ("ABIM's plans to keep certification-and itself-relevant," December ACP Observer, p. 2.)
Until managed care companies perverted the meaning of board certification by using it as a guarantee of physicians' competence, we accepted it as a professional merit badge, or, as Dr. Kimball said, "an accolade, a personal academic achievement." This perspective has served us well since the first board for ophthalmology was created in 1916.
Besides wrongly using board certification as an advertising tool, many managed care companies will not hire physicians unless they are board certified. For a large segment of our colleagues—about 90,000 nationwide—this represents a threat to their ability to practice medicine, because many of their patients are insured by HMOs. HMOs that refuse to hire capable physicians because of a lack of board certification are limiting their licenses to practice.
The American Board of Medical Specialties (ABMS) stipulates that the boards are voluntary examinations and should not be used in any way to infringe upon the rights of physicians to practice medicine. But the ABMS, which administrates the boards, has been silent for too long on this issue.
Why celebrate board certification if we allow it to be so easily misinterpreted and misused by HMOs? If we cannot count on the ABMS to defend the principles and standards of the boards, why would anyone aspire to have them other than to satisfy an HMO requirement? Finally, what does it say about us as professionals if we remain silent on this issue, allowing so many of our colleagues to be shamed and discriminated against because they are not board certified?
Edward Volpintesta, FACP
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