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Doctors MetroDoctors Physician Co-editor Thomas B. Dunkel, M.D. Physician Co-editor Richard J. Morris, M.D. Managing Editor Nancy K. Bauer Assistant Editor Doreen M. Hines HMS CEO Jack G. Davis RMS CEO Roger K. Johnson Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Susan Reed MetroDoctors (ISSN 1526-4262) is published bimonthly by the Hennepin and Ramsey Medical Societies, 3433 Broadway Street NE, Broadway Place East, Suite 325, Minneapolis, MN 554131761. Periodical postage paid at Minneapolis, Minnesota. Postmaster: Send address changes to MetroDoctors, Hennepin and Ramsey Medical Societies, 3433 Broadway Street NE, Broadway Place East, Suite 325, Minneapolis, MN 554131761.

CO N TEN TS VOLUME 3, NO. 5

LETTERS

PHYSICIAN’S SOAP BOX

SEPTEMBER/OCTOBER 2001

Has the AMA Taken its Third Strike?

PHYSICIAN’S SOAP BOX

The Failure of Integration

COLLEA GUE INTERVIEW

Norman Westhoff, M.D.

FEATURE

New Funding and New Expectations for the Academic Health Center

To promote their objectives and services, the Hennepin and Ramsey Medical Societies print information in MetroDoctors regarding activities and interests of the societies. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of HMS or RMS.

Changes to Health Provider Contract Law in 2001

Celebrate Women in Medicine Month

Index to Advertisers

Highlights of the Code of Medical Ethics of the AMA

HMS/RMS Winter Medical Conference

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MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

September/October 2001

LETTERS

Letter to the Editor: The article in MetroDoctors July/August 2001 concerning living conditions in Iraq was most interesting. According to a July 16, 2001 feature on National Public Radio by Michael Rubin who spent nine months teaching in the Kurdish sector of Iraq, living conditions are much different there. The Kurds are also under the same constraint of UN sanctions as the rest of Iraq, yet all of the money from the sale of oil is directed to its intended purpose, humanitarian support of the populace. According to Mr. Rubin, the Kurds have ample resources for children, medical services and the general economy is thriving. If the Iraqis do not understand why the UN forces bombed them, the Kurds certainly do not

understand why the Iraqis used poisonous gas on them. New weapons and uniforms are evident in the Iraq military, yet children starve. Should Saddam decide to direct the funds from UN sanctioned oil sales to the children and needy in his own nation, little of the suffering Dr. Ott was shown by his Iraqi government sponsors would be present. When Dr. Ott was shown the Al Ameriyah bombing site which the U.S. had targeted through faulty intelligence and the fact that the Iraqi government put civilians in a previously designated strategic site, did his Iraqi guides also tell of the systematic Iraqi murder, rape and pillage in Kuwait? That was not an error, but a planned and programmatic activity carried out over several months by the Iraqi military. To a physician, loss of life is tragic, yet anyone familiar with those events of a decade ago would have little difficulty differentiating between the two. Providing medical assistance and humanitarian aid to those in need, regardless of location or political situation is commendable. Placing blame for the tragic depravations in Iraq on UN sanctions which can provide for the needs of the civilian population, but do not allow Saddam to rebuild weapons of mass destruction, is both incorrect and naive. The Iraqi government has the resources to change the situation if it chooses to do so. ✦ J. W. Ogilvie, M.D. MetroDoctors welcomes letters to the editor. Send yours to: Nancy K. Bauer, Managing Editor MetroDoctors Hennepin & Ramsey Medical Societies Broadway Place East, Suite 325 3433 Broadway St. NE Minneapolis, MN 55413-1761 Fax: (612) 623-2888 E-mail: nbauer@mnmed.org

September/October 2001

Editor: If one were to criticize Gene Ott’s Soapbox (July/August 2001) description of the health problem of Iraq, that person would be considered calloused, insensitive and heartless. Gene’s description of the health and medical problems of ordinary Iraqi people is indeed heart-rending. Unfortunately, Gene’s exposition suffers from two important considerations. First, and probably of lesser importance, is his involvement with organizations and people with tunnel vision. Ramsey Clark and the Association of Friendship, Peace and Solidarity have never been friends of our foreign policy. Their views are notoriously naïve, and if acted upon, would only serve to encourage other despots and rogue nations. Far more important is Gene’s striking omission. Nowhere in his writing is there any mention of the role of Saddam Hussein and his government in the etiology of Iraq’s health problems. If Iraqi leadership had any resemblance to the surrounding Arabic states, the Iraqi people might be healthy and wealthy. Saddam’s unyielding despotism and tyranny is the root cause of the Iraqi problems Gene describes. He is the leader who had tens of thousands of Iraqis killed in Hamas years ago, their only crime being political opposition. Saddam sent diced pieces of a member of his leadership to the man’s wife, simply because he dared ask a question about Saddam’s actions. Indeed, the health problems of the Iraqi people would vanish with a change in leadership. The problems are not a direct result of our foreign policy. They are directly related to the awful leadership of that unfortunate country. Gene would be more convincing if he presented a more balanced picture. ✦ Sincerely yours, Seymour Handler, M.D.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

PHYSICIAN'S SOAP BOX

Has the AMA Taken its Third Strike?

ANOTHER TURNOVER IN CHIEF EXECUTIVE OFFICERS has occurred at our AMA. It seems this is becoming a recurring dream…or is it a nightmare? The person hired to take the AMA out of its sinking spiral of misdirection and missed opportunities has been fired by the board that restructured its governance and promised a “new AMA” only three years ago. Ratcliff J. “Andy” Anderson, M.D., was brought in from outside the AMA leadership ladders to right a sick organization after it initiated a soul-selling endorsement agreement with the Sunbeam Corporation. The deal was allegedly completed by its CEO, John Seward, M.D., without the Board of Trustees’ involvement. In its drive to create nondues revenue, the AMA appeared to violate its own Code of Ethics and the leadership had to be reminded by its rank-and-file members and outside observers that selling its AMA brand to a corporate bidder was viewed as bad business and a breach of its mission—dedicated to the health of America. Seward lost his job, but the board members escaped. So now we are treated to another debacle. The AMA legal counsel completes a real estate deal on behalf of the AMA that his boss, AMA EVP/CEO Andy Anderson, M.D., considered a give-away. Anderson relieves the general counsel, the counsel whines to his friends on the Board of Trustees, the board reinstates him and lets him resign with a golden parachute. The CEO says, “Wait a minute. I have a contract to manage the AMA staff, and you have circumvented my authority. Besides that, you have compounded the economic losses.” No internal resolution could be developed between the board, its chair, and the emasculated CEO. What happens? A public fight. A suit of the AMA Board of Trustees and its chair by the only person it is authorized to hire, its EVP/CEO. Everyone in the country who has any interest in the AMA learns that its governance body overstepped its authority, did a back-door deal with an employee, and revealed its faulty operations and mismanage-

ment. As a result, every physician, AMA member or not, is brushed with the taint of corruption in the profession. Two strikes, Sunbeam and Anderson. But if one looks back a few more years, there was another EVP/CEO, James Sammons, M.D., who after the 1987 stock market crash, tried to ensure members of his senior staff with unauthorized retirement benefits. Another public airing of bad management and corrupted practices that sunk another EVP/CEO and put egg on our collective faces. These recurrent public crises seem to indicate physicians cannot govern and physicians cannot manage. Physicians can neither get their act together to collectively improve the lives of their patients, nor enhance their profession. We have talked about getting adequate health care to all Americans for decades, but we are worse off today than 20 years ago. The gap between the haves and have-nots is wider. Disparities in health status between populations in America is a national tragedy and disgrace. Yet where is the AMA? Still working on the narrow issue of patient’s rights in order to get back at powerful insurance companies and showing the world it cannot manage its organizational affairs. I believe healthy organizations are honest, create an environment of open communication, exhibit respect in all its actions, and build trust with its members, employees, and customers. How do we grade our AMA today? Is our AMA failing? Is it fading? It seems to take another strike every few years. Can you do it three times and survive? ✦ A. Stuart Hanson, M.D., served as a delegate to the AMA for 12 years and was chair of the Minnesota Delegation.

BY A. STUART HANSON, M.D.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

September/October 2001

PHYSICIAN'S SOAP BOX

The Failure of Integration

WE ARE WITNESSING A SAD END TO A NOBLE DREAM and the enormous efforts of many dedicated professionals and community volunteers over the last eight years, as Allina spins off Medica and disintegrates into separate organizations. The significance of these events should not be under-estimated. Health care organizations across the country have looked to the vertically integrated Allina model as a possible solution to the intractable and growing crisis caused by our insatiable appetite for an increasing menu of important health care services and the contentious issue of how and who should pay for those items. The timing of the announcement, virtually simultaneous with the call for the breakup of Allina by the Attorney General amid charges of wasted money and administrative mismanagement, might seem to lend credibility to the accuracy of the charges, but, in fact, the decision is the culmination of a thorough strategic re-evaluation process by the Allina Board over the last eight months. The facts will show, I believe, that administrative expenses have played an insignificant role in this health care cost crisis, and that the Allina Board has been diligent and responsible in sorting through the many complexities of attempting to provide care for patients with dollars that fall far short of patients’ expectations. A disintegration requires a new Board and a redefinition for Medica of the proper constructive role it can play in providing health care for the state, but if we assume that we have by that act fixed the problem, we will be making an enormous mistake. We are at an important fork in the road. It is important to understand what went wrong. As we analyze what happened, we must set aside our prejudices, preconceived notions, and short-term political agendas. Does co-operation and collaboration ultimately imply collusion? Are the rights of patients best served by tension or cooperation between payers and providers? How much are we willing to pay in functional duplication to maintain that tension? If we misdiagnose the real reasons for the failure of integration, we may attempt to fix the wrong problem. Then, there is a very real risk of taking a giant step backwards, setting a fix to the problem even farther into the future. Recall the environment during which Allina was formed. It was the time of the Clinton health care reform, and the state legislature had passed plans for integrated service networks that would provide seamless

BY RONALD J. PETERSON, M.D. Former Allina Board Member

September/October 2001

health care for the citizens of the state. Big was not a bad word then. It seemed to make good economic and intuitive sense to organize the health care system to provide a seamless experience whereby the processes of registration, clinical information transfer, clinical care plans and after care, and payment processes would be transparent and automatic for the patient coursing through the system. Cost savings, then as now, had to justify every decision. The cost savings projected for the process of integration were based on the elimination of duplicative functions through the system and by promoting or requiring standardized, proven approaches to medical problems. Each party to the merger—the hospitals of Healthspan, Medica, and allied physicians had historically fantasized that the others held the keys to their financial destinies and improved, consistent patient care— and that given the opportunity, one or the other could do a more efficient job of cutting out and/or controlling the costs in the system. The health plan needed to gain greater control over the ability to control costs in the hospital and in physicians’ offices. The strategy was to partner with physicians in exchange for a transfer of risk to physicians so that each would be likely to manage costs as efficiently as possible wherever that care occurred. The hospitals wanted increased control over their revenues and an increased market share of patients with which to spread their large fixed costs. With a secure large patient base and a full house provided by a channeling feature of a health plan, the cost per patient would diminish and the savings would make the plan more competitive or provide needed capital for expanding medical capabilities and technology. Physicians wanted to minimize intrusive outside interference with their practice operations and medical decisions from the health plan and to be financially recognized for their laborintensive efforts in the hospitals to streamline processes of care. Uniting and justifying each of these specific interests was the sincere belief of each that patients would be the ultimate, unequivocal beneficiaries. Medical care would be organized and efficient with predictable and consistent quality based on proven literature based medical practice. It was to be win-win-win-win for all the parties involved. That clearly has not been the result. What happened to derail these worthy intentions? Unfortunately, first of all, no one part of the system had the pot of gold about which the others had fantasized. Then, in addition, the value that each had anticipated from the others never materialized. Risk transfer was a non-starter. Medical capabilities have increased MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

steadily over the last eight years. New expensive medications, new technologies, new imaging techniques, and new long-term strategies for controlling and preventing chronic disease make the prediction of medical costs virtually impossible for a health plan which must price a product some 12-18 months before it is offered to customers. Sophisticated medical practices wanted no part of assuming such an unpredictable economic risk themselves that would put their interests in conflict with that of their patients at a risk of personal bankruptcy. Promoting a “channeling” feature in the health plan presented an impossible paradox for both the hospitals and Medica. An integrated system works at its most efficient state when all the medical care stays within a given system. The hospitals sought for some way to promote the use of the hospital system preferentially to make that value equation work. Yet choice—of physicians and hospitals—has always been the hallmark and most attractive feature of Medica Choice. By de-emphasizing choice, one did so at the peril of the health of the Plan. The health plan faced a slightly different set of issues. In order to make a channeling product viable, it needed to be priced at a discount sufficient to neutralize the very attractive nature of Medica Choice. The size of that discount was so high that virtually the only providers who were members of the product were owned assets of the system. The mechanics of the merger also were much more difficult than anyone imagined. Recall again that the mergers of the hospitals—Abbott-Northwestern, United, and Unity-Mercy into Healthspan had really happened in name and concept only when Medica was added to the mix. The work of forging the differing hospitals and their staffs who had competing strategic interests and views of the world into a single unit had not as yet happened when Healthspan and Medica joined to form Allina. The grunt-work details of standardizing information technology, standardizing care and administrative policies, and the allocation of financial resources involve considerable pain and tension under the best of circumstances. Unfortunately, the nation-wide combination of exploding medical demands and diminishing government funding magnified these tensions explosively as competition for a diminishing pool of investment capital from a marginal balance sheet bottom line became more intense and bitter. Medica, which has struggled unsuccessfully for the hearts of physicians since the bitter days of Richard Burke, and hence also Allina, became the focus of that bitterness as the individual aspirations and strategic needs of hospitals and hospital programs collided with and were subordinated to wider corporate priorities. The Allina Board has for the last eight months been sorting through these realities. It painfully came to the conclusion on July 17 that all would best be served by dividing once more into separate

entities pursuing their own strategic goals. It turned out that the strategic goals of Medica and Allina and the Attorney General’s demands were for widely different reasons one and the same. Nonetheless, the health system still remains fragmented and disconnected. There is an overpowering imperative, in order to achieve health care improvement, to co-ordinate clinical and demographic information, and to standardize and validate differing approaches to medical problems, both to improve the quality of that care and to maximize the efficiency of the system. Allina was not that vehicle. Perhaps that co-ordination needs to be even broader—across the entire community of insurers, hospitals and health systems. That discussion needs to occur now. The root problems remain. A new Medica Board faces a set of almost impossible tasks. We must have realistic goals and expectations. Unfortunately, significant cost savings should not be one of them. Changing the board does not alter a stark set of realities. The cost increases in medicine of the last five or six years have been driven by new pharmaceuticals, new approaches to disease and new capabilities. Physicians have not had a meaningful increase in reimbursement in five or six years despite the steady increase in practice expenses and a very tight labor market from which to draw employees. Much of the work of medicine, answering phone messages and questions, refilling and monitoring medications, and providing advice for minor problems by phone is not reimbursed at all. Shrinking margins despite increasing workloads and everlonger days threaten the stability of the entire health care work force, including both doctors and hospital nurses. For the hospitals four or five years of minimal “profits,” which in a non-profit world provide the funding for investing in new capabilities and technology, have created a backlog of pent-up capital demand to deliver on the promises of new medical capabilities we all demand and expect. The new Board will face a very contentious set of negotiations almost immediately. Broader long term strategic issues of society-wide importance loom once that immediate hurdle is successfully negotiated. Should care be managed or not? If so, by whom? Who should set the priorities for medical care delivery in a society where we each feel our individual rights and interests are paramount? If we follow our instincts and wish to put each individual patient in charge, what device do we use to fund our individual needs and choices, provide catastrophic insurance coverage, and keep it affordable at the same time? The demographic time bomb that ticks for the Social Security system ticks as well for the health care system. Will it still be there when we all need it? ✦

Who should set the priorities for medical care delivery in a society where we each feel our individual rights and interests are paramount?

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

September/October 2001

COLLEAGUE INTERV IEW

Norman Westhoff, M.D. Editor’s Note: This interview was conducted by Penny Chally, HMS/ RMS Alliance member. Norman Westhoff, M.D. is an occupational health physician in Roseville, who, in the fall of 2000, led a group of health professionals from the Twin Cities to Dmitrov, Russia. The trip was at the invitation of the Department of Health in the Dmitrov Raion, and the Russian Farm Community Project, based in Edina. In addition to Dr. Westhoff, members of the delegation included: Dr. Cecil and Penny Chally, Wayne and Beverly Erickson, J. Michael Gonzalez-Campoy, M.D., Ph.D., Mark Harris, Dr. Austin and Mary Indritz, Carol Mason, and Robert Titzler, M.D.

Q A

What was the purpose of your 1998 and 1999 trips, prior to escorting the delegation, to Dmitrov, Russia? It was to get acquainted with some of the healthcare professionals in the area and to do a needs assessment. I was invited to do this because of ties that the Russian Farm Community Project (RFCP) had developed with the local administration in Dmitrov. RFCP has had a fair amount of success with their agricultural programs in the Dmitrov Raion over the past eight years and Governor Gavrilov asked Ralph Hofstad of RFCP to send professionals in the fields of health, medicine and social work, for the purpose of consultation with their local counterparts in Dmitrov. My first and second trips to Dmitrov, in1998 and 1999, were with Doug Aretz, the administrator of St. Benedicts Senior Health Care in St. Cloud. I visited a number of healthcare facilities in Dmitrov while Doug visited a number of social care facilities.

What was it during your first visit that really made you become further involved with this healthcare project in Dmitrov? When I went with Doug in 1998, I had no idea what to expect. I thought it might be an exotic educational activity to see how the Russians delivered healthcare. A combination of factors made me become interested in further involvement: their wonderful hospitality to their American guests and, obviously, their great need for help — not only for supplies and equipment, but also for help to effect some reform in the way healthcare is delivered. Even though the Communist system fell apart 10 years ago, the administration of the healthcare programs is still quite bureaucratic and centralized. That’s not all bad when you have a system with so many shortages, since they do need to allocate their resources carefully, but it does tend to slow down innovative ideas and initiatives. Yet, at the same time, the administrators and physicians are quite open to learn about what American physicians have to offer.

So, what has happened since those first visits? What were the results of these trips? Doug and I made a commitment to continue a dialog with Dmitrov healthcare and social care professionals, as well as to help with some physical needs such as hospital beds and other durable equipment. In addition, we would try to send some donated medicines and vaccines. We have since delivered five cargo containers of donated equipment and supplies to Dmitrov, with more shipments in the works. In the fall of 2000, I led a group of physicians and health professionals from the Twin Cities to Dmitrov, upon the request of officials from the Dmitrov Raion Department of Health who extended an invitation to RFCP for such a delegation to visit healthcare and social care facilities in the region. 6

September/October 2001

At the end of each trip, a good four to six hours have been spent between the Dmitrov healthcare administration and physicians and the American healthcare participants in panel discussions and exchanges, as well as setting priorities for further actions on programs and development. Besides the container shipments, we have also hand delivered a number of intravenous drugs, antibiotics, chemotherapy and pediatric immunizations. We were able to get these donated from pharmaceutical companies. However, that is just a drop in the bucket compared to the vast need. Now we are trying to focus on empowering the physicians and patients to take more responsibility for the delivery of healthcare. As an example, Dr. Bob Titzler, one of the physicians from the fall 2000 delegation, went back to Russia this past April and spent a month with the doctors in the health department working out treatment guidelines for MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

chest pain, diabetes outpatient care, and pediatric immunizations. The idea of treatment guidelines, while commonplace here in America, is brand new to them. Penny Chally, with the help of Marina Ostenny and others, had patient-oriented materials translated, or found already translated materials, which have been sent on to Dmitrov. Patient-geared information related to coronary care, diabetes, and other diseases fulfills another great need. In September, a group of ten Russian physicians and social service professionals will be arriving for a 14-day visit in the Twin Cities.

essary to enlist the support and develop mechanisms to find donations from those here who would welcome the opportunity to support this important piece of building bridges between Dmitrov and Minnesota. The Russian delegation is made up of 10 people; six of them are physicians, three are clinicians and three are administrators. We feel it is equally important that administrator-physicians come here because there are many things we are going to show them that are related to systems and organization. If there are to be any changes of that sort in Russia, it would have to be seen as important and, often, it would have to start at the top.

How did this trip come about?

Where are some of the places and areas that they will visit when they are here this fall?

As far back as my first visit in 1998, we, as a group of Americans and Russians, have talked about the possibility of a trip to the Twin Cities. Several Russian specialists have been to meetings in Western Europe, however, none of them have been to America. The biggest impediment to their coming here was the expense. Russian doctors, nurses, and feldshers (nurse practitioners) are paid very little compared to American standards. This, in part, has to do with tax revenues that are too low, and, in part, with healthcare being seen as a luxury rather than a necessity. In any case, they cannot pay for an airline ticket to the United States. The Russian 2000 delegation pledged to bring a Russian contingent here in the year 2001. Now it is going to happen and the Russian delegation is going to arrive September 18. For the dream of bringing them here and showing them some of the facilities and how our systems work, it is nec-

All details are not yet final at the time of this interview; however, they will be spending a fair amount of time at several hospitals and clinics in the Twin Cities and some in St. Cloud. There is a primary interest in heart disease prevention and treatment, as that is by far the greatest cause of premature death in Russia, about three times what it is in the United States. Among other areas of interest are diabetes management and pediatric preventative care. In the area of social services, especially the care of the elderly, they will visit some transitional care units in St. Cloud. They will see what handicapped accessibility involves, including vans for transportation of handicapped persons, which is virtually unknown in Russia. They will (Continued on page 8)

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September/October 2001

Colleague Interview (Continued from page 7)

also visit a variety of other social service locations, including those dealing with HIV/AIDS, in St. Paul and Minneapolis. At the invitation of the Omaha Medical Society, some of the delegation will be going to Omaha, Nebraska for a few days to see healthcare services in that area.

One final question, what future steps do you see for the Twin Cities-Dmitrov project?

What can physicians, and others within Minnesota, do to help defray the costs of the Russian visit to Minnesota? Also, what opportunities would they have to visit with the Russian group? There are several opportunities to visit with our Russian friends. The first is at the Minnesota Medical Association Annual Meeting in St. Cloud. The physicians have been invited as guests of the MMA to give them a view of the workings of a physician organization, something they do not have in Russia. There will be a place at the meeting where contributions can be made to help fund the visit. There are also two other opportunities to visit with the Russian delegation. One is a dinner at the Moscow on the Hill restaurant in St. Paul on Sunday, September 23, 6:00 p.m. The other is a boat cruise on Lake Minnetonka on Saturday afternoon, September 29, noon to 3:00 p.m. A letter with details about these events will have been sent out by the time of the printing of this article. However, if any member does not have the letter and wishes to come to one or both events, please call the RMS office

DR. MALINEE SAXENA was born in Romford, England and lived in India and Canada. She went to high school in Brookings, South Dakota. She graduated with a B.A. in physiology and child psychology from the University of Minnesota. Her medical degree was obtained in 1997 from the University of Minnesota Medical School. She then went on to complete her Transitional Internship at Hennepin County Medical Center in 1998. Dr. Saxena has completed her Dermatology residency at the University of Minnesota where she served as Chief Resident in 2000-2001. She currently resides in St. Paul with her husband Jeff.

September/October 2001

at 612/362-3704 for further details. We would like to have a great response! The reason for the need for fundraisers is that RFCP needed a loan to finance the roundtrip airfare. In addition, we need to raise money for expenses during their stay here. Members of the Russia 2000 delegation will be providing bed and breakfasts, transportation and time throughout the entire week.

The hope is that the physicians, administrators and social care workers will be excited and take home new ideas and, in addition, feel more empowered to carry through with these ideas and make them a reality. I would anticipate that there would be another visit to Russia in 2002 by more American physicians to continue with the sharing of ideas and understanding of each otherâ&#x20AC;&#x2122;s healthcare systems. If our readers have an interest in participating, you are invited to contact me at 763/7857731 for more information. In addition, we also have an ongoing commitment to send what medical equipment and supplies that we can to Dmitrov, as well as translated patient and physician education materials. While the needs are tremendous, I believe the people of goodwill here in the Twin Cities can, and will, help to make a difference for those in Dmitrov. â&#x153;Ś Interview conducted by Penny Chally, HMSA, RMSA, MMAA and member of the Russian 2000 delegation.

DERMATOLORY CONULTANTS, P.A. David W. Anderson, M.D. Lori R. Arnesen, M.D. Jennifer A. Biglow, M.D. Daryl A. Brockberg, M.D. Charles E. Crutchfield III, M.D. Humberto Gallego, M.D.

Pierre M. George, M.D. Noel A. Hauge, M.D. Dennis M. Leahy, M.D. Jane B. Moore, M.D. Harold G. Ravits, M.D. Jerry W. Stanke, M.D.

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The Journal of the Hennepin and Ramsey Medical Societies

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

September/October 2001

F EATU R E STO R Y

New Funding —

Academic Health Center New Expectations

T It’s clear that this new funding comes with new expectations ...

THIS PAST LEGISLATIVE SESSION PROVIDED a pointed discussion around the value and benefit of higher education. The argument centered on two key questions: Who benefits most from a college education—the individual or society? And then, who should fund the benefits of a college education—the public or the individual? In Minnesota and across our nation, the discussion surrounding appropriate levels of public funding for higher education will continue to draw attention to the very real value of education—to the individual and to the societies who benefit from an educated populace. This past legislative session, however, there was agreement in Minnesota on the importance of public funding for one area of higher education—health professional education at the University of Minnesota’s Academic Health Center. In a historic and unprecedented move, the Minnesota Legislature directed the next two tobacco settlement payments to an endowment for education within the Academic Health Center. Minnesota will benefit from this significant public investment in the education of health professionals. These are the doctors, nurses, pharmacists, public health professionals, dentists, and veterinarians who care for Minnesota. New Endowment Based on Strategic Vision

of positive outcomes for the state. It’s called accountability.

It’s clear that this new funding comes with new expectations—expectations of positive outcomes for the state. It’s called accountability. What Minnesotans are saying is that they want to understand what they’re getting for their public investment in educating new health professionals. They want to know that these professionals are committed to improving the health of our communities, conducting cutting-edge research to discover and deliver new treatments and cures and equipping our graduates with the knowledge and skills to help strengthen the economic vitality of our health industries. The Academic Health Center also heard that message loud and clear during a comprehensive planning and strategic visioning process completed more than a year ago by the faculty of the AHC. Supported by the Board of Regents, faculty engaged staff, students and the community in a process to lead health professional education, research and outreach/service in a new direction that reconnects with communities, produces new kinds of health professionals, and revitalizes the discovery mission—all in an environment of greater accountability. At the outset it was clear that meeting the expectations of Minnesotans required a new covenant with Minnesota to guide health education, research

BY FRANK B. CERRA, M.D.

September/October 2001

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

and outreach. The resulting plan—endorsed by the Board of Regents in July 2000—is now used as the basis for transforming the work taking place within the schools of the AHC. A key ingredient of the covenant was finding a new, sustainable source of funding. Anyone involved in health care today knows that traditional resources no longer provide the support necessary to fund education. In fact, the significant issues surrounding funding of health professional education—and medical education in particular—are not new in this state. As a leader in the development of managed care, Minnesota experienced the impact of reduced reimbursement rates earlier than most. The financial issues inherent in a teaching hospital led to the sale of University Hospital and a partnership with Fairview Health Services four years ago—a move that was recently reported by a distinguished external review panel to be the right decision at the right time. In an effort to provide efficient and quality patient care, the 18 individual university physician practices have now become one practice plan, University of Minnesota Physicians, or UMP, providing a more coherent entry point for patients and community physicians seeking the hope of scientific breakthroughs for their patients. By its very nature, however, education of health professionals is inefficient. The old mantra of “see one, do one, teach one” means that, at some point, you have to turn over the stethoscope and scalpel. Today’s health care marketplace is positioned for higher efficiency and greater productivity—the antithesis of quality one-on-one professional education. It simply takes time to transfer knowledge and skill from one generation to the next for professions as hands-on as ours. Yet it’s absolutely necessary for our students to train alongside community professionals throughout the state and to understand health care delivery within hospitals, clinics, schools and community centers. The cost of that type of mentorship is funded by decreasing sources of dollars—ranging from reduced Medicare/Medicaid payments to reductions in reimbursement rates spurred originally by managed care. Faculty within the Medical School, in particular, are caught in a strange paradox—as academic physicians, research is a key component of their role. In addition, care of patients, through UMP, places an increased demand on time—as it does for all practicing physicians. We see more patients to maintain the same level of practice income. When combined, the time that’s squeezed is that for the important work of educating students.

Today’s health care marketplace is positioned for higher efficiency and greater productivity — the antithesis of quality one-onone professional education.

(Continued on page 12)

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

September/October 2001

Academic Health Center (Continued from page 11)

Making the Case Involved a Lot of Help

How ironic that the core reason for the existence of a medical school—education—is the one area that has not been directly compensated. This endowment will allow us to change that fundamental gap for this institution.

Two years ago, there were a number of voices stating that the Academic Health Center—and in particular the University’s Medical School—were in trouble. Changes in academic medicine had led to the departure of more than 80 faculty members and the sale of University Hospital. Medical School morale issues affected the other

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September/October 2001

MetroDoctors

five disciplines. Yet we did not successfully make the case for immediate help. One of the key differences this year was the broad community consensus for adequate funding for the AHC and the placement of the Medical School front and center on the University’s agenda. Leaders from the AHC and individual schools met with leaders in business and industry, health care leaders, and community members. We traveled throughout the state to hear doctors, public health professionals, nurses, pharmacists, patients, and others tell us what was needed from our large public research university. And we had an opportunity to explain what would happen to enrollments in medicine, nursing, pharmacy, and other schools without a new, sustainable source of funding. These combined voices of community and business leaders were absolutely key. Also important was the voice of President Mark Yudof. He spoke of the Medical School’s needs from the date the Legislature began its session, also emphasizing the needs of Minnesota for expanded enrollments in nursing, dentistry, pharmacy, and other health professions. Faculty members from each of the health professional schools met with individual legislators to explain the problem— and to advocate for their peers and colleagues. The Medical School even set up a buddy program, pairing faculty with their own legislator. More than 40 organizations, including most medical societies and specialty associations, endorsed the University’s request on behalf of the AHC. It’s clear that those concerted voices led to the establishment of the new AHC endowment, which will, among other things, fund the core budget of the Medical School and help rebuild lost physicianscientist faculty. Unfortunately, the University overall did not share the same success. We’re very aware that our future strength is tied to the strength of this University— nationally, there is no such thing as a strong The Journal of the Hennepin and Ramsey Medical Societies

Medical School that’s not part of a strong University—so we’re now adjusting our timelines as we share the costs of the under-funding of core University services. New Covenant of Trust

Minnesotans should be proud of the size and significance of this new endowed investment in health professional education. Funded with the remaining two tobacco settlement payments in January 2002 and January 2003, the endowment is projected to reach nearly $374 million when fully funded in 2004. It is expected to generate $5.6 million next year, about $14.1 million in 2003 and up to $17 million annually thereafter. In the next two years, the endowment will be used to fund the Medical School’s core educational programs, hire new physician scientists in strategic areas, and expand our nursing, pharmacy, and rural dentistry programs. We see the endowment as a covenant of trust with the people of Minnesota. In fact, endowment funds will be committed to accomplishing exactly what we have promised through the seven elements of our strategic vision for the AHC. First and foremost, we are committed to creating and preparing the new health professionals for Minnesota. That means educating health professionals who understand how to promote the health of the increasingly diverse communities and cultures of this state, and who can work in a team with professionals from other disciplines. It is frequently humbling for me to recognize that the students who begin study this fall will exit our schools within four to eight years into a professional landscape I can’t begin to predict. Yet we do know that the new professionals must be able to use a broad range of integrative, preventive, and evidence-based tools. They must be able to understand and use information systems. And for the benefit of the people of this state, they must provide leadership within the health and care delivery community. MetroDoctors

Next, we are committed to sustaining the vitality and excellence of Minnesota’s health research. If we are to be on the leading edge of health research, we need to invest in our programs and reward excellence. We are actively rebuilding our research capacity. NIH awards are up, and our new Molecular and Cellular Biology Building will open next year. The third promise of our vision is to expedite the dissemination and application of new knowledge of health and delivery of health care in Minnesota. That’s an area where we clearly need improvement. Faculty within our schools and colleges regularly publish the outcomes of their research—yet we haven’t always shared our knowledge with the communities who’ve taught us so much. We also need to do a better job of translating our work into usable applications to benefit Minnesota’s health. However, we are working to develop three community sites for the education and training of our students as part of our effort to move more of education into the community. Next, we are committed to developing new models of health promotion and care for Minnesota, and we’re well-positioned to do this as we have six health disciplines within the AHC, not to mention the range of disciplines afforded by the University as a whole. We are working with state leaders through the National Institute of Health Policy in redefining health professional education and the state’s health care workforce needs. Health promotion will require more collaboration with public health, more significant communication skills training, nontraditional approaches, and a better understanding of anthropology and behavior. Actually, we can learn from our community colleagues in this area, including the Institute for Clinical Systems Improvement’s work in evidencebased medicine. A key promise of our vision involves the critical need to reduce health dispari-

The Journal of the Hennepin and Ramsey Medical Societies

ties in Minnesota and to address the needs of the state’s diverse populations. Over the years, we’ve regularly patted ourselves on the collective back when Minnesota is ranked in the top of surveys on health status. After all, we educate a majority of the health professionals for the state, so we must play a role, goes the thinking. If that premise is true, then we share in the responsibility for meeting the needs of those who don’t speak English and those whose culture views health differently than ours. Another expectation of our vision involves the commitment to using information technology to educate, conduct research, and provide service to individuals and communities in Minnesota. The practice of medicine today requires a familiarity with Internet resources merely to keep up with patients. We must teach our students—and the people who rely on them— the tools of life-long learning. And we must do so, not just because it’s the right thing to do, but also because health care knowledge today has an approximate lifespan of 18 months. The final element of our vision involves the largest community commitment—that of building a culture of service and accountability to Minnesota. There is no other way for us, in the Academic Health Center, to effectively meet the state’s needs for the right kind of health professional workforce without establishing stronger on-going relationships with the people we serve. That means continuing the work we began prior to, and during, the legislative session—of truly listening, talking and learning from the clinics and hospitals where our graduates work, to the businesses who fund health care for their employees, and to the people of Minnesota who have invested in us. ✦ Frank B. Cerra, M.D. is the Senior Vice President for Health Sciences at the University of Minnesota.

September/October 2001

Changes to Health Provider Contract Law in 2001

IMPORTANT CHANGES CAME ABOUT as

a result of the collaboration, planning and joint lobbying of the Fair Contracting Coalition representing Hennepin Medical Society, Ramsey Medical Society, Minnesota Medical Group Management Association, Minnesota Chiropractic Association, American Physical TherapyMN Chapter, Minnesota Spinal Cord Injury Association, and Minnesota Medical Association. The unprecedented results build on the prohibition on contract stacking won previously, leaving important work for the future such as a prohibition on managed care/no-fault (this year passed unanimously by the Senate), elimination of contract stacking everywhere; opening the black box of reimbursement allowables and withhold formulas; eliminating silent networks and fee shopping; preventing unilateral re-coding of claims and recoupments; and eliminating unreasonable delays in credentialing and contracting; etc. With the success attained in the 2001 legislative session, the Coalition is growing and dedicated to creating a fair contracting environment that will benefit providers and consumers by improving the accountability of health plan performance as it impacts the quality and accessibility of health services in Minnesota.

Minnesota Session 2001 Chapter 170 The Minnesota Legislature enacted chapter 170 in the 2001 session. Chapter 170 provides three areas of benefit to health care providers that will also help consumers: 1) Passive contracting limitations; 2) Mandatory disclosure of contract changes; these provisions became effective August 1, 2001; and 3) Provider options to decline and later participate in new categories of

medical service. The consumers benefit by a moratorium on managed care in auto medical health benefits. The Participation and Moratorium provisions were effective with the Governor’s signature on May 25, 2001. The Fair Contracting Coalition introduced this legislation to improve the relationships between physicians and other health care providers and health plans in Minnesota. Fairness in health care provider contracts is an area of significant concern for all members of the Coalition. The Coalition also believes that consumers would not receive “all appropriate medical care” as called for in the 1974 No-Fault auto

insurance statute if managed care plans limited consumers in the choice of providers and health services authorized for payment. (1) Passive Contracting Limits Previously, health plans were allowed to “passively contract,” that is, propose amendments to provider agreements with no need for the provider to respond, thus allowing new amendments to be automatically added by default. Under the new chapter 170, effective August 1, 2001, a provider must be given a notice in writing of an offer to participate in a new category of insurance under an existing provider

MMA Initiative Addresses Physician Hassles with Payers The Minnesota Medical Association has announced the launch of the new “Hassle Factor Surveillance System” in an attempt to resolve some of the administrative problems that pull physicians away from patient care. The Hassle Factor initiative responds to physician reports that glitches with third-party payers, including payment delays, drug formulary changes, and poor customer service, increase their job stress and decrease the time that they are available to patients. The Hassle Factor system will be used to track, analyze, and develop interventions for burdensome administrative problems. Copies of the Hassle Factor Log were mailed to physicians last May and can be found on the MMA Web site at http://www.mnmed.org/survey/HasselFactor/ HassleFactor_survey.htm. For more information on the MMA Hassle Factor Surveillance System, contact Janet Silversmith at (612) 362-3763 or jsilversmith@mnmed.org. ✦

BY RIC DAVENPORT Davenport & Associates

September/October 2001

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

agreement. The provider has 60 days from the postmarked date of the contract offer to consider participation. If the provider has not affirmatively signed the amendment and returned it indicating they want to participate, the health plan is prohibited from automatically adding them to the network for this new category of insurance. The effect of this amendment is to give the provider 60 days to review the implications of the proposed terms or relationship, and avoid being automatically put into a new category of service by default under a short or undefined timeline.

While the option to participate and the moratorium are scheduled to sunset or expire by June 30, 2002, the Coalition will work next session to make these permanent protections in law for providers and consumers. These changes improve the opportunity for providers to review proposed changes to their provider agreements and also work with health plans to improve terms based on reasonable opportunities to review and communicate prior to contract participation deadlines. ✦

The information provided in this article is not a substitute for legal advice. Providers interested in determining the specific application of this law to their practices or in negotiating the terms of provider agreements should discuss the matter with their own attorneys, accountants and consultants. Ric Davenport is a consultant with Davenport & Associates, (952) 471-0462.

(2) Mandatory Disclosure of Contract Changes The second area of protection for providers given by Chapter 170 is disclosure of contract terms. Changes to existing contracts must be disclosed to the provider. Changes that affect the financial reimbursement or alter contract policies and procedures governing the relationship between the health plan and the provider must be disclosed prior to the effective date of such changes. With this amendment, effective August 1, 2001 in Minnesota law, all health plan provider contracts, whether for medical services, workman’s compensation products, or auto medical coverages must have terms disclosed prior to the effective date. No longer can unilateral changes be made to provider agreements with notice given after the fact. For many health plans this is a major change in their method of contracting. We advise members to watch for changes in contracts that appear to be retroactive from the date you first became aware of the proposed change. Changes made without giving prior notice to the provider are now illegal. (3) Option to Participate Later After Initially Declining The third area of protection with Chapter 170 is the right to participate at a later date in a category of insurance previously offered where the provider initially declined participation. Should a provider decline to participate in the first offer of a new category of insurance they have the right to reapply in two years and bi-annually thereafter. Thus, no longer do providers need be concerned about being permanently “shutout” of a new product if they initially decline participation. MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

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September/October 2001

Celebrate Women in Medicine Month

EVERY YEAR THE FEDERATION of medi-

cine, led by the American Medical Association, designates September as Women in Medicine Month. This year’s theme—Leaders Making a Difference—celebrates the contributions of women physicians who are working hand in hand with their male colleagues to advance the profession and improve the health status of their communities. We’ve come a long way since 1915 when women represented 5 percent of the practicing physicians and the American Medical Association reluctantly seated its first woman delegate. That same year, the American Medical Women’s Association was founded to foster professional visibility and improve the standing of women in medicine.1 It would be another five years before women received the right to vote in the United States. Throughout the mid 20th century, women physicians continued to struggle for representation in their profession. Even during the World Wars, when doctors were in high demand, women were either barred from service or offered limited positions in the military. By the late 1960s, women in all walks of life began to question their place in society. With the growth of the feminist movement came an increased interest in the professions, including the practice of medicine. By the last decade of the 20th century, close to 45 percent of entering medical students were women. Women now make up 23 percent of all practicing physicians in the U.S. and in some specialties (OB-GYN, Pediatrics, Psychiatry) they are at parity or majority. Women physicians are, by and large, a young group—65 per-

B Y A N N E W . T O W E Y, M . D .

cent are under the age of 45 years.2 They lag behind their male colleagues in salary and academic rank, but there are positive signs of growth and acceptance in many areas. In the state of Minnesota, women are well represented in the Minnesota Medical Association, making up 22 percent of their membership, and 24 percent of the Minnesota physicians belonging to the AMA are women.3 So, how do we interpret the gains of women in the field of medicine? Has it been a positive experience? Will the momentum continue or will we see a backlash as occurred after the Flexner report of 1904 when 50 percent of

women’s medical schools closed within five years? Certainly, there have been many changes in our society over the past 100 years. Women receive an education equal to men, and are held to the same high standards of practice. Advances in science and technology have brought us such breakthroughs as antibiotics, organ transplantation, elimination of many communicable diseases, and more. Computers and information technology have put vast stores of knowledge at the fingertips of anyone with an Internet connection. Our culture has advanced and embraced the concept of basic human rights for all

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Ophthalmologist, Lakeview Clinic

September/October 2001

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

races, genders, creeds, and other minority groups. Men are justifiably proud of their wives’ and daughters’ accomplishments. Women are now free to pursue their goals, both educationally and professionally. So, how have women changed the face of medicine? I think that women have brought a sense of compassion, an innate ability to communicate, and a willingness to partner with their patients, which has humanized the face of medicine. From the early days of the women’s movement when women demanded the right to know and participate in areas of reproductive health and childbirth, women have been advocates for advances in wellness, long before it became fashionable to do so. I believe that women have also helped their male colleagues to achieve a more humane lifestyle by showing that however difficult, it is still possible to balance a family and a practice. Many courageous women refused to take “no” for an answer when told that “Girls can’t be doctors,” or “You can’t get married and still practice medicine,” to “Don’t you dare get pregnant on my residency service.” They gracefully, but forcefully, showed the way to others following in their footsteps. Where do we go from here? The theme of this year’s women in medicine month is leadership. Leadership seems to be like the weather, everyone talks about it, but not much is done. As physicians, we are already leaders whether we know it or not. Our patients look to us to set a good example and to give good advice. Just a few simple activities can yield tremendous results and be rewarding as well. How can you get involved? Join Minnesota Women Physicians. This organization started as an outgrowth of Alpha Epislon Iota, a sorority for women medical students present for many years at the University of Minnesota. Every year Minnesota Women Physicians hosts a series of informative workshops, lectures, and opportunities for networking for women in and around the Twin Cities. Each summer a picnic to welcome incoming female medical students is hosted by Minnesota Women Physicians at the home of Karin Tansek, M.D. The next event, scheduled for September 15, is a half-day seminar on “Financial Planning and Mid-Career Options.” A membership directory serves as a valuable resource for women physicians in the area. Volunteer to attend a function of Hennepin MetroDoctors

or Ramsey Medical Societies. In addition to governance opportunities, there are social events such as the recent Minneapolis Institute of Arts “Star Wars” Exhibit, and the upcoming Moscow-on-the-Hill dinner party or Lake Minnetonka Boat Cruise to meet and interact with physicians from Russia. Volunteer to be a delegate to the Minnesota Medical Association’s Annual meeting and House of Delegates. This is a wonderful opportunity to meet some of the leaders of our medical community. They want to meet YOU too! You will have an opportunity to learn about policy issues and even draft your own resolutions. The MMA’s committee on Women Physicians has sponsored a number of such resolutions including providing access to contraceptives, a ban on guns in school, protection from noisy toys, which can permanently damage hearing. As past chair of this committee, I have had a chance to meet many fine individuals who would never have otherwise crossed my path. Join the Women Physicians’ Congress of the American Medical Association. This congress focuses on addressing women’s health and professional issues of special interest to women physicians. A one-year trial membership is free. Membership information is available on-line at www.ama-assn.org/wps. In March 2002, the Women Physicians’ Congress will sponsor a program on women’s leadership issues and more in Los Angeles, California.4 It is important for women physicians to get involved in organized medicine at all levels. The family of medicine needs us to carry forward the great legacy of good health and equal access to health care in the 21st century. Other members of our society rightly look to physicians for advice and value our opinions. Let’s give them something to admire. ✦

References: 1. More, ES “The American Medical Women’s Association and the Role of the Woman Physician 19151990”. JAMWA 1990:45(5): 165-180 2. JAMA, September 6, 2000-Vol. 284, No. 9, 11141120 3. Minnesota Medical Association, Minneapolis, MN, membership services 4. American Medical Association, Women Physician Section at: www.ama-assn.org/wps

The Journal of the Hennepin and Ramsey Medical Societies

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September/October 2001

Highlights of the Code of Medical Ethics of the American Medical Association

SECTION E-2.00: OPINIONS ON SOCIAL POLICY ISSUES In the previous issue of MetroDoctors, we examined the historical evolution and overall structure of the AMA’s Code of Medical Ethics, along with the first of 10 sections. In this article, we turn to the section of the Code that encompasses the wide array of Opinions that are related to “social policy.” Social Policy and the Revised Principles of Medical Ethics To begin with, it should be noted that the original Code devoted an entire section to the relationship between physician and society. The importance of this relationship has been retained, not only through the provisions that are included in the section on “Social Policy Issues,” but also in the Principles of Medical Ethics. The preamble specifically refers to physician’s responsibility to society. Principle III, which remains unchanged from the 1980 version, elaborates upon this obligation by calling upon physicians to seek changes in laws that are contrary to the best interests of the patient. Principle VII emphasizes that a physician as a citizen of a community holds a special social responsibility to participate in activities contributing to its improvement. According to the June 2001 revision of this Principle, this extends to a responsibility to participate in activities that promote the betterment of public health. Finally, Principle IX, which has been added through the 2001 revision of the Principles, addresses the very basic social need for access to medical care. Topics Addressed Under “Social Policy” This section of the Code contains the largest

number of Opinions, which cover a large array of topics that are central to medical ethics. However, the majority of Opinions can be categorized under a few broad topics, including reproductive issues, genetics, organ transplantation, research, end-of-life care, and allocation of resources. The first Opinion of the section, also one of the oldest of the section, pertains to reproductive rights but also to physicians’ autonomy and freedom of practice within limits set by the law. Opinion 2.01 specifically states that Principles of Medical Ethics do not prohibit physicians from performing abortions. This is a clear illustration of how the AMA’s Code stands apart from the Hippocratic tradition, although in other instances, it builds upon that tradition more closely, for example in safeguarding confidentiality. Other Opinions related to reproduction address issues related to artificial insemination, in vitro fertilization, and surrogate motherhood, and consider various procedures related to embryos and fetal tissues. Some of these Opinions overlap with genetic issues, such as genetic testing, counseling and therapy, culminating with an Opinion on human cloning. At the other end of the biological spectrum stand all the Opinions related to end-of-life care, including advance directives, the withholding or withdrawing of life-saving treatment, as well as euthanasia and physician-assisted suicide. In regard to both of these activities, the Code states clearly that they are fundamentally incompatible with the physician’s role as healer. Other Opinions in this section address many of the ethical questions that often are raised in the context of end of life, such as futility and quality of life. Many ethicists have pointed to the difficulty of building consensus

BY FRANK A. RIDDICK, JR., M.D. AND KARINE MORIN, L.L.M.

September/October 2001

MetroDoctors

when using such terms, since they rely on highly subjective determinations. In this regard, the Opinion on futility in end of life care (Opinion 2.037) proposes a procedural approach at resolving disputes that can occur between physicians and patients, or more likely their surrogate decision-makers, when treatment decisions are made for those who are terminally-ill. Section 2.00 of the Code also addresses matters related to organ transplantation, a relatively recent development in medicine that has raised fundamental ethical questions in regard to individuals’ absolute control over their bodies and all of its parts, and the possibility to use organs or other tissues to save the lives of other individuals. In fact, issues related to organ transplantation present a vivid illustration of concepts fundamental to contemporary medical ethics, namely the principle of patient autonomy and the concept of utilitarianism, which often is referred to when arguing for a maximization of social goods, even at the expense of individual rights. Thus, the current system of organ procurement requires that an individual specifically consents to the donation of his or her organs. In the absence of such consent, organs are not removed, and the lives of patients waiting for organs remain in jeopardy. In contrast, if it were acceptable to society to maximize resources such as organs, and to ensure that patients in need of them had a high chance of receiving timely transplants, organ donation could be mandatory instead of voluntary, with arguably little harm to the dead donors. A similar tension between protecting the rights of individuals and maximizing social utility exists in the context of biomedical research, whereby new scientific knowledge can be gained that will benefit all of society and future generations of patients. Yet, current ethical standards, as captured in Opinion 2.07 on clinical

The Journal of the Hennepin and Ramsey Medical Societies

investigation and other related Opinions, ensure that the design of clinical research protocols be rigorously evaluated so to assure that the data produced will be scientifically valid and significant and that those who participate in research do so voluntarily. This fundamental requirement of human participation in research has given rise to the doctrine of informed consent. In fact, one of the earliest references to the notion of consent appeared in the Code in relation to human experimentation, in parallel to the development of the Nuremberg Code. And, despite the fact that these issues have been debated for several decades, controversy surrounding clinical trials continue to arise, as addressed in recent ethics policies developed by CEJA, including one on “sham” surgery (Opinion 2.076, “Surgical ‘Placebo’ Controls”) and a Report on international research adopted last June (CEJA Report 2 – A-01, Ethical Consideration in International Research). A small number of Opinions included in this section of the Code serve to reinforce that the role of physicians is defined in terms of their relationship to patients in need of medical care and not in terms of other social goods or state interests. Particularly, Opinion 2.06 prohibits physicians’ participation in capital punishment, even though executions are lawful in many states and at the federal level. However, this should not mean that physicians are not sometimes called upon by society to play a role in protecting society’s interests, such as intervening in cases of abuse or neglect (Opinion 2.02, (Abuse of Children, Elderly Persons, and Others at Risk) or in cases of risks to the public (Opinions 2.23, “HIV Testing” and 2.24, “Impaired Drivers and Their Physicians”). Together, these and all the other Opinions in section 2.00 of the Code that were not highlighted in this discussion, present ethical guidance that physicians can rely on when dealing with the many aspects of medical practice that are influenced by social attitudes and norms, and that conversely help shape changes within society. Physicians, therefore, may view the practice of medicine as a unique dialogue with society. The full content of the AMA’s Code of Medical Ethics is accessible online at www.amaassn.org/go/ceja. ✦ Frank A. Riddick, Jr., M.D. is Chair, Council on Ethical and Judicial Affairs. Karine Morin, L.L.M. serves as Secretary, Council on Ethical and Judicial Affairs.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

MARK

YOUR

CALENDAR

SEPTEMBER 2001 21 Contemporary Issues in Dialysis Midway Sheraton, St. Paul OCTOBER 2001 4-5 Annual Forensic Science Seminar Pillsbury Auditorium, HCMC 19-20

Society for Acupuncture Research Annual Symposium Pillsbury Auditorium, HCMC

25-26

Advanced Life Support in Obstetrics Pillsbury Auditorium, HCMC

Annual Mpls. Medical Research Foundation Event: Focus on Pediatrics

NOVEMBER 2001 29 – DEC.1 Annual Orthopaedic and Trauma Seminar Minneapolis Convention Center DECEMBER 2001 14 10th Annual Family Practice Update Ramada Inn, Bloomington The mission of Hennepin County Medical Center’s CME program is to provide organized, planned education activities to help physicians improve the delivery of medical care.

For more information, please call

HCMC Continuing Medical Education at (612) 347-2075. Fax (612) 904-4210. Toll Free 888-263-4262. www.hcmc.org

September/October 2001

Medical School Seeks to Increase Presence in “Silicon Valley of India”

IF KUMAR BELANI and international educa-

tion leaders at the University of Minnesota get their wish, the Medical School will have a stronger presence in Bangalore, India, in the near future. For starters, this would mean increasing the number of medical students doing clinical work in Bangalore, and developing faculty exchanges to collaborate on research in specific diseases. At the recommendation of Belani, who is spearheading the project, he and a contingent of medical school leaders traveled to the city in 1999 to explore its potential for clinical work and research. As a Bangalore native and graduate of the city’s renowned St. John’s Medical College, Belani knew the city’s untapped resources. “I knew Bangalore was the perfect place for the Medical School to make strides in globalizing medical education and research to benefit patient care,” said Belani. Disease, including heart disease and rheumatic fever, is rampant in Bangalore, linked likely to the country’s extreme poverty. More than 400 million or 40 percent of the country’s one billion people now live in substandard conditions. Tuberculosis is India’s number one health problem, and the incidence of HIV/ AIDS is increasing. It is also going largely untreated. This widespread disease has spurred the establishment of world-class heart hospitals and other medical facilities in the city, including HOSMAT Hospital, the Manipal Heart Foundation and Manipal Pediatric Heart Hospital. “Bangalore has an excellent medical infrastructure in place, in which students and faculty can learn and make a real contribution,” said Phil Peterson, infectious disease specialist and codirector of the Medical School’s office for international education and research programs. MetroDoctors

The opportunities for research there are also excellent, and include prospects for funding from NIH and other sources. A research collaboration on HIV/AIDS is already underway, University of Minnesota faculty with faculty from St. John’s Medical headed by infecCollege that visited Bangalore in December 2000 to conduct the first tious disease and International Medical Update. public health specialist Alan Lifson. These and other factors make Bangalore a Similar collaborations are in the offing. desirable place for students and faculty everyThree University of Minnesota medical where. Several medical schools, including students have completed clinical rotations in Harvard and Johns Hopkins, have entered the Bangalore since 1999, when exchange agreecompetition to establish a presence. “We’d be ments were signed with St. John’s, HOSMAT, open to working with other medical schools as and Manipal Hospitals. Several more students well as the talented physicians in Bangalore,” are exploring this option. said Peterson. “All of us can learn from their “The student learning opportunities in dedication and third force humanitarianism.” Bangalore are tremendous,” said medical school Bangalore has potential for public health, education dean Greg Vercellotti. “The quality nursing and veterinary medicine as well. Uniof the facilities is excellent and the chance to do versity Senior Vice President for Health Sciences clinical work and research in this part of the Frank Cerra is interested in establishing proworld provides our students with an invaluable grams in these areas. “Students and professioneducation.” als in all the health sciences can learn and make Last year, Mary Ollapally, dean of St. John’s contributions in this important arena,” he said. Medical College, visited the medical school to Part of the University’s capital campaign explore increased student and faculty exchanges has been earmarked to fund international mediwith Bangalore. To date, funding has prevented cal education and research projects like the BanBangalore students from completing clinical rogalore exchange. If funding allows, an advance tations here. team will head to Bangalore again this fall, Known as the Silicon Valley of India, the headed by Cerra and Dean Michael. There, they medical school is looking forward to the day will finalize expansion of the University’s preswhen the technology companies located in Banence in Bangalore. All those concerned in both galore will become involved in medical research countries have only to benefit. ✦ in priority areas. “The fact that the city is so advanced technologically, and that it is English speaking, are great advantages,” said Peterson.

The Journal of the Hennepin and Ramsey Medical Societies

September/October 2001

MN PERSPECTIVE

Public Health Fared Well in Legislative Session

THE HEALTH OF THE PUBLIC generally fared well during this past legislative session. I’m pleased that in response to the Governor’s proposals, more health initiatives were passed this session than had been the case for a number of years. We, in public health, very much appreciate the support and involvement of physicians and others in passing and implementing these and other initiatives to improve the health of our communities. The Children’s Health Insurance Expansion initiative, in the Department of Human Services budget, provides funding to ensure continuous health care coverage for 20,000 lowincome kids who either don’t have coverage now, or fall in and out of coverage due to the complexity of eligibility rules. This represents the first major step in years toward insuring all kids in our state. One of our biggest victories in the Department of Health budget was the initiative to eliminate racial and ethnic disparities, which was passed with most of the funding that we requested ($13.9 million over the biennium and ongoing). This legislation gives us added resources to address long-standing health disparities among American Indians, populations of color, and immigrants and refugees. Virtually across the board (and notably at all income levels), these populations have worse health outcomes than their white counterparts here, and often worse than the same populations in other states. Our Office of Minority and Multicultural Health published a report a few years ago, and an update more recently, which outlines some grim statistics and offers recommendations on how to improve them. This legislation focuses particularly on immunizations, infant mortality, BY JAN MALCOLM Minnesota Commissioner of Health

September/October 2001

HIV/AIDS and sexually transmitted diseases, breast and cervical cancer screening, cardiovascular disease, diabetes, and unintentional injuries and violence. The Minnesota Department of Health’s Office of Minority and Multicultural Health can help practices assess their “cultural competency” to ensure that medical treatment and patient education are understood and used by all their patients. $2.2 million for the biennium was funded to provide grants to communities for suicide education and outreach. Depression is a significant cause of suicide. More outreach and education, complemented by increasing recognition of depression in the primary care setting, should result in more people seeking advice from their health care providers about depression. Our Emerging Health Threats initiative received $3.6 million, about 75 percent of what we’d proposed. It helps to stabilize funding and add capacity for the MDH Public Health Laboratory, which has been funded by a combination of dwindling federal grants and fee revenues intended for other purposes. The Medical Education Endowment Expansion, begun in 1999, will receive an additional $374 million in principal, (yielding a total of approximately 17 million per year in investment income). This dedicates all of the state’s remaining one-time tobacco settlement proceeds for the University of Minnesota Academic Health Center to expand medical education in Minnesota. The state Poison Control System received $2.7 million, which fully funds its operation for this biennium. However, the Legislature still has declined to guarantee base funding for future years. This system provides the public and health care providers statewide with information and treatment advice about poisonings and toxic exposures. MetroDoctors

MDH received $2.65 million to support initiatives recommended by the Long Term Care Task Force to support planning grants, construction projects and additional options for Minnesota’s long-term care system. Physicians are well aware that the population is aging, and that we need a variety of care settings and approaches to meet those needs. For the first time, there will be direct state funding for community clinics ($4 million per year), and a doubling of current funding for rural hospital capital improvement grants (to $5 million per year). In addition, a new intergovernmental transfer will generate additional federal funding to help offset the disproportionate costs of charity care born by Hennepin County Medical Center and Regions Hospital. Direct public funding should help to eliminate some of the cost shifting on to private payers to support all of these important safety net providers. While the Governor’s proposal for a comprehensive teen pregnancy prevention effort was not adopted, a number of Youth Health Improvement activities were funded, including youth risk behavior programs and expansion of public health nurse home visiting services. All told, there were more health policy issues on the table this year than we’ve seen in awhile. And given the number of issues still to be addressed to keep high quality health care available and affordable in our state, we should expect that trend to continue.✦ Jan Malcolm was appointed Minnesota Commissioner of Health by Governor Jesse Ventura in January 1999. The Minnesota Department of Health is the state’s lead public health agency, responsible for protecting, maintaining and improving the health of all Minnesotans.

The Journal of the Hennepin and Ramsey Medical Societies

October 11 is Declared Turn off the Violence Day

IMAGINE A DAY WITHOUT VIOLENCE.

No need to inquire about a patient’s bruises. No bandages to cover batterings. No surgeries to cut out bullets. No stitches to pull together knife wounds. No sexual assault evidence exams. No disrespect among colleagues in the workplace. And for those of us who are parents, no worries that our child might be among the next victims. That’s the goal of the Turn Off the Violence campaign. October 11 has been proclaimed Turn Off the Violence Day this year. On that day the Turn Off the Violence Coalition — which brings together the voices of medical professionals, educators, law enforcement, social service agencies, clergy, and parents — asks people to start with the simple step of turning off violent media. Many Americans are horrified and baffled by real life crime and violence and yet sit down every evening to watch violent videos, listen to violent music, play violent video games, go to violent movies, and watch television shows that make violence and disrespect look ordinary, macho, heroic, and even humorous. And for too many people, violence is becoming the ordinary way of resolving conflict, releasing emotions, and demonstrating power. Among those who have concluded that there is a direct causal link between media violence and violent behavior are the American Academy of Pediatrics, American Medical Association, American Psychological Association, National Institute of Mental Health, National Institute on Media and the Family, U.S. Centers for Disease Control, and the U.S. Surgeon General’s Office. Kids in violent families or violent neighborhoods may be most at risk. Media violence is one form of violence we can all turn off. But that’s just the beginning! Turn Off the Violence is also working to educate people about anger management and nonviolent conflict resolution. Among the free resources downloadable from their website are an Educators’ Guide and a Community Action Guide, both filled with practical, concrete ideas about how each of us can help turn off violence in our homes, workplaces, schools, and communities. In 1994 the Minnesota Medical Association recognized Turn Off the Violence “for work that has significantly benefited victims of violence and for efforts to end violence in the state of Minnesota.” BY SHEILA MILLER C o - f o u n d e r, Tu r n o f f t h e V i o l e n c e

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

For more information about the Turn Off the Violence campaign and coalition membership, visit their website at www.turnofftheviolence.org or contact Sheila Miller, Executive Director, Turn Off the Violence, P.O. Box 27321, Minneapolis, MN 55427, (763) 529-6227. Excerpts from Turn Off the Violence reproducible handouts. At home... 1. Turn off violent entertainment and do something fun, safe, and healthy. 2. If you’ve already chosen to turn off violent entertainment, turn it back on and see what America’s children are being exposed to. 3. Write at least one letter to a television advertiser, video game company or music company. Turn Off the Violence offers sets of postcards you can use to voice your opinions. If you have kids... 1. Teach your kids to love reading. (Language skills help them express anger without violence.) 2. Demonstrate respect. 3. Demonstrate nonviolent conflict resolution. 4. Talk about your values. 5. Listen. 6. Set boundaries. At work... 1. Consider how you resolve conflict and react to stress. Do you ever use words that shame, humiliate, intimidate? Do you hold in your anger and take it out later on others? Managing anger is a discipline that takes practice. 2. Lead by inspiration rather than intimidation. 3. Sponsor a Turn Off the Violence event for employees and their families, or the community. Today you can be part of the solution by turning off the violence. ✦ Footnote: Turn Off the Violence began in Minnesota in 1991 but had lain dormant in recent years after a change in leadership. The Hennepin Medical Society, an original member of the Turn Off the Violence coalition, is pleased to announce that the campaign is back under the wings of its founders and an enthusiastic board of directors and they’re soaring with a renewed sense of energy.

September/October 2001

P R E S I D E N T ’S M E S S A G E ROBERT C. MORAVEC, M.D.

From Where I Sit… “Patient Communication and Disclosure as Patient Safety Tools” RMS-Officers

President Robert C. Moravec, M.D. President-Elect Peter H. Kelly, M.D. Past President John R. Gates, M.D. Secretary Jamie D. Santilli, M.D. Treasurer Peter J. Daly, M.D. RMS-Board Members

Kimberly A. Anderson, M.D., Specialty Director Victor S. Cox, M.D., Specialty Director Charles E. Crutchfield, III, M.D., At-Large Director Kelley C. du Ford, Medical Student Thomas B. Dunkel, M.D., MMA Trustee Michael Gonzalez-Campoy, M.D., At-Large Director James J. Jordan, M.D., Specialty Director Kathryn M. Klingberg, M.D., Resident Physician Charlene E. McEvoy, M.D., At-Large Director Ragnvald Mjanger, M.D., Specialty Director Kenneth E. Nollet, M.D., Ph.D., At-Large Director Thomas F. Rolewicz, M.D., Specialty Director Paul M. Spilseth, M.D., At-Large Director Lyle J. Swenson, M.D., MMA Trustee Charles G. Terzian, M.D., Specialty Director Jon V. Thomas, M.D., At-Large Director David C. Thorson, M.D., Specialty Director Russell C. Welch, M.D., At-Large Director RMS-Ex-Officio Board Members & Council Chairs

Brent R. Asplin, M.D., AMA Young Physician Section Blanton Bessinger, M.D., MMA President Kenneth W. Crabb, M.D., AMA Alternate Delegate Paul J. Dyrdal, M.D., Sr. Physicians Assoc. President Stephen P. England, M.D., Community Health Council Chair *Michael Gonzalez-Campoy, M.D., Education Resource Council Chair Eleanor Goodall, Alliance President Frank J. Indihar, M.D., AMA Delegate William E. Jacott, M.D., U of MN Representative Matthew D. Layman, M.D., AMA Delegate for American Society of Anesthesiologists Melanie Sullivan, Clinic Administrator *Lyle J. Swenson, M.D., Public Policy Council Chair *Russell C. Welch, M.D., Communications Council Chair *Also elected RMS Board Member RMS-Executive Staff

Roger K. Johnson, CAE, Chief Executive Officer Doreen M. Hines, Membership & Web Site Coordinator Sue Schettle, Director of Marketing & Member Services

September/October 2001

RECENTLY THE MINNESOTA Medical Association convened its Patient Safety Task Force to help address physician specific issues in the patient safety arena. This task force will help provide a voice from the physician’s perspective in dialogues with Minnesota groups that are addressing patient safety issues and will help identify strategic methods for improving patient safety in the clinic practice setting. It is expected to make specific recommendations to the MMA Board of Trustees regarding policies specific to patient safety. A key issue to be addressed initially by the task force is that of disclosure. Disclosure is defined as the communication of information regarding the results of a diagnostic test, medical treatment or surgical interventions. Disclosure in the face of an adverse patient outcome involves the honest and factual description of the occurrence as well as the possible implications of the event on the patient’s health and wellbeing. Disclosure is not meant to be an admission of guilt or liability or finger pointing to quickly allay the blame somewhere else. Disclosure should be timely, purposeful and disciplined. Disclosure also means a commitment by the physician to follow through with the patient’s family and to stay involved and be available to discuss questions with the patients and their family. A key determinate in many malpractice suits is the lack of response by the physicians involved in an adverse event. Many patients sue their physicians and hospitals just to find out what happened and answer questions that could (should) have been answered shortly after the event. Disclosure helps enable the emotional healing that should occur following an adverse event. Many times the emotional healing is just as important as the physical healing following an illness or injury. Failure to disclose and openly communicate with the patient and family following an adverse event has the potential to become malignant with buildup of resentment and anger. Communication is an important safety MetroDoctors

tool. It is a skill set that should be actively cultivated and developed. For many of us, it may require professional training or assistance to overcome some of our bad habits. But, communication is a fundamental component of the physician-patient relationship and one in which we should be setting the standard. It cannot be taken for granted. The substitution of a designee to speak on a physician’s behalf can have its own unintended consequences. The designees may not have the background to adequately discuss the events and outcome at hand. More importantly, it can give the impression that the physician did something wrong and has something to hide. Communication and disclosure go hand in hand. Documentation of such discussions is also critical to its success as a patient safety tool. The documentation should identify who was present during the discussions as well as what was discussed and also should try to document the questions that were answered. Remember, a key message to patients and families is that an adverse event is multi-factorial in a complex system and a significant amount of investigation and review must be completed as part of the event review process. Physicians should avoid jousting and finger-pointing when discussing errors. So what can you do right now to improve communication and disclosure? I would suggest the following steps: • Work with your clinic staff and office managers to develop a policy around disclosure and patient communication in the event of an adverse outcome. • Critically evaluate your own patient communication skills (be honest) and look for opportunities to enhance your (Continued on page 25)

The Journal of the Hennepin and Ramsey Medical Societies

RMS ALLIAN CE N EW S

President’s Message (Continued from page 24)

In Memoriam SUBBAYAMMA ATLURU, M.D. died July 13 at the age of 49. She graduated from Guntar Medical College, India in 1980 and completed her internship and residency at the University of Minnesota in 1993. Dr. Atluru was board certified in Family Practice and practiced at North Suburban Family Physicians in Shoreview. She joined RMS in 1993. ✦ MetroDoctors

WHO? WHAT? The Ramsey Medical Society Alliance has been a force in our medical community for almost 80 years and, yet, I am continually amazed at how many people do not know who we are or what we do. Clearly there is a need to better promote ourselves within our community. The more people understand what it is that we do, the more people will be interested in participating and joining us in our mission to promote educational and charitable endeavors, which improve health and quality of life within our community. The Alliance has many valuable projects of which we should all be proud. This past March, we raised almost $20,000 with the RMS Foundation to support Spare Key Foundation in their mission to help families with critically ill children. Those of you who have heard Patsy Keech from Spare Key speak about the difficulties that these families endure know that there is seldom a dry eye in the house by the time she is finished. This past April, our Body Language Health Fair once again educated St. Paul third graders about healthy, life-long habits. Volunteers, from our Alliance and the community, staffed booths including physical fitness, nutrition, mental health and self-esteem, a mock hospital room, our skeletal system, a HiTECH Heart as well as a presentation by The Extinguisher (The AMA’s anti-smoking superhero). The gratitude expressed by these young students and their teachers was reward enough, but we also got to see several of our members dress up as The Extinguisher in a high tech body suit complete with muscles. Talk about the rewards of volunteerism! Our annual Holiday Auction not only provides us with the opportunity to get together with friends for a relaxing, fun-filled evening, but also raises funds for our various philanthropic projects. This past year those included the American Cancer Society, Caring Hearts for the Homeless, Festival of Trees, First Steps, Growing Home, Model Cities, Sexual Violence Center, Wigs Without Worry and the AMA Foundation. We choose our projects based on what our members are interested and involved in. We choose to serve our community, but we also want to support you.

The Journal of the Hennepin and Ramsey Medical Societies

Brenda Andrewson Co-President

Our Alliance is not just about health education and fundraising. We also provide support to our physicians, our families and each other. We’ve hosted programs about mid-life career changes, the stresses of the medical marriage and how to have an impact on the legislative process. We have a variety of interest groups such as a book club, two bridge groups, an investment club and a trusted friends group. For many of us, the best benefit of belonging to the Alliance is the strong network of friends who truly care for one another. So, how do we go about promoting ourselves? I think each and every one of us needs to take on the task of letting others in the medical community know what we do. If each of us makes a point of telling at least one potential member about the great things we do and encourages that physician spouse to attend a meeting or program, we will see results. We all know physician spouses who are not yet members of the Alliance. Perhaps some of them are the husbands/wives of your spouse’s partners, your friends or your neighbors. The next time you see them, why not tell them about what we do? You don’t need to become a telephone solicitor, just tell them about the parts of the Alliance that you most enjoy and invite them to give us a try by attending a meeting or program. Some of you may feel uncomfortable trying to “sell” the Alliance to your friends and acquaintances. Hey, I’m a charter member of the Minnesota Shy Club myself, but we all have to take part in this membership effort. Our September meeting is designed to make this easy for all of us. On September 19, join us for lunch and a discussion about the RMS Alliance, who we are and what we do. We encourage each of you to invite a potential member to join us. And if a luncheon meeting doesn’t fit with your schedule, join us for a wine tasting with spouses on October 4. The Ramsey Medical Society Alliance has given so much to our community and to each of us personally. We owe it to ourselves, and to our Alliance, to keep it strong and growing. ✦ September/October 2001

Ramsey Medical Society

skills by participating in communication workshops. Remember that 20 to 25 percent of patients will switch physicians solely because of communication issues! • Get involved in your health care system to review and lobby for good disclosure policies. Ask to see a copy of the policy from your administrator or patient safety committee representative. • Involve your patients in a discussion about their safety within the healthcare delivery system. Encourage them to ask questions of the healthcare team. Give your patients tips to improve their well-being during hospitalization. Ask patients to verify the site of surgery prior to entering in the hospital. • If you are involved in an adverse event, ask your healthcare system administration leaders to involve you in the discussions with the patient and family and take an active role in their healing process that is needed following an adverse event. (Hospital policies may already require that physicians lead the discussion with patients and families). To shy away from our responsibility for communication is to abdicate a key component of the doctor-patient relationship. This is a critical issue that will help define our overall success in improving patient safety. ✦

C H A I R ’S R E P O R T VIRGINIA R. LUPO, M.D.

HMS-Officers

Chair Virginia R. Lupo, M.D. President David L. Swanson, M.D. President-Elect T. Michael Tedford, M.D. Secretary Richard M. Gebhart, M.D. Treasurer Michael B. Ainslie, M.D. Immediate Past Chair David L. Estrin, M.D. HMS-Board Members

Michael Belzer, M.D. Carl E. Burkland, M.D. Jeffrey Christensen, M.D. William Conroy, M.D. Paul A. Kettler, M.D. James P. LaRoy, M.D. Kathy Larson, Alliance President Ronald D. Osborn, D.O. Joseph F. Rinowski, M.D. David F. Ruebeck, M.D. Richard D. Schmidt, M.D. Leah Schrupp, Medical Student Marc F. Swiontkowski M.D. D. Clark Tungseth, M.D. Joan M. Williams, M.D. HMS-Ex-Officio Board Members

Barbara H. Subak M.D., Senior Physicians Association Lee H. Beecher, M.D., MMA-Trustee Karen K. Dickson, M.D., MMA-Trustee John W. Larsen, M.D., MMA-Trustee Robert K. Meiches, M.D., MMA-Trustee Henry T. Smith, M.D., MMA-Trustee David W. Allen, Jr., MMGMA Rep. HMS-Executive Staff

Jack G. Davis, Chief Executive Officer Nancy K. Bauer, Associate Director

September/October 2001

NOW THAT I’VE HAD my 25th medical school

class reunion, I realize I’ve been around long enough to appreciate the fact that there are pendulums in medicine and that they are actively swinging. They have a slow periodicity, possibly measured in decades, but they do swing. I was struck most obviously by this recently as I see the controversy in my field surrounding vaginal birth after C-section. In 1981, I remember the sense of walking into uncharted, but wellreasoned, territory when we let the first few women with one previous C-section undergo a closely monitored trial of labor, and they succeeded beautifully. The difference in post-delivery morbidity and hospital stay almost made us giddy, after the routine of scheduling five to seven repeat sections a week. We were seeing the 99 percent success rate then, not the 1 percent severe complication rate. Now, though, as a specialty, we’re looking much more at the 1 percent devastating uterine rupture rate, complete with fetal neurologic morbidity and infectious hemorrhagic complications in the mother. And so we are quickly turning back towards repeat C-sections, probably until the problems inherent in operating for the fifth time on a patient rise again to our collective consciousness. Similarly, I speculate on whether there aren’t other pendulums out there, that may not be recognized because we may not be in one place long enough to observe them. For instance, we’ve all heard anecdotes about residents in the first half of the 1900s, in which residents almost paid for their own training rather than being paid for it. As teaching hospitals lost funding for postgraduate medical training in the last decade, the notion of requiring payment from prospective residents, in exchange for their being given access to patients and a place within a learning environment, has seemed not completely improbable on occasion. Another pendulum could be swinging. The recent increase in membership in organized medicine within the Twin Cities is another ebb and flow phenomenon that has been MetroDoctors

very welcomed by existing members of the Hennepin and Ramsey Medical Societies. I like to think it is due to awareness by physicians of the need to join together to speak with one voice as a profession committed to taking care of people and not just a pendulum swing, but I can’t be certain of that. The current turmoil in medical cost reimbursement that we have seen so dramatically played out in the Twin Cities in the last month in the Allina/Medica tsunami restructuring makes me wonder if there may be a pendulum going toward the direction of fee-for-service reimbursement that we thought we’d left behind a couple of decades ago. Some of these reflections beg the question of the other under-appreciated importance of corporate memory in our medical institutions. For without such memory, our institutions are bound to be periodically as barren as the northern Minnesota forests leveled by the fires of a couple of years ago. When an old tree or two fall, the rest of the forest structure remains and can regenerate around the framework still present. But when an entire forest is wiped out, from the old growth hardwoods to the weeds, new growth is completely dependent on what blows into the area or is deposited by visiting birds. I strongly argue that as baby boomers start to approach retirement years and deplete the ranks of practicing physicians in massive numbers, and that as institutions try to restructure in the interests of re-defining their core missions, that we not throw out all the old trees — those who would provide a framework for new trees to fill in and eventually grow to full stature. Not all clocks are quartz; some have pendulums and a periodicity that we can only define after more than half the cycle has been completed. ✦

The Journal of the Hennepin and Ramsey Medical Societies

HMS ALLIAN CE N EW S K AT H Y L A R S O N

• •

How does HMSA fulfill this mission statement? How do we impact educational and charitable priorities in our community? • Body Works 2002, April 8-12 at Lutheran Brotherhood Auditorium, will be our 19th annual health fair for Minneapolis public school third graders. We have over 100 volunteers to present this successful health project that educates and motivates children to work at staying healthy. • Provide materials to STOP America’s Violence Everywhere (SAVE). This topic is also one of the Body Works areas. • September 2000 was the first “Stepping Stones Gala” in celebration of the first 90 years of the HMSA (the oldest medical alliance in the country). This event raised more than $12,000 for three teen clinics. We hope to be involved in another gala fundraising event next year. • HIV/AIDS education folders have been distributed to more than 200,000 middle school students. This project, under the able leadership of Diane Gayes and Dianne Fenyk, has provided information folders to adolescents with an accompanying curriculum guide for teachers. We believe this is an effective model for the primary prevention of STDs and HIV/AIDS within the targeted middle school population. These materials have been distributed throughout Minnesota and several other states plus in Tanzania, Kenya and Russia. Who are the others with whom we work in partnership? • Since all the above activities involve funding, we are grateful to The Minnesota MetroDoctors

•

Medical Association, Hennepin Medical Society, Hennepin Medical Foundation and our own HMSA membership for support. We have also benefited from other county alliances for HIV/AIDS funding. Through the HMSA Philanthropic Fund we have also contributed to the American Medical Association Foundation to benefit the University of Minnesota Medical School and the Medical Student Assistance Fund and the Medical School Excellence Fund. We lend our support to U of M medical student and resident partners organizations and plan to work on SAVE projects with them. We have a tradition of an annual planned event with Ramsey Medical Society Alliance and look forward to more joint involvement in the future.

How does HMSA promote the health and well-being of its members? • By providing volunteer service opportunities to our community we feel we help enrich and add balance to our members’ lives. • We also value the old and new friendships and social activities this organization provides. We start off each September with our Opening Event, a relaxed mid-day gathering of members for lunch and socializing. This year, Dr. Gary and Barbara Hanovich have graciously opened their home to us for this occasion to be held Friday, September 14. • Another fall tradition is the joint meeting of Hennepin Medical Society Alliance and Ramsey Medical Society Alliance. This year is HMSA’s turn to host this gathering. We have arranged a backstage tour Friday, October 26 at the Guthrie Theater followed by a lobby lunch and speaker to discuss the past and future Guthrie with us. This should be a delightful and informa-

The Journal of the Hennepin and Ramsey Medical Societies

tive day with the new facility plans underway for the theater. We are fortunate to have this world-class theater available and affordable for our enjoyment for the past 38 years. Here are words from Guthrie Artistic Director Joe Dowling to get us ready for our visit:

A Place of Magic Welcome to the Guthrie Theater! The Guthrie is a place of magic. Visiting our backstage gives you a glimpse of the magic in the making. A thriving and lively artistic community is based in this building, where extraordinary actors, artisans and artists work. The process is complex and challenging, and it’s all aimed at serving our audience by presenting the very best of the world’s theatrical literature to the very best of our abilities. There’s nothing like the Guthrie. Everything you see on our stage is built to create the world of the play, where talented actors bring the words of the best playwrights to life for you. Enjoy your visit and come back soon. Alliance members of both Ramsey and Hennepin are encouraged to plan to come to this event and invite your friends to join you. Watch your mail for further information. We welcome any physician spouse (male or female) to visit our activities and consider joining HMSA. For more information please call Kathy Larson (952) 925-4476. ✦

September/October 2001

Hennepin Medical Society

THE HENNEPIN MEDICAL ALLIANCE is an educational and charitable volunteer organization, working in partnership with others, to promote the health and well-being of its members and the community through education, advocacy and service.

Ethical Accountability Guidelines for Physicians in our Changing Healthcare Environment Background Since 1997, the Hennepin Medical Society’s Ad Hoc Ethics Task Force, co-chaired by Drs. Barbara LeTourneau and Burton Schwartz, has worked with Karen Gervais, Ph.D., Director of the Minnesota Center for Health Care Ethics, to respond to concerns of the Society’s members about challenges to the physician-patient relationship in our changing health care environment and society. Chief among these concerns were the independence of physician clinical judgment, and the ability of physicians to be effective patient advocates. Initially, the Task Force discussed case studies to help it define ethical guidelines for physicians. Commentaries based on Task Force discussions of several cases were published in the HMS Bulletin throughout 1997-99. Then, in September of 1999, the Task Force began a formal process to articulate ethical accountability guidelines for physicians. In August, 2000, the HMS Board discussed and made recommendations concerning the resulting Task Force document, Ethical Accountability Guidelines for Physicians in our Changing Healthcare Environment. Then, at its March 22, 2001 meeting, the HMS Board unanimously passed the motion that “each HMS member consider and voluntarily adopt these guidelines as an ethical framework for practice.” We are pleased to present the fruits of our labor on the pages that follow. Member responses to the Guidelines is welcome. Please address your responses to Jack Davis at jdavis@mnmed.org or Barbara LeTourneau, M.D., at bletournea@aol.com. Introduction Health care is a vital human service, not a commodity. Health care services are delivered through a unique human relationship, one patient at a time. While the complexity of modern health care necessitates a team approach to care delivery, the physician-patient relationship remains the centerpiece of each patient’s encounter with the health care system. In an environment characterized by “perverse financial incentives, fierce market competition, and the erosion of patients’ trust,” the professionalism of the physician, and thus the integrity of the physician-patient relationship, is increasingly challenged and questioned.1 Marketplace rules and governmental regulations are insufficient bases for the preservation and protection of this crucial relationship. Ultimately, the professionalism of the physician is its critical safeguard.

September/October 2001

The Ad Hoc Ethics Committee of the Hennepin Medical Society has elaborated ethical guidelines for core domains of physician responsibility in the physician-patient relationship. These domains include: (1) Fiduciary obligations (2) Medical decision making obligations (3) Obligations due to patient vulnerability (4) Obligations to deliver culturally responsive health care (5) Obligations to protect patient confidentiality (6) Obligations to monitor personal standards2 The Committee’s guidelines for ethical accountability in each of these domains flow from its understanding of the physician-patient relationship as a fiduciary relationship. The largest obligation of the physician is to serve as the fiduciary of the patient’s best interest insofar as the patient requires medically appropriate health care services to avoid harm and to receive benefit. In the pursuit of this fiduciary relationship, the physician must strive to be attentive to, and respectful of, the values and beliefs of the patient. The physician’s complex role as trustee of the individual patient’s welfare is unique and irreplaceable. The guidelines are intended to capture the crucial dimensions of physician accountability in the physician-patient relationship.

(1) FIDUCIARY OBLIGATIONS The historic calling associated with the physician is a fiduciary one: the physician is to promote the best interest of the patient. To act in the patient’s best interest is to provide medically appropriate care that, in the physician’s professional judgment, will: • remove or prevent harm to the patient, and • benefit the patient. General Fiduciary Guideline: As the patient’s fiduciary, the physician has an ethical responsibility to always act in the patient’s best interest (i.e., provide medically appropriate care that the physician believes will remove or prevent harm to the patient and benefit the patient). (a) CONFLICTS OF INTEREST: Conflicts of interest and conflicts of obligation have great potential to compromise the physician’s pursuit of the patient’s best interest in our

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The Journal of the Hennepin and Ramsey Medical Societies

current health care environment. A conflict of interest may arise between physicians’ self-interest and physician’s fiduciary obligations. A conflict of obligation exists when the physician is positioned as a double agent: as an agent of the patient and as an agent of a third party with potentially competing interests. Guidelines: • The physician has an ethical responsibility to act in the patient’s best interest in preference to self-interest. • The physician has an ethical responsibility to clearly recommend and explain, and advocate coverage for, the diagnostic/therapeutic option consistent with the patient’s best interest and the patient’s informed choice. • The physician has an ethical responsibility to analyze and personally clarify what kinds and degree of risk-sharing arrangement, and/or contractual terms might compromise their pursuit of the patient’s best interest. • The physician has an ethical responsibility to disclose conflicts of interest to patients with patient informed consent whenever appropriate. • The physician has an ethical responsibility to seek ongoing education about conflicts of interest. (b) CONFLICTS OF OBLIGATION: Some argue that the physician has a duty to both patient and society. While this is certainly in some senses true, some argue that societal interests concerning health care resources expenditure should be factored into the physician’s recommendations concerning individual patient care options. The Committee categorically rejects this view. While a physician has an ethical responsibility to practice cost-effective medicine, the physician’s fiduciary role in relation to the patient becomes unrecognizable if the physician engages in rationing access to health care services on a patientby-patient basis. To be fair, rationing must be a population-based policymaking activity, the results of which must be applied evenhandedly (i.e., similarly situated persons should be treated similarly) across a population. Even then, policy-making is a value-laden, highly controversial activity. Physicians should seek to contribute their special expertise to such policy decisions, and at times may be called upon to implement resource allocation decisions at patients’ bedsides. To the extent that the physician considers a resource allocation policy detrimental to the best interests of the category of patients affected by it, the physician should advocate for the interests of patients and oppose the allocation policy. The ethical principles of avoiding foreseeable harm, promoting foreseeable benefit, and equity, should guide the physician in acting to influence resource allocation policies. But the physician should not confuse this policy-influencing role with his/her fundamental role as patient fiduciary. To the extent that the public believes physicians engage in bedside rationing in order to serve societal interests apart from individual patients’ best interests, to that extent the public rightfully ceases to trust physicians as their fiduciaries.

Guidelines:

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The physician should not engage in bedside rationing in relation to individual patients. To the extent that the physician considers a resource allocation policy unduly or unfairly detrimental to the best interests of the patients affected by it, the physician has an ethical responsibility to oppose that allocation policy.

As the patient’s fiduciary, the physician is an advocate for the patient’s best interests so far as access to needed health services is concerned. In our current health care arrangement, access to coverage and access to services cannot be separated. Therefore, as the patient’s fiduciary, the physician has an additional ethical responsibility of advocacy under certain circumstances. If the patient is denied coverage for a prescribed service, the physician has an ethical responsibility of advocacy for coverage proportionate to the physician’s belief that the treatment is medically necessary to avoid harm and/or provide benefit. The ability of a patient to pay for health care services should not be a barrier to getting necessary care. In former times, it was accepted that the physician had a duty to provide pro-bono care. Changes in the organization of health care, specifically the embeddedness of the physician’s practice in a clinic, group practice, and health plan, effectively constrain the capacity of the physician to do pro-bono work. The impacts of pro-bono work fall not only on the individual physician, but on the clinic, health plan, and arguably, the enrolled population of patients as well. The clinic and health plan should define a safe haven for limited pro-bono work on the physician’s part, and the physician should determine the strength of the obligation to provide pro-bono services on a case-by-case basis in light of the ethical responsibility to prevent avoidable harm. Physicians should actively encourage their health care organizations and their professional organizations to undertake and support initiatives that will improve access to health care to all in our society. Guidelines: • The physician has an ethical responsibility to advocate for coverage of medical services in proportion to the physician’s judgment that the services are in the patient’s best interest. • The physician has an ethical responsibility to provide pro-bono services guided by the duty to prevent avoidable harm, consistent with duties to clinic, health plan, and enrolled population. • The physician has an ethical responsibility to encourage health care organizations to define a safe haven for limited pro-bono work. • The physician has an ethical responsibility to encourage health care organizations and professional associations to promote improvements in access to health care for all. • Physicians have an ethical responsibility, individually and collectively, to advocate for payers’ coverage of medical services, which meet standards of community practice, research efficacy, and serve the patient’s best interest.

(Continued on page 30)

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September/October 2001

Ethical Accountability Guidelines (Continued from page 29)

(d) EQUITY: Physicians are frequently required to justify their recommendations for patient treatment with reference to practice guidelines. Coverage policies, decisions about what will be covered for a population, are the basis for coverage in individual cases. Such guidelines and policies may, from a physician’s perspective, be ill grounded. In such cases, the physician has an ethical obligation to advocate for change. Alternatively, in the case of an individual patient, such guidelines and policies may be hostile to an individual patient’s best interests, even though generally consonant with patients’ collective best interests. The physician has an ethical responsibility to advocate on the patient’s behalf in such cases. A patient may be an outlier with respect to a practice guideline, such that equity may require the physician to advocate for the patient as an exception. While similar cases should be treated similarly, dissimilar cases may warrant dissimilar treatment. Likewise, there is an important distinction between a coverage policy and an individual coverage decision. Equity may require the physician to advocate for the patient as an exception to a coverage policy as well, on the ground that the failure to provide coverage can be expected to have a more devastating impact on this patient’s best interest than in the standard case. Guidelines: • If the physician considers a practice guideline or a resource allocation policy detrimental to the best interests of the patients affected by it, the physician has an ethical responsibility to advocate for the interests of patients and oppose or seek to modify the practice guideline or allocation policy. • The physician has an ethical responsibility to advocate that the patient be treated as an exception to a practice guideline, proportionately to the physician’s judgment that the practice guideline is hostile to the best interest of the individual patient. • The physician has an ethical responsibility to advocate that the patient receive coverage, proportionately to the physician’s judgment that a coverage policy is hostile to the best interest of the individual patient.

(2) MEDICAL DECISION-MAKING OBLIGATIONS The physician has central responsibility for the quality of patient/surrogate medical decision-making. Consistent with the rights of patients to be fully informed of their health status and to be enabled to make informed choices concerning their health care options, the physician has an ethical responsibility to seek a therapeutic relationship with a patient, in which the physician’s knowledge, skill, and concern for the patient, and the patient’s values concerning health care options, meaningfully partner. Guidelines: Autonomous patient/surrogate health care decisions:

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The physician’s interactions with the patient as decision maker must be informed by the ideal of patient autonomy. The physician has an ethical responsibility to determine patient competency to understand health circumstances and treatment options, and patient capacity to apply personal beliefs and values to make a health care decision. September/October 2001

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The physician has an ethical responsibility to provide the patient with sufficient understandable information so that the patient can effectively apply personal beliefs and values to make a health care decision. The physician has an ethical responsibility to disclose all medically necessary and appropriate treatment options a reasonable person would wish to know, regardless of coverage. The physician has an ethical responsibility to explain, in relation to each option, associated risks and benefits and their likelihood, quality of life implications, and other information pertinent to the individual patient’s choice. The physician has an ethical responsibility to recommend and explain the rationale for the treatment option the physician considers would be most likely to avoid harm and promote benefit.

Conflicts between patient and physician:

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When patient decision-making is seriously at odds with the physician’s best interests assessment of the patient’s options, the physician has an ethical responsibility to understand the source of the patient’s decision and address it appropriately. The patient may be incompetent to make a decision and so the physician has an ethical responsibility to seek a qualified surrogate; The patient may be in need of further information and so the physician must provide it; or The patient may be making a decision from a different value or belief perspective than the physician (for example, on the basis of cultural or religious assumptions, beliefs, and values), and so the physician has an ethical responsibility to understand, address, and respect the patient’s decision.

Conflicts between patient and others:

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The physician has an ethical responsibility to advocate for the patient when family members or other decision-makers make decisions contrary to the autonomously expressed wishes of the patient. The physician has an ethical responsibility to advocate for the patient when surrogates make decisions the physician considers inconsistent with the best interest of the patient. The physician has an ethical responsibility to seek assistance in timely conflict resolution through ethics consultation or other appropriate resources.

(3) OBLIGATIONS DUE TO PATIENT VULNERABILITY Vulnerability is a matter of both kind and degree, and is present in all physician-patient interactions. Physicians have special responsibilities to address the multiple sources of patient vulnerability. Some vulnerability concerns apply to all patients. For example, physicians must both understand the potential harm to patients from, and avoid, boundary violations. Other obligations arise out of the specific characteristics and circumstances of the patient. A patient may be especially vulnerable for one of

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The Journal of the Hennepin and Ramsey Medical Societies

many reasons: for example, they may be in the midst of a health care crisis; they may have just received bad news; they may be in a weakened state, confused, or in pain; they may be unaccustomed to health care settings, separated from loved ones and customary support persons, trying to understand western health care options in terms of diverse cultural or religious beliefs, or facing a frightening diagnostic or treatment event; and/or they may be potential patient candidates for research. Guidelines: • The physician has an ethical responsibility to be trained in the types of boundary violations that undermine the therapeutic relationship and avoid them. • The physician has an ethical responsibility to determine the patient’s individual vulnerabilities and adjust his/her practice style to address those vulnerabilities, seeking specialized help whenever necessary. • The physician who would recruit patients into research has an ethical responsibility to: (i) Be trained in research methods and in the ethics of the respect and protection of human research subjects; (ii) Engage in research with patients only with prior IRB review and approval; (iii) Have reason to think the potential risks associated with research participation are reasonable in relation to potential benefits for the patient; (iv) Disclose the conflicts of interest present for the physician, i.e., the specific respects, financial or otherwise, in which the physician stands to benefit if the patient decides to participate; (v) Assure that patients understand the change in role that will occur from physician/patient to researcher/patient; and (vi) Meaningfully assure the patient that a decision not to participate in research will in no way compromise their relationship with their physician or the quality of their care.

(4) OBLIGATIONS TO DELIVER CULTURALLY RESPONSIVE HEALTH CARE Persons of non-mainstream cultures often bring unique perspectives to health care decision-making that challenge physicians’ explanatory, advisory, and relational capacities. The physician has special obligations in relation to such patients, in order to fulfill the conditions of the fiduciary relationship. In addition, because health care organizations and institutions have so much influence over the provision of care, physicians should advocate for changes that will lead to better service of culturally diverse patients and families. Guidelines: • The physician has an ethical responsibility to endeavor to understand and respect the patient’s culturally-based beliefs and values as they relate to health care decision-making. • The physician has an ethical responsibility to seek the assistance of cultural intermediaries who work within the health care system to facilitate communication and decision-making when it is needed. • The physician has an ethical responsibility to communicate, in understandable terms, the patient’s options, and the risks and benefits associated with each. MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

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The physician has an ethical responsibility to make a treatment recommendation, along with a rationale respectful of the communication customs, beliefs, and values of the patient, at the same time that he/she conveys the respects in which he/she sees the option to be most consistent with the patient’s best interest from a western health care perspective. The physician has an ethical responsibility to endeavor to make certain that the patient’s decision reflects the patient’s perspective and values. While the physician has an ethical responsibility to refuse to engage in any actions he/she considers harmful, the physician should attempt to accommodate non-harmful cultural practices, as he/she attempts to promote the patient’s best interest as the physician sees it. The physician has an ethical responsibility to bear in mind that every patient has a right to refuse unwanted treatment, even when, from a western medical perspective, such refusal is likely to result in avoidable harm. The physician has an ethical responsibility to advocate for institutional practices consistent with culturally responsive health care.

(5) OBLIGATIONS TO PROTECT PATIENT CONFIDENTIALITY The duty to protect the patient’s confidentiality is virtually an absolute duty. Only anticipated harm to others justifies the physician’s abrogation of this ethical responsibility. Consistent with the role of the physician as fiduciary, the medical record must be a private record between patient and physician, unavailable for non-medical purposes. The physician has an ethical responsibility to keep an accurate medical history – only in this way can a patient’s long term health history be understood and the crucial issue of continuity of care be managed. Except with the authorization of the patient (or his/his representative) or as permitted or required by law, physicians must resist uses of the patient history for insurance, employment, or other non-medical purposes. Any use of the patient’s record for research purposes must be disclosed and consented to by the patient. In the case of minors, physicians are responsible for knowing and following state laws related to informing the parents or guardians of minor patients about treatment obtained or needed by the minor. The minor has a right to know in advance whether the physician has a legal obligation to disclose certain medical information to a parent or guardian. Guidelines: • The physician has an ethical responsibility to be familiar with and adhere to the standards of confidentiality surrounding a patient’s medical record, unless the patient is a threat to the welfare of others. • The physician has an ethical responsibility to keep an accurate patient medical history. • Except with the authorization of the patient (or his/her representative) or as permitted or required by law, physicians must resist uses of the patient history for insurance, employment, or other non-medical purposes. • Patient consent must be sought and obtained for the use of patient information for research purposes. (Continued on page 32)

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Ethical Accountability Guidelines (Continued from page 31)

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If the law requires disclosure of a minor patient’s medical information to a parent or guardian, the physician should inform the adolescent of this in advance.

(6) OBLIGATIONS TO MONITOR PERSONAL STANDARDS The level of physician training and expertise, as well as the physician’s personal moral convictions, behaviors, conditions, or illnesses may be pertinent to the physician’s capacity to act as the patient’s fiduciary and to assure patient protection. Physicians should disclose their level of training and expertise to patients, and they should submit to mechanisms to protect patients where matters of personal behaviors, conditions, or illnesses are a source of concern. Guidelines: Patient protection:

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The physician has an ethical responsibility to disclose to patients their level of training and expertise. The physician has an ethical responsibility to participate in screening for competence. The physician has an ethical responsibility to participate in screening and treatment for compromising behaviors, habits, and illness.

(a) PHYSICIAN’S MORAL CONVICTIONS: Another aspect of physician’s personal standards, in contrast to the physician’s professional standards, is the physician’s personal moral beliefs and values. These may sometimes conflict with legitimate treatment choices on the part of patients. Thus, the physician might conscientiously refuse to participate in a particular intervention. The goal of medical decisionmaking is that a patient will make a knowledgeable treatment choice by applying his or her beliefs and values to the information concerning treatment options the physician has thoroughly and thoughtfully provided, along with the physician’s own recommendation of one of those options. When a physician’s personal moral standards become the basis for that recommendation, the fiduciary quality of the physician-patient interaction is lost. Guidelines: • The physician has an ethical responsibility to disclose personal moral convictions to the patient when those convictions would lead to a physician’s conscientious refusal to provide the patient a lawful treatment option. • If the physician refuses to provide a patient’s lawful treatment choice on personal moral grounds, the physician has an ethical responsibility to support the patient in pursuing the patient’s choice of treatment by referring to an appropriate physician.

Guidelines:

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If professional treatment standards agree, and there is conflict between physician and patient concerning treatment, the physician has an ethical responsibility to provide a full rationale for the physician’s professional objections to the patient’s/surrogate’s request, and refuse to provide the treatment requested. Only if the patient/surrogate requests a referral should the physician refer. If professional treatment standards differ, and there is conflict between physician and patient concerning treatment, the physician should refer the patient for further consultation.

(c) CONFLICT-RESOLUTION: • In general, the physician has an ethical responsibility to seek to avoid conflict through thorough, clear, and respectful communication. • In the event of conflict, the physician has an ethical responsibility to seek timely ethics consultation or other approaches to conflict resolution, and inform patients/surrogates that such options are available to them as well. Conclusion The above discussion and ethical accountability guidelines reflect the deliberations and conclusions of the Ad Hoc Ethics Committee of the Hennepin Medical Society. The ethical principles from which these ethical accountability guidelines derive are the central principles of bioethics established over the past 35 years. These principles are: autonomy, nonmaleficence, beneficence, and justice. The guidelines fill in a fiduciary conception of the physician’s role in today’s health care system: They rest most significantly on the physician’s obligation to ascertain and promote the patient’s best interests, attentive to and respectful of patient values and beliefs. It is this specific understanding of the physician’s obligation to promote the patient’s best interests that is the ethical touchstone of each of the ethical accountability guidelines contained in this document. ✦ 1) Wynia, MK, Latham, SR, Kao, AC, “Medical Professionalism in Society,” NEJM 1999;341:21 2) The Committee was guided by the delineation of domains of physician ethical accountability in Emanuel, LL, “A Professional Response to Demands for Accountability: Practical Recommendations Regarding Ethical Aspects of Patient Care,” Ann Intern Med 1996;124:240-249

This document is intended only to serve as an ethical guide for physicians. It is not intended to establish or define clinical or legal standards of care or to be a statement of the law of Minnesota.

(b) PHYSICIAN’S PROFESSIONAL STANDARDS: Personal standards differ from professional standards. When a physician’s professional standards are the basis of a conflict with a patient or surrogate treatment request, what are the physician’s duties?

September/October 2001

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