Portal de Periódicos da CAPES

Fiduciary disparity clarity: Ethics of divided allegiances

2016; Elsevier BV; Volume: 63; Issue: 2 Linguagem: Inglês

10.1016/j.jvs.2015.12.008

1097-6809

James W. Jones, Laurence B. McCullough,

Human Resource and Talent Management

An experienced senior vascular surgeon, Dr H. O. Nest, at a university medical center is asked to evaluate a patient with a rare complex vascular problem. The patient is a high-ranking university official, Mr N. Otable, well known to all in the university setting. Dr Nest has had very limited experience with the condition. He has viewed presentations about it but is aware of a world expert at another institution. He discusses transfer with the patient, who agrees on that approach. Later that day, when Dr Nest receives a visit from the Chief-of-Staff and the hospital CEO asking about Mr Otable, they are very concerned that transfer will reflect badly on the medical center's reputation. Dr Nest is strongly requested to reconsider his recommendation — almost at gunpoint. What should he do?A.If he believes that the outcome will be satisfactory, he should schedule the operation.B.He should explain the situation to the patient and let him choose where he wishes to have his surgery.C.He should continue with the plan to refer the patient to another center.D.He must understand his limits and base his decision accordingly.E.He should arrange a conference with the surgeons in the vascular division and the administrators. An experienced senior vascular surgeon, Dr H. O. Nest, at a university medical center is asked to evaluate a patient with a rare complex vascular problem. The patient is a high-ranking university official, Mr N. Otable, well known to all in the university setting. Dr Nest has had very limited experience with the condition. He has viewed presentations about it but is aware of a world expert at another institution. He discusses transfer with the patient, who agrees on that approach. Later that day, when Dr Nest receives a visit from the Chief-of-Staff and the hospital CEO asking about Mr Otable, they are very concerned that transfer will reflect badly on the medical center's reputation. Dr Nest is strongly requested to reconsider his recommendation — almost at gunpoint. What should he do?A.If he believes that the outcome will be satisfactory, he should schedule the operation.B.He should explain the situation to the patient and let him choose where he wishes to have his surgery.C.He should continue with the plan to refer the patient to another center.D.He must understand his limits and base his decision accordingly.E.He should arrange a conference with the surgeons in the vascular division and the administrators. Man's got to know his limitations.—Clint Eastwood, Magnum Force A camel is a horse designed by committee.—Alec Issigonis Ethical conflicts can originate from the belief that all surgeons and others performing procedures are equally capable. This concept allows state medical boards to grant universality of practice and specialty boards to do the same. The system depends on the individual physician's professionalism to decide his or her qualifications and most of the time it works. Physicians, especially surgeons whose skills are directly connected to outcomes, do not want complications both because of fiduciary obligations to the patient and a legitimate self-interest in sustaining their reputations as competent health care professionals. In these circumstances, fiduciary obligations and self-interest are in synergy with each other. By contrast, when self-interest becomes disconnected from professional responsibility for patient care, preventable conflicts of interest occur for physicians. When an organization's self-interest become disconnected from professional responsibility for patient care, preventable conflicts of interest also occur. The prevention and management of such conflicts of interest threaten to become more complex with continuing changes in medical reimbursement, forcing institutions to have their staffs readjust their practices. “Certain aspects of health care can be predicted with considerable confidence, however: an increasing role for bureaucracies and decreasing power of physicians. These trends pose dilemmas for surgeons, particularly when a conflict of loyalties is created when hospital administrators demand that physicians place the interests of the medical center before the interests of patients”.1Fenton K. Ellis J. Sade R.M. Should a thoracic surgeon transfer a complicated case to a competing medical center against the hospital's order?.Ann Thorac Surg. 2015; 100: 389-393Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Estimates of the appropriateness of referral should always foremost consider the patient's welfare, with individual and organizational self-interest kept systematically secondary. When outcomes cannot be reasonably predicted, the independent surgeon's efforts to expand his armamentarium can be rightly considered reckless experimentation.2Colvin S.B. Grossi E.A. Galloway A.C. Regarding ethics of rapid surgical technological advancement.Ann Thorac Surg. 2000; 70: 1758Abstract Full Text Full Text PDF PubMed Google Scholar The emergent nature of the patient's condition is another variable that can alter the decision but does not apply here. Urgency does not permit the quiet reflection on alternatives typically available before elective operations. When a dangerous condition requiring special skills presents, and a better qualified surgeon is available, a referral should be strongly urged.3Jones J.W. McCullough L.B. When to refer to another surgeon.J Vasc Surg. 2002; 35: 192Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar There is no question that outcomes are related to a specific surgeon's case volume in a variety of procedures.4Birkmeyer J.D. Stukel T.A. Siewers A.E. Goodney P.P. Wennberg D.E. Lucas F.L. Surgeon volume and operative mortality in the United States.N Engl J Med. 2003; 349: 2117-2127Crossref PubMed Scopus (2583) Google Scholar Cowan et al5Cowan Jr., J.A. Dimick J.B. Thompson B.G. Stanley J.C. Upchurch Jr., G.R. Surgeon volume as an indicator of outcomes after carotid endarterectomy: an effect independent of specialty practice and hospital volume.J Am Coll Surg. 2002; 195: 814-821Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar studied outcomes from carotid endarterectomies in over 35,000 patients, according to an individual surgeon's case volume. The overall results were generally acceptable, but the stroke rate in low-volume surgeons' cases doubled and their hospital mortality was 2.5 times that of high-volume surgeons. These results were highly significant. The correlation makes sense; vascular surgery is a referral specialty requiring patronage of a number of other physicians who do not tolerate substandard results well. The referral system, with all its impreciseness, works to better patient care. First, it is determined if patients are likely to need further treatment by a physician, not directly involved with the therapy, which amounts to a first opinion, with the consult a second opinion—albeit more authoritative. Also, referrals decrease because cases having complications can take up huge amounts of time and stain reputations. The learning curve strongly supports the salubrious effects of vascular surgical volume.6Lobato A.C. Rodriguez-Lopez J. Diethrich E.B. Learning curve for endovascular abdominal aortic aneurysm repair: evaluation of a 277-patient single-center experience.J Endovasc Ther. 2002; 9: 262-268Crossref PubMed Scopus (54) Google Scholar The study found that not only case load but also frequency of performing cases was important. The present case is beyond learning curve thresholds; Dr Nest's knowledge is from the other surgeon's experience. Knowledge in surgical specialties in necessary but is utterly inadequate when, as is the case for Dr Nest, one has only limited experience and is therefore putting the patient at increased preventable risks of complications and adverse outcomes. Knowledge can make a diagnosis or prescribe a medicine; surgical treatment requires performance of some of the most complicated series of hand-eye coordination maneuvers known to man and the development of good judgment to carry them to satisfactory completion. Dr Author Beall, a great surgeon, repeatedly stated: “Good judgment comes from bad experience” (attributed to a number of persons) but then he would break out in a great smile and say, “but it doesn't have to be your bad experience.” Dr Nest is an experienced vascular surgeon and likely has no reason to believe that he hasn't the skills to perform any procedure ardently. Also, the pressure not to have notables sent from your medical center to another for medical care because it may imply a lack of expertise is real, but institutional reputation is hardly an operative indication. To make it an indication is to put the ethical cart before the horse. Retaining the patient would be doing the wrong thing for the wrong reason. Reject option A. The first part of option B is correct; explain the situation to the patient. However, patients are always owed an explanation but in very few situations should they be presented with the need to decide what the recommendation for their care should be. Giving patients that choice makes as much sense as Yogi Berra's statement: “When you come to a fork in the road, take it.” This is good advice when each fork in the road is professionally acceptable; that is not the case here. Option B is out. Option D is correct but inane at this point because Dr Nest has no data to know his limits as regards this particular case. Option E assembles a committee of possible pundits with less knowledge than the attending and includes political interests. Politics don't go well with science or medicine; logic takes a trouncing. The resulting delay in transferring the patient lacks ethical justification altogether. Option C is the only ethical answer. When a surgeon has made a decision in the best interest of the patient, fortitude must arise to oppose other forces and there is no doubt that other forces are becoming more oppressive each year. In cases like this, surgeons have the professional responsibility to protect patients from individual or organizational self-interest from becoming the primary consideration. Sometimes, surgeons need to speak truth to power. If the Chief-of-Staff and CEO are not persuaded by information about outcomes when one is not even on the learning curve and its implications for professional patient care, it will become necessary for Dr Nest to be more direct about the ethical impermissibility of acting on organizational self-interest as the primary considerations and thus refocus the hospital's leaders on the maintenance of professional standards of care as the source of the reputation that the hospital should want to have.