Special CME Issue - West Virginia State Medical Association

Commentary Article | Special Issue
individual patient autonomy and
discharging patients who fail
to accept, adopt and follow the
physician’s recommendations.
And a third ethical issue involves
the role of the physician as a
“steward” of society’s scarce
resources by assisting to reduce
and eliminate unnecessary,
wasteful and minimally effective
preventive services in order
to conserve societal resources
—while still maintaining the
primary duty to best care
for each unique patient.
Promising preventive screening
tests, e.g., PP13 for preeclampsia,
and interventions, e.g., Malaria
vaccine, roll off the assembly
line weekly. It is difficult to track
which patients in one’s practice
might be prime candidates for new
services (or tried and true ones) in
order to assure appropriate and
timely communication, contact
and discussion with them. Without
expanded health information
technology (HIT) and/or assistance
from other health staff, it is
difficult for most physicians (with
the possible exception of those
in small concierge practices) to
know who has been offered and
received a recommended preventive
service in a timely manner.
Furthermore, without a formal
“enrollment” procedure, at times
it is not even clear to a physician
or patient to which “practices(s)”
the patient belongs as regards any
“prospective” obligation and/
or whether the patient wants to
be proactively tracked, monitored
and contacted. Nevertheless, HIT
and organizational adjustments
might well have portended a better
outcome in the first case above.
However, the degree to which such
factors as sub-standard automation,
poor organizational integration,
and misaligned reimbursement
incentives contribute to the failure to
receive essential services is largely
conjecture. Nevertheless, there are
multiple new bureaucratic initiatives
such as “medical homes” and “pay
for quality” to change these factors.
Medicare has proposed reimbursing
physician $20 per patient per
month to correct such alleged care
deficiencies they contend results in
poor health status and higher costs.
Although not opposed, many
doubt these initiatives will result in
significant improvements in health
status. They contend the failure to
obtain essential services and modify
unhealthy health status behavior
is primarily a manifestation of an
“excess” culture. It results in risky
overindulgence and an unwillingness
to expend energy and disposable
income on health, as opposed to
recreational and unhealthy behavior,
e.g., cigarettes, fast food, alcohol,
drugs, tanning booths, inactivity.
Daniel Akst writes about this in his
book “We Have Met the Enemy:
Self-Control in an Age of Excess”
and notes it affects all types of
behavior such as eating, drinking,
irresponsible credit purchases,
smoking, and sexual promiscuity.
Many tests and interventions—
or the frequency of their
application—are subjects of
disagreement, not consensus.
Mammography in younger, low
risk women, PSA screening, HPV
screening and pap smears are a
few examples of recent debates.
In many instances, some believe
side effects and the morbidity
associated with chasing false
positives support more limited use
of many services and also would
conserve scarce health resources.
This extends to the appropriate use of
screening tests that yield interesting
information but add little to future
care management. Medicare recently
expanded coverage for clinical
depression screening and CDC
recommended increased screening,
although, according to CDC, twothirds
of those with diagnosed
severe depression are not receiving
treatment. In a recent New York Times
article Dr. Danielle Ofri reinforced
the value of “clinical inertia” as
discussed by Drs. Dario Giugliano
and Katherine Esposito in JAMA.
The issue is further complicated
by the facts that even with adequate
contact and counseling many patients
refuse recommended interventions
or fail to make suggested behavioral
changes. The second case above
is an obvious example. Refusal of
immunizations and circumcision,
continued use of tanning booths
and harmful substances, inactivity,
poor diet, failure to take medications
as prescribed are a few others.
Did the women’s physician in the
first case take a thorough sexual
history and was she offered a
timely Pap smear or HPV test but
never got around to getting it?
These factors present a formidable
challenge even in a milieu of strong
scientific consensus and maximum
professional autonomy. The challenge
becomes even more difficult within
the current environment where there
are major debates over the scientific
validity and cost-effectiveness
of various behavioral practices
and preventive interventions.
Moreover, there is a concerted
move by advocacy groups,
politicians, bureaucrats and payers
to entice or coerce physicians to
provide certain services to all
patients who meet certain criteria
and parameters, regardless of
whether the individual physician
believes they are appropriate and
cost-effective. How many wasteful
tests and referrals did the man in the
second case above receive despite
his physician knowing they were
for naught? Recently, pediatricians
have engaged in a debate regarding
whether they should refuse to see
children whom the parents refuse
12 West Virginia Medical Journal