De Camp, M, & Sulmasy, L. S.
Annals of Internal Medicine
Position Paper: 16 March 21
Abstract
The environment in which physicians practice and patients receive care continues to change. Increasing employment of physicians, changing practice models, new regulatory requirements, and market dynamics all affect medical practice; some changes may also place greater emphasis on the business of medicine. Fundamental ethical principles and professional values about the patient–physician relationship, the primacy of patient welfare over self-interest, and the role of medicine as a moral community and learned profession need to be applied to the changing environment, and physicians must consider the effect the practice environment has on their ethical and professional responsibilities. Recognizing that all health care delivery arrangements come with advantages, disadvantages, and salient questions for ethics and professionalism, this American College of Physicians policy paper examines the ethical implications of issues that are particularly relevant today, including incentives in the shift to value-based care, physician contract clauses that affect care, private equity ownership, clinical priority setting, and physician leadership. Physicians should take the lead in helping to ensure that relationships and practices are structured to explicitly recognize and support the commitments of the physician and the profession of medicine to patients and patient care.
Here is an excerpt:
Employment of physicians likewise has advantages, such as financial stability, practice management assistance, and opportunities for collaboration and continuing education, but there is also the potential for dual loyalty when physicians try to be accountable to both their patients and their employers. Dual loyalty is not new; for example, mandatory reporting of communicable diseases may place societal interests in preventing disease at odds with patient privacy interests. However, the ethics of everyday business models and practices in medicine has been less explored.
Trust is the foundation of the patient–physician relationship. Trust, honesty, fairness, and respect among health care stakeholders support the delivery of high-value, patient-centered care. Trust depends on expertise, competence, honesty, transparency, and intentions or goodwill. Institutions, systems, payers, purchasers, clinicians, and patients should recognize and support “the intimacy and importance of patient–clinician relationships” and the ethical duties of physicians, including the primary obligation to act in the patient's best interests (beneficence).
Business ethics does not necessarily conflict with the ethos of medicine. Today, physician leadership of health care organizations may be vital for delivering high-quality care and building trust, including in health care institutions. Truly trustworthy institutions may be more successful (in patient care and financially) in the long term.
Blanket statements about business practices and contractual provisions are unhelpful; most have both potential positives and potential negatives. Nevertheless, it is important to raise awareness of business practices relevant to ethics and professionalism in medical practice and promote the physician's ability to advocate for arrangements that align with medicine's core values. In this paper, the American College of Physicians (ACP) highlights 6 contemporary issues and offers ethical guidance for physicians. Although the observed trends toward physician employment and organizational consolidation merit reflection, certain issues may also resonate with independent practices and in other practice settings.
