Internists Continue to Grapple With Tough Choices

Almost 90% of internal medicine specialists say they would report a colleague whose judgment seems impaired by drugs, alcohol, or illness, either straightaway (37%) or after speaking with their colleague first (51%).

That’s among the findings of Medscape’s new “Tough Choices” survey about how they would respond to various ethically thorny challenges.  

More than 4100 physicians from various specialties completed the semi-annual survey, with 57% of respondents identifying as male and 40% as female. Of those, approximately 500 identified as internists.

More than half of internists (53%) feel a responsibility to speak out regarding a lack of resources, such as inadequate or insufficient personal protective equipment. One in three (33%) say they would speak out depending on the specific situation, and 13% say they would not speak out.

Arthur Caplan, PhD, a bioethicist at NYU Langone Medical Center in New York City, and a frequent contributor to Medscape Medical News, said that “speaking out” has multiple meanings. For some people, doing so might mean going to the media; for others, it might involve working internally through a chain of command.

Almost all internists (86%) have always reported suspected domestic abuse of a patients, while 9% have sometimes failed to do so. These figures match those in the overall survey, with 86% of physicians always reporting their concerns about such violence and 10% sometimes not.

Approximately half (48%) of internists believe physician-assisted dying should be legal for terminally ill patients. Nearly 3 in 10 (29%) say the practice — which is currently legal in 10 US states as well as the District of Columbia — should not be legal, while 1 in four (24%) say it depends.

Roughly three fourths of internists (77%) say they would reveal a potentially harmful medical mistake to a patient. 1 in 5 (20%) say this depends, and only 3% would not reveal this information. “From a health law perspective, being up front with the patient is standard practice,” said Eric Mathison, PhD, a clinical ethicist at the University of Toronto.

The large majority of internists (73%) would report a colleague for sexual harassment or bullying, with 22% saying it depends and only 6% stating they would not report. 

Far fewer internists (54%) would report a doctor for making racist remarks then for sexual harassment or bullying. Approximately 3 in 10 respondents (31%) say it depends, while 16% state they would not report such remarks. “I would first discuss with the physician and point out the racist remarks, with the hope that he/she will realize how inappropriate they are,” one respondent said.

Three fourths (74%) of internists surveyed would not ‘upcode’ a patient’s condition to improve their odds of getting insurance. Close to 1 in 5 internists (18%) say this depends on the situation, while the rest (9%) did not oppose the practice. Caplan noted that most doctors will lobby for their patients with representatives of insurance companies, but few will commit fraud.

When asked about conflicts of interest, most internists (55%) say accepting a meal or gift from pharmaceutical companies would not affect their clinical decisions. However, 31% say such blandishments would be problematic while 14% say the influence would depend on the circumstances. In 2020, a larger share of internists (61%) said such gifts or meals would have no influence.

The large majority of internists (73%) would not use capitation plans to weed out complicated patients with multiple comorbid conditions. Almost 1 in 5 (19%) say this decision would depend on the specifics of the case, while 8% of internists would regularly invoke such capitation plans. “I don’t like [the idea of] weeding out, but I think it goes on,” Caplan said.

Slightly more than half of internists (53%) are comfortable with breaching patient confidentiality when someone’s health might be at stake. That figure is essentially identical to overall physician numbers in 2020 (54%) but significantly less than in 2012 (63%), when more doctors were prepared to breach confidentiality depending on the situation; in this survey, about one third (34%) said breaching confidentiality depends on the circumstances.

More than half of internists (52%) feel an ethical obligation to see patients on Medicaid, despite red tape and low reimbursement rates.  

Finally, a large majority of internists (80%) believe it is important to publicly speak out against misinformation about COVID-19 pushed by public officials.

Marcus A. Banks, MA, is a journalist based in New York City who covers health news with a focus on new cancer research. His work appears in Medscape, Cancer Today, The Scientist, Gastroenterology & Endoscopy News, Slate, TCTMD, and Spectrum.

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