Surgery News - December 2007 - (Page 17)

DECEMBER 2007 • SURGERY NEWS ETHICS THE RIGHT CHOICE 17 The Perils of Intentional Overtreatment BY JAMES W. JONES, M.D., PH.D., FACS Editor’s note: The following is condensed from an article published in the Journal of Vascular Surgery (2007;46:605-7). “It is asking more than human perfection to assume that a surgeon’s judgment may not be influenced unconsciously by a pressing financial need.” —Edwin P. Lehman, M.D. (Surgery 1950;28:595) r. I.R. Tepid, highly regarded in residency, joined a group practice 9 months ago. He has not covered his expenses thus far, and 15 months remain for him to receive a lucrative salary and benefits. Everyone except Dr. Tepid gets his or her salary from professional fees after expenses. The other surgeons are overloaded with work while Dr. Tepid attends meetings and studies for his boards. Dr. C. Ponzi, the founding partner who championed the hiring, wants Dr. Tepid released. What should be done? D A) Give him time to become known in the area. B) Start encouraging him in a jocular manner to operate more. C) Hire a leg-biter attorney to connect his salary and travel to productivity. D) Send more of the group’s patients needing consults to him. E) Separate him from the group. No other secular profession—except perhaps military officers in combat situations—exceeds medicine in having so many potential conflicts of interest (COI) in which the stakes of remaining clearly focused on the interests of those served are so high. The medical profession is as close as secular gets to sacred but, as with all professions that society idealizes, medicine rapidly becomes profane if it is exploited. Professional COIs are temptations that blur the objectivity that is crucial to evidence-based medical practice. COIs can involve nonmonetary interests, such as convenient hours, time for activities outside of medicine, or religious beliefs. But the conflicts that occur most often, and are the most identifiable, involve money. The present case emphasizes a conflict at the palpable marrow of medical practice. Personal financial pressures may di- rectly influence recommendations of care. Overtreatment is rarely overt; it slips in beneath watered-down indications. Intentional overtreatment is an obvious ethics breach. We consider auto mechanics as potential black-hearted scoundrels every time our cars require repair, and some of them are, but even the worst mechanics cheat us only of money. Medical overtreatment can cost and then injure, maim, or even kill; it is fraudulent antiprofessionalism. Yet it exists. Economists developed and studied the target-income model of Supplier (Physician)–Induced Demand early in Medicare’s fee regulation era. To compensate for the decrease in Medicare fees, physicians did in fact increase their services to Medicare patients, enough to replace 40%-70% of lost income—disturbing evidence that COI occurs (Health Politics Law 1999;24:1307; J. Health Econ. 1998;17:675). Our scenario is often repeated as practices grow and new associates are recruited. We have all heard of newly added surgeons “not working out” after a few years. “Not working out” has multiple causality: personality clashes, moral issues, and newly minted surgeons’ passing through professional adolescence or becoming too successful, to name a few problems. Nudging Dr. Tepid to do more operations—without providing him with more referrals—pressures him to lower his threshold for recommending surgery and puts his patients at systematic risk of overtreatment. Option B tries to cover a serious moral breach; it overtly pressures while deceptively seeming not to do so. Options C and E are inappropriate moral and legal responses because they would violate the surgeon’s contractual rights. Groups should help new members become successful. Hiring new members to lessen the group’s on-call pressures or for reasons unrelated to patient care violates administrative fiduciary responsibilities. Option A is unacceptable: Delaying longer without helping the new member become known will make things worse. A group practice should include members of like abilities and mind-sets who share equally in the workloads and ultimately the rewards of the practice. Option D implements these ethical considerations and should be adopted in this case. ■ DR. JONES is a visiting professor at the Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, and an ACS Fellow (jwjones@bcm.tmc.edu). 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Alinsod, MD, FACOG, ACGE Haneef Alibhai, MD, CM, CCFP Todd K. Malan, MD, FACOG Gregory Alouf, MD, PC Anil Gandhi , MD For more information and to register for a workshop: visit www.cosmeticphysicians.org call American Academy of Cosmetic Physicians @ 520.574.1050 send email to info@aaocg.org, or fax to 520.574.7944 FOR CLASSIFIED RATES AND INFORMATION: Danny Wang Elsevier-Surgery News 360 Park Avenue South New York, NY 10010 (212) 633-3158 FAX: (212) 633-3820 Email ad to: d.wang@elsevier.com 2ND ANNUAL MEETING AWAKE Tummy Tuck Performed under local tumescent anesthesia, patient is AWAKE throughout the procedure. • Proper Patient Selection & Patient Management • Pre-Op & Post-Op Photography • Room & Equipment Setup • AWAKE Tummy Tuck Techniques & Methods • Hands-on Surgical Training • Malpractice Insurance • Patient Safety & Complications http://www.cosmeticphysicians.org http://www.cosmeticphysicians.org http://www.cosmeticphysicians.org

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Surgery News - December 2007 Contents Breast Radiation Boost Cuts Cancer Recurrence Mortality Soars in Some Patients With Respiratory Distress New Codes Promote Alcohol Screening New Ideas News From the College: Quality Standards General Surgery: Helping Hand Trauma: Spleen Protocol

Surgery News - December 2007

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