The Physician and the

Allied Health Professionals:

How to Avoid a Family Feud

Patrick Gerard L. Moral, MD, FPCCP

Chair, Department of Ethics
University of Santo Tomas Faculty of Medicine & Surgery

Date
Medical Professionalism

✤ Most of the efforts to understand, inculcate, and assess medical

professionalism have occurred within institutional settings such as
schools of medicine, residency review committees, or professional
organizations

✤ Daily expressions of professionalism occur most frequently not in

the academic health center but in physicians' offices and in the
communities they serve, reflecting simply the numbers of physicians
in practice versus the number in academic medicine
Morally acquired virtues of HCP

✤ Fidelity
✤ Honesty
✤ Humility
✤ Compassion / Justice
✤ Courage
✤ Prayerfulness
✤ Competence
✤ Integrity
What are the roles of nurses according to physicians?

Advocate and liaison Order implementor

MD eyes and ears Maintain environment

Emotional support MD assist / partner

Patient educator Case manager/coordinator

What are the roles of physicians according to nurses

Most important player Problem solver

Team leader Directs care

Assesses and Diagnose Collaborates

Writes orders Develops plans

Name the top six reasons for nurse - physician conflicts?

Role conflict Communication conflict

Status differences Goal conflict

Education differences Monitoring function

What are the weaknesses of physicians according to nurses?

Lacks personal touch Arrogant/Bossy

Not holistic Puts nurses down

Money oriented Hard to reach after 5 pm

Low interaction/communication Can’t deal with end of life

Takes on too much Too many tests / fears suits

 Nurses

✤ The ethical physician should neither expect nor insist that nurses
follow orders contrary to standards of good medical and nursing
practice.

✤ In emergencies, when prompt action is necessary and the physician is

not immediately available, a nurse may be justified in acting
contrary to the physician’s standing orders for the safety of the
patient.

✤ Such occurrences should not be considered to be a breakdown in

professional relations.
Models of interaction

✤ unproblematic subordination: nurses unquestioning

obedience

✤ informal covert decision making: the doctor-nurse game

✤ informal overt decision making: open involvement of

nurses

✤ formal overt decision making: including the nursing

process in decision making
 Nonscientific Practitioners

✤ unethical to engage in or to aid and abet in treatment

which has no scientific basis and is dangerous, is
calculated to deceive the patient by giving false hope, or
which may cause the patient to delay in seeking proper
care
 Allied health professionals

✤ often practice in concert with allied health professionals such as, but
not limited to, optometrists, nurse anesthetists, nurse midwives, and
physician assistants in the course of delivering appropriate medical
care to their patients

Principles:

✤ It is ethical for a physician to work in consultation with or employ

allied health professionals, as long as they are appropriately trained
and duly licensed to perform the activities being requested.
Allied health professionals

Principles:

✤ Physicians have an ethical obligation to the patients for whom they

are responsible to ensure that medical and surgical conditions are
appropriately evaluated and treated.

✤ Physicians may teach in recognized schools for the allied health

professionals for the purpose of improving the quality of their
education. The scope of teaching may embrace subjects which are
within the legitimate scope of the allied health profession and
which are designed to prepare students to engage in the practice of
the profession within the limits prescribed by law.
Allied health professionals

Principles:

✤ It is inappropriate to substitute the services of an allied

health professional for those of a physician when the
allied health professional is not appropriately trained and
duly licensed to provide the medical services being
requested.
PMA Code of Ethics

✤ Section 2. When necessary, the attending

physician should always seek consultation
from an available appropriate specialist.
 Referrals

✤ for diagnostic or therapeutic services to another physician whenever

he or she believes that this may benefit the patient

✤ based on their individual competence and ability to perform the

services needed by the patient
Referrals

✤ evaluation

✤ evaluation and management

✤ procedure

✤ co-management

✤ temporary suspension of service

PMA Code of Ethics

✤ Section 4. With the consent of the patient, in cases where a physician

has to suspend service during temporary absences, the substitute
physician shall treat the patient with the same dedication and quality
of care extended to his/her own patient. The patient should be
returned to the care of the primary physician as soon as possible.
Peers as patients

✤ a privilege and may represent a gratifying experience and serve as a

show of respect or competence

✤ in emergencies or isolated or rural settings when options for care by

other physicians are limited or where there is no other qualified
physician available, physicians should not hesitate to treat peers
Peers as patients: ethical considerations

✤ alerted to the possibility that their professional relationship with the

patient may affect their ability to exercise objective professional
judgment and make unbiased treatment recommendations

✤ physician-patient may be reluctant to disclose sensitive information

or permit an intimate examination.

✤ physicians providing care to a professional colleague have an

obligation to respect informational and physical privacy of physician-
patients as they would for any patient
Peers as patients: ethical considerations

✤ recognize that special measures may be required to ensure that the

physician-patient’s physical privacy is respected

✤ respect the physician-patient’s right to participate in informed

decision-making

✤ make no assumptions about the physician-patient’s knowledge about

her or his medical condition and should provide information to
enable the physician-patient to make voluntary, fully informed
decisions about care.
Peers as patients: ethical considerations

✤ Physicians-in-training and medical students face unique challenges

when asked to provide or participate in care for peers given the
circumstances of their roles in medical schools and residency
programs.

✤ Except in emergency situations or when other care is not available,

physicians-in-training should not be required to care for fellow
trainees, faculty members, or attending physicians if they are
reluctant to do so
PMA Code of Ethics

✤ Section 1. A physician shall waive his professional fees

to a colleague, his or her spouse, children and parents
who are financially dependent on him.
Covenants not to compete

✤ It is unethical for a teaching institution to seek a non-

competition guarantee in return for fulfilling its
educational obligations.
✤ Physicians-in-training should not be asked to sign
covenants-not-to-compete as a condition of their
entry into any residency or fellowship program.
Physician Health and Wellness

✤ to preserve the quality of their performance, physicians have a

responsibility to maintain their health and wellness

✤ preventing or treating acute or chronic diseases, including mental

illness, disabilities, and occupational stress

✤ when failing physical or mental health reaches the point of

interfering with a physician’s ability to engage safely in
professional activities, the physician is said to be impaired.
Physician Health and Wellness

✤ every physician should have a personal physician whose objectivity

is not compromised

✤ physicians whose health or wellness is compromised should take

measures to mitigate the problem, seek appropriate help as
necessary, and engage in an honest self-assessment of their ability to
continue practicing.

✤ physicians caring for colleagues should not disclose without the

physician-patient’s consent any aspects of their medical care, except
as required by law, by ethical and professional obligation, or when
essential to protect patients from harm
Physician Health and Wellness

✤ The medical profession has an obligation to ensure that its members

are able to provide safe and effective care.

✤ promoting health and wellness among physicians

✤ supporting peers in identifying physicians in need of help
✤ establishing mechanisms to assure that impaired physicians
promptly cease practice
✤ assisting recovered colleagues when they resume patient care; -
reporting impaired physicians who continue to practice, despite
reasonable offers of assistance, to appropriate bodies as required by
law and/or ethical obligations
Reporting incompetent colleagues

✤ Physicians have an ethical obligation to report impaired, incompetent,

and/or unethical colleagues in accordance with the legal
requirements in each state and assisted by the following guidelines:

✤ Impairment. Ethically and legally, it may be necessary to report an

impaired physician who continues to practice despite reasonable
offers of assistance and referral to a hospital or state physician health
program. The duty to report under such circumstances, which stems
from physicians’ obligation to protect patients against harm, may
entail reporting to the licensing authority.
Reporting incompetent colleagues

✤ Incompetence.

✤ initial reports of incompetence should be made to the appropriate

clinical authority who would be empowered to assess the potential
impact on patient welfare and to facilitate remedial action.

✤ hospital peer review body should be notified where appropriate.

✤ poses an immediate threat to the health and safety of patients should

be reported directly to the state licensing board.

✤ physicians without a hospital affiliation should be reported to the

local or state medical society and/or the state licensing or disciplinary
board.
Reporting incompetent colleagues

✤ Unethical conduct.

✤ threatens patient care or welfare should be reported to the

appropriate authority for a particular clinical service
✤ conduct that violates state licensing provisions should be reported
to the state licensing board.
✤ conduct that potentially violates criminal statutes to law
enforcement authorities.
✤ all other unethical conduct should be reported to the local or state
professional medical organization
Reporting incompetent colleagues

✤ inappropriate conduct of a physician continues despite the initial

report(s), the reporting physician should report to a higher or
additional authority.

✤ person or body receiving the initial report should notify the reporting
physician when appropriate action has been taken.

✤ Physicians who receive reports of inappropriate behavior, including

reports submitted anonymously, have an ethical duty to critically,
objectively, and confidentially evaluate the reported information
and assure that identified deficiencies are either remedied or further
reported to a higher or additional authority.
Reporting incompetent colleagues

✤ Information regarding reports or investigations of

impairment, or of incompetent or unethical behavior
should be held in confidence until the matter is resolved.
Disruptive conduct

✤ Personal conduct, whether verbal or physical, that negatively affects

or that potentially may negatively affect patient care constitutes
disruptive behavior.

✤ However, criticism that is offered in good faith with the aim of

improving patient care should not be construed as disruptive
behavior.
Disputes with medical supervisors
and trainees
✤ adequate provisions for protecting the confidentiality of
complainants whenever possible

✤ confidentiality of complainants should be protected when doing so

does not hinder the subject’s ability to respond to the complaint.

✤ access to employment and evaluation files should be carefully

monitored to remove the possibility of tampering.

✤ Resident physicians should be permitted access to their employment

files and also the right to copy the contents thereof, within the
provisions of applicable federal and state laws.
Disputes with medical supervisors
and trainees
✤ Medical students, resident physicians, and other staff should refuse to
participate in patient care ordered by their supervisors in those rare
cases in which they believe the orders reflect serious errors in clinical
or ethical judgment, or physician impairment, that could result in a
threat of imminent harm to the patient or to others.

✤ In these rare cases, the complainant may withdraw from the care
ordered by the supervisor, provided withdrawal does not itself
threaten the patient’s immediate welfare. The complainant should
communicate his or her concerns to the physician issuing the orders
and, if necessary, to the appropriate persons for mediating such
disputes.
Medical Testimony

✤ When a legal claim pertains to a patient the physician has treated, the
physician must hold the patient’s medical interests paramount,
including the confidentiality of the patient’s health information,
unless the physician is authorized or legally compelled to disclose the
information.

✤ Physicians who serve as fact witnesses must deliver honest

testimony. This requires that they engage in continuous self-
examination to ensure that their testimony represents the facts of the
case.
Medical Testimony

✤ When treating physicians are called upon to testify in matters that

could adversely impact their patients’ medical interests, they should
decline to testify unless the patient consents or unless ordered to do
so by legally constituted authority.

✤ If, as a result of legal proceedings, the patient and the physician are
placed in adversarial positions it may be appropriate for a treating
physician to transfer the care of the patient to another physician.

✤ When physicians choose to provide expert testimony, they should

have recent and substantive experience or knowledge in the area in
which they testify, and be committed to evaluating cases objectively
and to providing an independent opinion.
Peer Review

✤ Medical society ethics committees, hospital credentials and utilization

committees, and other forms of peer review have been long
established by organized medicine to scrutinize physicians’
professional conduct. At least to some extent, each of these types of
peer review can be said to impinge upon the absolute professional
freedom of physicians. They are, nonetheless, recognized and
accepted. They are necessary, and committees performing such work
act ethically as long as principles of due process (Opinion 9.05, "Due
Process") are observed. They balance the physician’s right to exercise
medical judgment freely with the obligation to do so wisely and
temperately. (II, III, VII)
Knowledge itself has no intrinsic
moral value.
It is the way in which knowledge is
put to use that it acquires an ethical
dimension.