Lois Snyder Sulmasy

Online Medical Professionalism: Patient and Public Relationships: Policy Statement From the American College of Physicians and the Federation of State Medical Boards

User-created content and communications on Web-based applications, such as networking sites, media sharing sites, or blog platforms, have dramatically increased in popularity over the past several years, but there has been little policy or guidance on the best practices to inform standards for the professional conduct of physicians in the digital environment. Areas of specific concern include the use of such media for nonclinical purposes, implications for confidentiality, the use of social media in patient education, and how all of this affects the publics trust in physicians as patient-physician interactions extend into the digital environment. Opportunities afforded by online applications represent a new frontier in medicine as physicians and patients become more connected. This position paper from the American College of Physicians and the Federation of State Medical Boards examines and provides recommendations about the influence of social media on the patient-physician relationship, the role of these media in public perception of physician behaviors, and strategies for physician-physician communication that preserve confidentiality while best using these technologies.

Policy Recommendations to Guide the Use of Telemedicine in Primary Care Settings: An American College of Physicians Position Paper

Telemedicine-the use of technology to deliver care at a distance-is rapidly growing and can potentially expand access for patients, enhance patient-physician collaboration, improve health outcomes, and reduce medical costs. However, the potential benefits of telemedicine must be measured against the risks and challenges associated with its use, including the absence of the physical examination, variation in state practice and licensing regulations, and issues surrounding the establishment of the patient-physician relationship. This paper offers policy recommendations for the practice and use of telemedicine in primary care and reimbursement policies associated with telemedicine use. The positions put forward by the American College of Physicians highlight a meaningful approach to telemedicine policies and regulations that will have lasting positive effects for patients and physicians.

Talking with Patients about Other Clinicians' Errors

The authors discuss the challenges facing a clinician who discovers that her patient has been harmed by another health care workers medical error. They provide guidance to help clinicians and institutions disclose such errors to patients.

Prescription drug abuse: executive summary of a policy position paper from the American College of Physicians.

Prescription drug abuse is a serious public health problem. Physicians and other health professionals with prescribing privileges are entrusted with the authority to use medications in the treatmen...

Ethics and the Legalization of Physician-Assisted Suicide: An American College of Physicians Position Paper

Calls to legalize physician-assisted suicide have increased and public interest in the subject has grown in recent years despite ethical prohibitions. Many people have concerns about how they will die and the emphasis by medicine and society on intervention and cure has sometimes come at the expense of good end-of-life care. Some have advocated strongly, on the basis of autonomy, that physician-assisted suicide should be a legal option at the end of life. As a proponent of patient-centered care, the American College of Physicians (ACP) is attentive to all voices, including those who speak of the desire to control when and how life will end. However, the ACP believes that the ethical arguments against legalizing physician-assisted suicide remain the most compelling. On the basis of substantive ethics, clinical practice, policy, and other concerns articulated in this position paper, the ACP does not support legalization of physician-assisted suicide. It is problematic given the nature of the patient-physician relationship, affects trust in the relationship and in the profession, and fundamentally alters the medical professions role in society. Furthermore, the principles at stake in this debate also underlie medicines responsibilities regarding other issues and the physicians duties to provide care based on clinical judgment, evidence, and ethics. Societys focus at the end of life should be on efforts to address suffering and the needs of patients and families, including improving access to effective hospice and palliative care. The ACP remains committed to improving care for patients throughout and at the end of life.

Hidden Curricula, Ethics, and Professionalism: Optimizing Clinical Learning Environments in Becoming and Being a Physician: A Position Paper of the American College of Physicians

Hidden curricula are lessons learned that are embedded in culture and are not explicitly intended. Medicines hidden curriculum powerfully influences student and resident norms and values. More than half of 2016 medical school graduates said that they experienced disconnects between what [they were] taught about professional behaviors/attitudes and what [they saw] being demonstrated by faculty (1). Learners receive conflicting messages about ethics and professionalism when the actions or words of role models are not consistent with the values espoused by the profession. Uncovering inconsistent messages and revealing and reinforcing inspiring examples of doctoring is challenging. The concept of a hidden curriculum is neither new nor limited to medical education. It was identified by Philip Jackson, who described elementary education as a socialization process (2)the method by which the values, skills, and attitudes of a group being joined are adopted. In medicine, it is distinct from the formal curriculum of coursework and classroom lessons sanctioned by the institution, the informal curriculum of ad hoc instruction (such as bedside rounds), and the null curriculum of what is not taught (see the Table for definitions). Awareness of all of these curricula adds important perspectives for assessing learning environments, but this articles focus is the hidden curriculum. Table. Types of Curricula* In medicine, the hidden curriculum is transmitted in the clinic, the hospital, the operating room, the team room, and the cafeteria. The culture of medicine is passed down through examples, stories, rituals, symbols, and defined hierarchies (4, 5). A primary care physician visiting her hospital patient in the evening after clinic is a positive example of the hidden curriculum; making disparaging comments about frequently admitted patients is a negative example. Disrespect can also occur between clinicians, such as disparaging comments about nonacademic physicians by academic physicians or about a specialty. The hidden curriculum has large-scale effects. For example, systemic bias against primary care contributes to the U.S. health care system being unprepared to meet the needs of an aging population (6, 7). Negative comments from leadership and greater financial rewards for subspecialists can discourage students from choosing primary care despite societal need, intellectual rigor, and the importance of longitudinal healing relationships. System structure and culture reflect what society values. The intensity of medical training is a cultural immersion in which values are often communicated and adopted without adequate reflection and critique. The professionalization of future physicians is affected, but the effects go beyond learners to practicing clinicians and patients. This American College of Physicians (ACP) position paper on the relationship among hidden curricula, ethics, and professionalism identifies challenges, opportunities, and strategies for optimizing learning environments. Ethical principles should apply to all health care environments. Strategies to identify and address discrepancies between our values and actions are proposed to help align positive hidden curricula with formal curricula. This executive summary is a synopsis of position statements of the ACP. The rationales for the position statements are presented in the Appendix. Methods This position paper was developed on behalf of the ACP Ethics, Professionalism and Human Rights Committee (EPHRC). Committee members abide by the ACPs conflict-of-interest policy and procedures (www.acponline.org/about-acp/who-we-are/acp-conflict-of-interest-policy-and-procedures), and appointment to and procedures of the EPHRC are governed by the ACPs bylaws (www.acponline.org/about-acp/who-we-are/acp-bylaws). After an environmental assessment to determine the scope of issues and literature reviews, the EPHRC evaluated and discussed several drafts of the paper. The paper was then reviewed by members of the ACP Board of Governors, Board of Regents, Council of Resident/Fellow Members, Council of Student Members, and other committees and experts. The paper was revised on the basis of comments from these groups and individuals. The ACP Board of Regents reviewed and approved the paper on 16 February 2017. ACP Positions and Recommendations 1. The hidden curriculum must become a positive curriculum that aligns with the formal curriculum. Faculty and senior clinicians should model empathy, encourage reflection and discussion of positive and negative behaviors in the training environment, and promote clinician wellness. What is taught in the classroom must be reinforced and enhanced by what is practiced at the bedside. 2. The learning environment should foster respect, inquiry, and honesty and empower every individual, including learners, to raise concerns about ethics, professionalism, and care delivery. Teamwork and respect for colleagues must be both taught and demonstrated. 3. Leaders should create and sustain a strong ethical culture by encouraging discussion of ethical concerns, making values in everyday decision making explicit, and embodying expectations of professionalism in which patient well-being is a core value. Conclusion The educational and social milieu of medical learning environments is a complex system of influences. Role models across peer relationships and the hierarchy of medicine contribute to the formation of professional identity, behaviors, and attitudes of future physicians. The best solutions to the influence of the hidden curriculum will uncover it, integrate its positive aspects into the formal curriculum, and lead to development of approaches to understand and mitigate its negative aspects by educators and practicing clinicians. The hidden curriculum in medicine presents challenges but also opportunities to help reshape not only education but also the culture of medicine.

Ethical Implications of the Electronic Health Record: In the Service of the Patient

Electronic health records (EHRs) provide benefits for patients, physicians, and clinical teams, but also raise ethical questions. Navigating how to provide care in the digital age requires an assessment of the impact of the EHR on patient care and the patient–physician relationship. EHRs should facilitate patient care and, as an essential component of that care, support the patient–physician relationship. Billing, regulatory, research, documentation, and administrative functions determined by the operational requirements of health care systems, payers, and others have resulted in EHRs that are better able to satisfy such external functions than to ensure that patient care needs are met. The profession has a responsibility to identify and address this mismatch. This position paper by the American College of Physicians (ACP) Ethics, Professionalism and Human Rights Committee does not address EHR design, user variability, meaningful use, or coding requirements and other government and payer mandates per se; these issues are discussed in detail in ACP’s Clinical Documentation policy. This paper focuses on EHRs and the patient–physician relationship and patient care; patient autonomy, privacy and confidentiality; and professionalism, clinical reasoning and training. It explores emerging ethical challenges and concerns for and raised by physicians across the professional lifespan, whose ongoing input is crucial to the development and use of information technology that truly serves patients.Electronic health records (EHRs) provide benefits for patients, physicians, and clinical teams, but also raise ethical questions. Navigating how to provide care in the digital age requires an assessment of the impact of the EHR on patient care and the patient–physician relationship. EHRs should facilitate patient care and, as an essential component of that care, support the patient–physician relationship. Billing, regulatory, research, documentation, and administrative functions determined by the operational requirements of health care systems, payers, and others have resulted in EHRs that are better able to satisfy such external functions than to ensure that patient care needs are met. The profession has a responsibility to identify and address this mismatch. This position paper by the American College of Physicians (ACP) Ethics, Professionalism and Human Rights Committee does not address EHR design, user variability, meaningful use, or coding requirements and other government and payer mandates per se; these issues are discussed in detail in ACP’s Clinical Documentation policy. This paper focuses on EHRs and the patient–physician relationship and patient care; patient autonomy, privacy and confidentiality; and professionalism, clinical reasoning and training. It explores emerging ethical challenges and concerns for and raised by physicians across the professional lifespan, whose ongoing input is crucial to the development and use of information technology that truly serves patients.

On substituted arguments

In their essay, “ Clarifying Substituted Judgment: the Endorsed Life Approach ,”1 Wendler and Phillips add to a growing body of literature that acknowledges what has been apparent to many clinicians and commentators for a long time: something is seriously wrong with the contemporary US approach to surrogate decision making. Their essay summarises background that has been more extensively reviewed elsewhere: the history of how we came to this impasse, and the many theoretical and empirical critiques of substituted judgement.2 Drawing on this background, they propose an alternative to substituted judgement that differs little from the Substituted Interests Model that we proposed in 2010,3 doing so, in part, by misrepresenting our published views. The overlap between their model and ours is befuddling, but by calling their approach an attempt to ‘clarify’ rather than replace the substituted judgement standard, they only further muddy the waters. The approach they advocate is so similar to our Substituted Interests Model that giving it a different name and calling it an ‘interpretation’ of substituted judgement will only wind up being confusing for surrogates, clinicians and policy makers. Their primary motivation seems to be to ‘save’ substituted judgement since it is so well established in law and bioethical education. After noting some of the many problems with substituted judgement, they nonetheless both propose retaining the name and advise asking the surrogate to provide ‘the decision the patient would make for herself, if competent.’ They give two reasons for this: (1) they believe this directive is a useful approximation of the standard they think is really the correct one, namely, to provide the decision most consistent with the life the patient seems to have endorsed for herself, and (2) they think substituted judgement has become so ensconced in policy and practice that it would …

Ethical Issues in the Design and Implementation of Population Health Programs

Spurred on by recent health care reforms and the Triple Aim’s goals of improving population health outcomes, reducing health care costs, and improving the patient experience of care, emphasis on population health is increasing throughout medicine. Population health has the potential to improve patient care and health outcomes for individual patients. However, specific population health activities may not be in every patient’s best interest in every circumstance, which can create ethical tensions for individual physicians and other health care professionals. Because individual medical professionals remain committed primarily to the best interests of individual patients, physicians have a unique role to play in ensuring population health supports this ethical obligation. Using widely recognized principles of medical ethics—nonmaleficence/beneficence, respect for persons, and justice—this article describes the ethical issues that may arise in contemporary population health programs and how to manage them. Attending to these principles will improve the design and implementation of population health programs and help maintain trust in the medical profession.

Emailing Test Results to Patients

650 mg) would have produced larger anti-inflammatory effects than the lower dose (81 mg) after only 7 days. Furthermore, aspirin is known to increase the risk of bleeding, as was also demonstrated in the investigation by Kor and colleagues, although it was not statistically significant (odds ratio, 2.27 [90% CI, 0.92-5.61]; P = .13). Patients were exposed to a predictable risk without sufficient evidence for potential benefit. Instead, data should have been generated supporting the safety and appropriateness of the aspirin regimen in a relevant population.