Interference with the Patient–Physician Relationship

“Life is like a boomerang. Our thoughts, deeds and words return to us sooner or later, with astounding accuracy.”-Brant M. Bright, former project leader with IBM

A recent sounding board in the New England Journal of Medicine discussed legislative interference with the patient-physician relationship (1).  The authors, the executive staff leadership of the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American College of Physicians, and the American College of Surgeons believe that legislators should abide by principles that put patients’ best interests first. Critical to achieving this goal is respect for the importance of scientific evidence, patient autonomy, and the patient-physician relationship. According to the authors, lawmakers are increasingly intruding into the realm of medical practice, often to satisfy political agendas without regard to established, evidence-based guidelines for care.

The article goes on to cite examples including:

1. The Florida Firearm Owners’ Privacy Act, which substantially impaired physicians’ ability to deliver gun-safety messages to patients.
2. New York legislation requiring physicians to offer terminally ill patients information and counseling regarding palliative care and end-of-life options.
3. A Virginia bill requiring women to undergo ultrasonography before an abortion including mandated transvaginal ultrasonography in some instances.
4. Pennsylvania, Ohio, Colorado, and Texas legislation limiting a physician’s ability to disclose information about exposure to chemicals such as benzene, toluene, ethylbenzene, and xylene used in the process of hydraulic fracturing (“fracking”).

The authors condemn these actions that undermine physician autonomy and the fundamental principles of respect for patient autonomy, beneficence, nonmaleficence, and justice that shape physicians’ actions and behavior. The authors go on to state that “laws and regulations are blunt instruments… that reduce health care decisions to a series of mandates …for political or other reasons unrelated to the scientific evidence and counter to the health care needs of patients”. However, these legislative actions are an extension of the trend where multiple individuals and groups have increasingly dictated patient care.

It would be remiss not to point out that those clinician groups have been as guilty of dictating healthcare as some of the politicians by publishing or endorsing mandates for care. As the authors state mandates “do not allow for the infinite array of exceptions-cases in which the mandate may be unnecessary, inappropriate, or even harmful to an individual patient”. Although the authors would likely argue that they publish guidelines rather than mandates, their guidelines have as much authority as laws given that both threaten a physician’s ability to practice. Penalties for noncompliance with guidelines such as removing hospital privileges, reducing payments or listing physicians in the National Practioner Database are as much a threat to physicians as legislative action.

These clinician groups would also likely argue that their guidelines are evidence-based and in the patient’s best interests. However, there are multiple instances where the mandates are not evidence based and ineffective (e.g., pneumococcal 23 polyvalent vaccine in adults) (2-4) or even harmful (e.g., tight control of glucose in the ICU) (5). Patient autonomy and individual needs, values, and preferences must be respected. Physicians must have the ability and freedom to treat their patients “freely and confidentially, to provide patients with factual information relevant to their health, to fully answer their patients’ questions, and to advise them on the course of best care without the fear of penalty” (1).

These clinician groups should speak out against political mandates or when the scientific evidence is premature, weak or contradictory regardless of the source. Medical guidelines should have patients' best interests at heart and not political agendas whether from politicians or others. Importantly, these clinician groups should “recognize the infinite array of exceptions” to each mandate or guideline. Finally, they should condemn the practice of allowing regulatory agencies to promote a political or financial agenda by threatening physicians to conform to the ever increasing numbers of mandates and guidelines that are based on poor quality evidence. Those that are members of the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American College of Physicians, or the American College of Surgeons who agree that mandates undermine the physician-patient relationship and ultimately adversely affect patient care should speak loudly to their executive staff leaders to ensure their voices are heard. Better ways of informing clinicians of best current practice are needed, but also needed are ways of making the accomplishment of best practices easy and rewarding, rather than punitive.

Richard A. Robbins, MD*

Editor, SWJPCC

References

1. Weinberger SE, Lawrence HC 3rd, Henley DE, Alden ER, Hoyt DB. Legislative interference with the patient-physician relationship. N Engl J Med 2012;367:1557-9.t
2. Fine MJ, Smith MA, Carson CA, Meffe F, Sankey SS, Weissfeld LA, Detsky AS, Kapoor WN. Efficacy of pneumococcal vaccination in adults. A meta-analysis of randomized controlled trials. Arch Int Med 1994;154:2666-77.
3. Dear K, Holden J, Andrews R, Tatham D. Vaccines for preventing pneumococcal infection in adults. Cochrane Database Sys Rev 2003:CD000422.
4. Huss A, Scott P, Stuck AE, Trotter C, Egger M. Efficacy of pneumococcal vaccination in adults: a meta-analysis. CMAJ 2009;180:48-58.
5. Robbins RA, Singarajah CU. Critical care review: the high price of sugar. Southwest J Pulm Crit Care 2011;3:78-86

The views expressed in this editorial are those of the author and not necessarily the views of the Arizona, New Mexico or Colorado Thoracic Societies.

Reference as: Robbins RA. Interference with the patient-physician relationship. Southwest J Pulm Crit Care 2012;5:253-5. PDF