Medscape Ethics Report 2018: Money, Romance, and Patients

Physicians are often faced with ethical decisions in the course of patient care. These decisions may be emotionally wrenching and can have an impact on a patient's life, affect a physician's career or income, and make a difference in how physicians feel about themselves and their mission. Medscape surveyed more than 5200 physicians in over 29 specialties to find out how they feel about the key ethical issues they cope with in their practice.

According to Medscape's Sexual Harassment of Physicians Report 2018, 10% of clinicians say they were sexually harassed within the past 3 years.

"This is one of my hot buttons to act proactively and confront the harasser!" —Internist

"Yes, my job is to be a healer. Preventing harm is part of what I do." —Family physician

"I reported my boss, and I faced repercussions for years. I suffered far more than he did." —Internist

"They must do an investigation. If there is evidence to support the claim, then yes." —Nephrologist

"There should be at least a reprimand for the alleged behavior, as well as required sexual harassment education and probation with a zero- tolerance policy." —Gastroenterologist

"A person is innocent until proven guilty. There are many people who would make this accusation just because they have some other issue with you. I watched my coworker's life get destroyed because of this, and in the end he was found totally innocent." —Emergency medicine physician

The Centers for Disease Control and Prevention reported that vaccination rates have flattened out over the past few years among healthcare workers, although vaccinations were highest among physicians.[1]

"Physicians should determine what's best for their own health, but if they refuse the vaccine and contract the flu, they should be obligated to refrain from seeing patients for a predetermined number of days in order not to spread the virus." —Internist

"My libertarian self says no, but you are foolish if you are a physician and don't get it. Our hospital will not let you use sick time if you didn't get your flu shot and you call out for the flu." —Oncologist

"If it was the best treatment for the patient, yes—but I would make it clear so the patient wasn't surprised if they received a higher bill than expected." —HIV/infectious diseases physician

"I try to do what I would want done for me, but if it's at the risk of my income, then no, as long as the patient would get acceptable results." —Family physician

"I would do so if that is the patient's choice, or the outside physician can offer the patient something that an internal physician cannot." —Family physician

Plastic surgeons (44%), orthopedic surgeons (38%), and orthopedists (31%) were most likely to answer "yes" to this question, and critical care physicians (5%), oncologists (8%), and radiologists (9%) were least likely, according to Medscape's report.

"No. I abhor financial motivations that encroach on the sacred trust between patients and physicians." —HIV/infectious diseases specialist

"As a surgeon, you are judged on your outcomes, which may necessitate you to not operate on extremely high-risk patients from time to time." —General surgeon

"I consider this unethical. It is not what I got into medicine for." —Internist

"I reported several that I was concerned about. A few didn't pan out. The patient and relatives were mad, but I felt it was the right thing to do. It's easier to explain why you reported a case than why you didn't." —Internist

"In pediatrics, I may be providing more protection for a child by providing counseling and family intervention prior to reporting. When we report, and the family is angry and immediately changes pediatricians, I feel strongly that the child or battered wife may be at greater risk." —Pediatrician

"I failed to report once with a child who later showed up with severe, life-threatening injuries. I learned my lesson, and now I have a much lower threshold for reporting suspected abuse." —Pediatrician

"Seriously, who does this?!? And, if they do, why are they still allowed to practice medicine? I have seen one or two cases like this in my career, and I find it abhorrent." —Ophthalmologist

"People find love in all places. If it were to be a truly meaningful relationship, I don't see why someone shouldn't be able to start a relationship. I would think they would end the patient-doctor relationship by referring to a colleague." —Neurologist

Among female physicians, 72% said "no," and 8% said "it depends." Among male physicians, 59% said "no," and 10% said "it depends."

"Yes, doctors are human; things happen, even if one takes all precautions." —Internist

"Two consenting adults should be able to have a romantic relationship." —Physical medicine

"You just need to find them a new doctor from the time you get involved and onward." —Family physician

In Medscape's 2010 report, Physicians' Top 20 Ethical Dilemmas, physicians replied to a similar question as follows: no (94.9%), yes (1.6%), and it depends (3.5%).

"No. Maintaining trust in the profession requires transparency." —Anesthesiologist

"There are many studies that show if you are honest with a family, they are willing to accept an apology and move on. If you are not, you increase your likelihood of being sued." —Urologist

"I once cut an L5 nerve doing a discectomy. I wrote it in the op report and told the patient. A couple of weeks later, I assisted a neurosurgeon. He did the same thing, except he didn't mention it. I was lucky. My patient said, 'I don't care, Doc, my pain is gone!'" —General surgeon

"I did occasionally when I was in private practice, and felt it was the right thing to do then. I am now employed by an organization that prohibits this practice." —Internist

"Patient education is key. Treat the underlying problem. I don't think placebo-type treatment is the way to go." —Family physician

"Placebo therapy under the conditions noted above should be accepted practice, since placebo works in 30%-35% of research studies of drug management." —Orthopedist

"Yes. Sometimes you fear missing something and it can become an issue later." —Gastroenterologist

"I would not perform an unwarranted procedure, but I have obtained X-rays I thought were probably going to be negative when the patient really wanted them or the risk of NOT doing so could be bad." —Emergency physician

"A medically unwarranted treatment IS malpractice." —Family physician

"Yes, if I had hard data to support my opinion. I would certainly let them know if I felt strongly that they might consider another opinion or provider." —Family physician

"Politically, it's not possible and I would risk my own employment." —Anesthesiologist

"Absolutely! Please, please, please do this for the good of us all. For the same reason that airline pilots are tested." —Neurologist

"If a physician has a past history, then yes, I can see why that should be done." —Cardiologist

"If there is cause for concern, yes!" —Internist

"For illegal drugs: yes. Impaired on the job: yes. Legal drugs or on his own free time, then no." —Critical care physician

The rate of addiction among practicing physicians is between 10% and 15%. Alcohol is the substance most commonly abused. Doctors also have higher rates of prescription drug abuse than the general population.[2]

"Physicians are not above the law." —Anesthesiology

"It is degrading in a way, but other less critical professions require it." —Endocrinologist

"How are you defining abuse? In state where marijuana is legal, then is presence of marijuana in system the same as evidence of abuse?" —Family physician

"Of course. I would be a criminal if I did not." —Family physician

"I would first address my concerns with the individual, and if there were no change, I would report." —Emergency medicine physician

"I would talk to my friend, but as a friend I would never report him/her." —Family physician

"Insurance dictates prescription choices for patients every day." —Pediatrician

"I usually tell the patient of the treatment and explain that they need to SUE their insurance company to get treatment." —Urologist

"I would explain the risk/benefit/cost to the patient including the potential nonpayment by the insurer with result balance billing and let them decide if they would like to proceed or not." —Neurologist

"It depends. The finances of the organization is important." —Psychiatrist

"Extra costs must be balanced with efficacy of probable outcomes. Under financial pressure, I would audit the risk/benefit profile for each patient more carefully than otherwise." —Pathologist

"Profiteering should not come above human life." —Internist

"Only if the practice was at risk of going bankrupt as a result." —Family physician

"No. The insurers are money-hungry. I am hungry to save lives and care compassionately." —General surgeon

"I am attached to my patients and would not let them down." —Anesthesiologist

"Physicians should have the ability to set up their practice to meet their financial, personal, and families' needs." —Emergency medicine physician

"I don't like it. Concierge (with some exceptions) is money-driven. I often volunteer. It is good to keep our profession very noble." —Family physician

"People can pay for pampering if they want. There is a free market." —Pediatrician

"For billing? Never! For prior authorization, hell yes!" —Pathologist

"That is called billing fraud. I don't want to be targeted for fraud. However, it does get frustrating fighting for prior authorization for studies that I know are indicated." —Orthopedist

"The coding is often ambiguous. If I think a procedure or test is really needed, I will help the patient get it." —Family physician

"Isn't informing the Department of Health technically breaching confidentiality? You still have to do it though." —Family physician

"It would be difficult to do, but yes, if—for example—someone was infected with HIV or syphilis and did not tell a spouse." —Pediatrician

"If I were a paid speaker, it would most likely influence my prescribing habits, but accepting a lunch or two would not influence them." —Anesthesiologist

"Most docs I know don't take time out on their own to learn about new treatment. Luncheons are good to learn about new meds and to read the technical data." —Dermatologist

"Often the information helps update the physician as to new or emerging therapies as well as their risks and benefits, which a conscientious physician will then read up about." —Critical care physician

Other responses:

"I worked with a lot of patients whose families did not immunize, and I have seen babies die of whooping cough, a preventable illness."

"Helping patients with no financial means and no insurance."

"Trying to convince a parent their child needed treatment for meningitis, when the parent wanted to try homeopathic treatments. Hospital lawyer was involved; the parents went home; the child died."

"A healthy 24-year-old was avoiding the draft by joining some religious cult AND collecting free medical care. He required a tonsillectomy, and I wouldn't perform it. I felt that my anger and emotional state could endanger him as a patient."

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