READ THIS:The Course of The Topics Here

I want to take a moment to explain to my new visitors what has been the direction of the topics here since I started the blog in July 2004. What I have written,provided excerpts and links to resources, is all about the various ethical issues that arrive from the doctor-patient relationship and the some of the issues in the general topic of medical professionalism. Starting with the first posting about the office visit (at the bottom of the Main Page), I have tried to develop each posting in some form of continuity. Soon, I will migrate to other bioethical issues. Please write me e-mail or as a comment to this posting about what issues in bioethics that you have concern and would like me to cover. Thank you.. Maurice.

E-Mail in Medical Practice: My View

There is not enough time spent in face to face communication between patient and physician in the doctor-patient relationship. So many of the conflicts, errors and misunderstandings in medical practice are clearly related to deficiencies in communication. Even telephone communication may be inadequate in certain clinical situations. With the introduction of e-mail communication in medical practice, these obstructions to good medical care of the patient can only worsen unless attention is taken by both sides to avoid the wrong kind of e-mail communication.

My view is that the use of e-mail in medical practice should be very limited to simply the transmission of data between patient and physician where no discussion, explanation or detailing is necessary. In this context, the data the physician would send to the patient might include appointment dates or changes, laboratory values or results about which the patient would already be aware of the clinical significance, non-personal general health information and so forth. The data the patient would send to the physician might include appointment date requests or changes, specific self-monitoring information (such as blood sugars or weights)or non-urgent followup symptom reporting.

Issues of privacy of information also must be considered. It may be necessary to transmit this data only on secure server websites. Since consultations via e-mail should not be an e-mail activity, professional compensation specifically for appropriate use of e-mail would not be of significance.

Though, to some, my view of e-mail in medical practice might seem unduly constrained and conservative, I believe anything beyond the functions that I have written would be harmful to the profession. ..Maurice.

Electronic Communication Between Physician and Patient

Lets go back to the topic of ethical issues in doctor-patient relationships and think about the increasing role of the use of e-mail in medical practice. The National Center for Ethics in Healthcare of the Veterans Health Administration in July 2004 issued a report by their ethics panel, which speaks to this role. The benefits and cautions are presented after consideration of the ethical issues involved and recommendations (pasted below) are made. The VA is developing a website called My HealtheVet to help support this new kind of communication.
For the full report go to National Center for Ethics Veterans Health Administration
and click on “Online Patient-Clinician Messaging”. Let me know how you feel about the use of e-mail and web posting as a means of communication between patient and doctor. ..Maurice.

Excerpts from VAH Report

Surveys repeatedly show that patients want to be able to communicate with their clinicians online. And online patient-clinician communication is widely held to have significant potential to enhance patient-clinician relationships, promote greater involvement by patients in their own care (including self-monitoring), and ultimately improve the outcomes of care. Concerns have been raised, however, about patient privacy, the effects of online communication on patient-clinician relationships, and the potential impact on clinicians’ workload and reimbursement.
This report by VHA’s National Ethics Committee (NEC) examines the nature of online communication and explores the ethical challenges of online communication between patients and clinicians. It offers the following recommendations to assure the ethical practice of online patient-clinician messaging within VHA:

(1) Clinicians and health care organizations should ensure that online communication takes place only when the confidentiality and security of personal health information can be reasonably assured. Once implemented nationally, My HealtheVet will provide the foundation for a secure environment required for responsible online communication between patients and clinicians.

(2) Clinicians should ensure that patients who do not interact electronically receive the same quality of care as their online peers. Online communication should not be allowed to exacerbate existing inequalities in health care by discriminating against those who have no or limited access to online communication.

(3) Clinicians should be aware of the potential effects of online messaging on the patient-clinician relationship and take steps to avoid “depersonalization.” Just how online interaction affects patient-clinician relationships is an empirical question that is still unsettled.

(4) Participation in online messaging should be voluntary for both patients and clinicians. As VHA gains more experience with this medium, requiring clinician participation may some day be justified. However, patient participation should remain voluntary.


(5) Clinicians should assure that patient participation in online communication is well informed. Clinicians should enter into an explicit agreement with patients, either orally or in writing, regarding the terms and conditions that will govern their online communication. However, there is no need to require patients to sign an informed consent form.

(6) Clinicians should limit their online communication with patients to appropriate uses. Online communication should not be used to initiate a patient-clinician relationship, to handle situations of an urgent nature, or to convey information that is highly sensitive. Messages should be carefully worded and organized to ensure effective communication, and should conform to organizational standards with regard to message handling.

(7) Health care organizations should recognize online interactions with patients as part of clinicians’ professional activities in institutionally appropriate ways.This may be accomplished, for example, by formally scheduling time for messaging, or by adopting the recently proposed AMA CPT code for online evaluation and management of patients to capture data regarding online patient communication, evaluation, and management as a professional clinical activity.

Physician As Patient (2)

What is the VIP syndrome? The Very Important Person (VIP) syndrome is a pattern of behavior by both the ill physician and his/her healthcare providers that may be deleterious to the established standards of medical care. From the ill physician’s point of view, his or her illness as a physician requires special attention by the caregivers not given to the other patients. The physician is to be treated as a professional and is to be kept fully informed about all the clinical details and is to be consulted as a colleague by the treating physician. The ill physician may request that appointments or lab tests take priority over others for personal convenience. When hospitalized, the physician may be demanding about which nurses are assigned and how they respond to requests. Also, the family of the sick doctor may be similarly demanding.

I suspect that the VIP behavior by the ill physician is not as common as the potential for altered behavior by the treating physician. Unless the treating physician has had lengthy experience caring for medical colleagues, the experience of being a doctor’s doctor can be emotionally traumatic with anxiety, uncertainty, anger and guilt. From the outset, history taking of the doctor may be more incomplete than the average patient since there may be a tendency to avoid asking important but personally embarrassing questions such as involving mental illness, family problems, sex or drug and alcohol use. Physical exams of the ill physician may be more casual and pelvic, breast or rectal exams may be omitted. Testing may be inadequate especially if the appropriate test is uncomfortable. Telling the ill physician the diagnosis and treatment options may be difficult if the treating physician is personally uncomfortable with the conclusion and identifies with a patient with whom he or she has professionally interacted. All of these VIP elements do nothing but worsen or delay proper diagnosis and treatment

Proper communication with the ill physician is essential and probably the most important thing that a treating physician can do is at the outset to make it clear that the sick doctor is going to be treated as a patient and not as a doctor.

For more reading on this topic: "’Doctoring’ Doctors and Their Families” by Stuart A. Schneck, MD
JAMA. 1998; vol.280, pages 2039-2042.