Inappropriate clinicians

An article in the December 28th 2011 JAMA reports a study of doctors and nurses in 82 ICUs across Europe and Israel. These clinicians were asked whether they had provided inappropriate care, defined as “care that clashes with your personal beliefs and/or professional knowledge,” on a particular day. More than one-fourth believed the care they provided on that day was inappropriate.

An accompanying editorial asks the million-dollar question, “If so many clinicians are providing care that is not motivated by its appropriateness, what then are they trying to accomplish?”

What, indeed? Isn’t providing care that contradicts one’s beliefs and knowledge tantamount to providing unethical care?

From my own experience, I will hazard a guess that if the clinicians had been questioned about a longer time period than just one day, way more than one-fourth of them would have reported providing inappropriate care; and that the problem of providing inappropriate care extends well beyond the ICU to clinicians everywhere. I will also hazard a few guesses at just some of the motivations behind providing inappropriate care:

-The clinicians want to please patients or families, and/or are experiencing pressure from the families to provide inappropriate care;

-The clinicians are required to follow guidelines that are based on the statistical analysis of large populations, but happen not to apply to the individual patient being treated;

-The clinicians are attempting to prevent a malpractice lawsuit by doing more tests and procedures than are appropriate;

-The clinicians are following inappropriate laws, such as the one  drafted by the NRA and the Florida legislature restricting physicians’ ability to properly counsel patients.

Most reasons underlying inappropriate care stem not from the deliberately unethical practice of the clinician (although I do not deny that such things occur), but from characteristics of the system which induce them to act in ways that they feel are inappropriate.

The idealist in me believes that most people who go into medicine and nursing do so because they want to help people. Virtually all of the nurses and physicians I know (and I know quite a few) want to do the best thing for their patients. But all of these idealistic people are taken and thrown into a system that influences them to act in ways that they believe are inappropriate. The clinicians find themselves, for reasons beyond their control, giving inappropriate care.

Is inappropriate care always unethical care? How can one be an ethical clinician in a system that prevents one from acting appropriately?

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Jamie
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Joe, this is a very large and very tricky subject. But one I’m glad you brought up for us to ponder. I do believe that if we need healthcare reform it is to change the system that has become a place for influencing everyone that comes into it, for better or worse. We should focus more on finding the real issues and fix them…I’m just not sure how 🙁
Thanks for the post

Joseph Gibes
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Joseph Gibes

Jamie – I think your comment about healthcare reform is right on. Our current healthcare “system” incentivizes escalating costs with ever-more tests and treatments — many of which are “inappropriate.” Whatever system reform is contemplated must incentivize appropriate, ethical care that helps reign in costs. – Joe