AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. November 2011, Volume 13, Number 11: 796-798.

Policy Forum

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Aligning Values with Value

Medical stewardship is a way of describing a relatively new obligation to maximize health care resources. A professionwide conversation about its meaning and value is needed.

Audiey C. Kao, MD, PhD

The Doctor, by Sir Luke Fildes, was once one of the most recognized of all Victorian paintings, in part because reproductions of it hung in many doctors’ offices. To this day, the painting is often used to portray the core values of what it means to be a good doctor [1].

The parents depicted in the painting are powerless to help their sick child. The truth is that there was little the doctor could do to alter the course of this patient’s illness either. At most, the doctor could be wholly present, tend to his patient’s needs to the best of his abilities, and comfort the family when the time came. This professional commitment to do whatever one can in the patient’s best interest remains a central ethic upheld by modern-day physicians.

While much remains constant in the artful practice of medicine, much has changed in the clinical and scientific basis of medical practice since Fildes painted The Doctor. With dramatic advances in biomedical knowledge and technology over the past 25 years, there is no shortage of diagnostic tests and therapeutic modalities that physicians can employ to intervene for the benefit of their patients’ health and welfare. The increased capabilities of modern medicine to treat and cure has seemed inextricably linked to the escalating financial cost of providing care to patients. Consequently, there is growing pressure on physicians to be more cost conscious and better stewards of health care resources and on policymakers, at national and local levels, to get more value out of every dollar that is spent on medical care.

How does this relatively new obligation of medical stewardship fit with physicians’ long-standing ethic of doing whatever is in the patients’ best interest regardless of personal discomfort or financial cost? Through focus groups and a nationally representative survey of physicians conducted in 2011, the American Medical Association (AMA) sought to better understand what physicians thought about the idea of medical stewardship, its relevance in the practice of medicine, and what may facilitate and hinder cost-conscious clinical decision making.

In web-based focus groups, most physicians reported having heard or used the term “stewardship” in other arenas, but not as it relates to health care.

Stewardship is a word I hear at church. [Being] responsible, taking ownership, looking out for the best interest of the majority, doing what is right—not necessarily what is popular—careful use of resources [2].

While physicians’ response to the term “stewardship” was mostly positive or neutral, there were some skeptical reactions as well.

My obligations—professional, legal, and ethical—are to my individual patients. While there are not unlimited resources in any community (including the country as a whole), I don’t see my care as a zero-sum game—giving care to one patient does not take away care from another [2].

AMA survey data also revealed that physicians are evenly split about whether they take cost into consideration when making treatment decisions on individual patients (AMA, unpublished data, 2011). Preliminary analyses of qualitative and quantitative data collected by the AMA suggest that physician stewardship of health care resources is accepted as a professional obligation by many physicians, but whether stewardship is a core ethical value in medicine remains an open question. A significant number of physicians believe that taking cost into consideration when making clinical decisions would be antithetical to being a “good” doctor.

In light of this evolving values landscape in medicine, a variety of policymakers and stakeholders are moving ahead with initiatives designed, in part, to bend the cost curve and to get more value out of every dollar spent on health care. These initiatives range from proposing new ways for physicians to be reimbursed (such as pay for performance or value-based purchasing) [3] to considering how patient care could be delivered (such as the medical home or accountable care organizations) [4, 5]. In addition to fundamental changes in financial incentives and the work environment in which care is delivered, there are educational efforts designed to help physicians make better cost-conscious decisions. Some have even recently advocated for a new stewardship “competency” to be included as part of the core set of competencies that residency programs should be responsible for imparting to the newest physicians [6].

A lack of professional consensus about the ethical status of physician stewardship may hinder educational programs and policy efforts to lower costs. By engaging in a professionwide conversation about the relevance and appropriateness of stewardship as a core value in medicine, can we hope to reach reasonable consensus on this matter of ethical import? If that does occur, an alignment between professional values and health care value will increase the likelihood that we can build an economically sustainable health care system.



References

  1. Moore J. What Sir Luke Fildes’ 1887 The Doctor can teach us about the practice of medicine today. Br J Gen Pract. 2008;58(548):210-213.
  2. Wynia MK, Hotze T, Clement L, Allen A, Wicher J, Tomaszewski KJ. How do physicians think about stewardship in health care? A qualitative national study. Paper presented at: SGIM Annual Meeting; May 9, 2011; Phoenix, AZ.
  3. Damberg CL, Raube K, Teleki SS, dela Cruz E. Marketwatch: Taking stock of pay-for-performance: a candid assessment from the front lines. Health Aff (Millwood). 2009;28(2):517-525.
  4. Reid RJ, Coleman K, Johnson EA, et al. The group health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood). 2010;29(5):835-843.
  5. Rosenthal MB, Cutler DM, Feder J. The ACO rules—striking the balance between participation and transformative potential. N Engl J Med. 2011;365(4):e6.
  6. Weinberger SE. Providing high-value, cost-conscious care: a critical seventh general competency for physicians. Ann Intern Med. 2011;155(6):386-388.

Audiey C. Kao, MD, PhD, is vice president of the ethics group at the American Medical Association in Chicago.

How Medicare and Hospitals Have Shaped American Health Care, November 2011

The American Medical Association Code of Medical Ethics’ Opinion on Pay-for-Performance Programs and Patients’ Interests, November 2011

Maine’s Medical Liability Demonstration Project—Linking Practice Guidelines to Liability Protection, November 2011

Teaching Resource Allocation—And Why It Matters, April 2011

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