Imagine a resident who cannot get her patient the drug he desperately needs because his health insurance does not cover the medication that the hospital has on its formulary. Or the surgeon who leaves the operating room after a difficult procedure, unsure of how much to reveal to his patient about the nature of the complications because he fears that he will not be compliant with the hospital's risk management policies or that the patient may file a lawsuit against him. Now consider a quality improvement program that alters a clinic's functioning so that the doctor is no longer running an average of 30 minutes late for his appointments. Finally, think about an affiliation between a practice of internists and a nearby radiology clinic that facilitates easier access to radiology services and reports; though this seems straightforward enough, the agreement may be prohibited by federal anti-kickback laws. Each of these examples illustrates an interaction between a physician and the larger system in which he or she practices medicine.
Physicians care for patients within a framework of complex systems that, like the support beams of a building, provide the foundation for and define the limits of the structure they support. In health care, these systems operate at many levels and take many forms: ancillary medical services, institutional policies, private and governmental insurance regulations, the medical malpractice system, and national and international bodies that govern health policy.
Systems impact patient care because doctors must balance what they think is medically optimal with the limits of the relevant systems in which they function. This issue of Virtual Mentor examines ethical controversies that arise when systems influence medical practice. It introduces clinical scenarios in which lab results go missing due to a processing error, "secret shoppers" are used to assess and improve quality of medical service, insurance coding regulations restrict care, malpractice liability and risk management impose on the patient-doctor relationship, and a patient who has broken U.S. law by paying for an organ transplant in another country seeks posttransplant care in the U.S.
Stepping back from specific clinical situations, VM next examines efforts to improve health care through system changes. The medical education article discusses a residency program that trains physicians and staff in collaborative systems-based practice competencies. The journal discussion broaches a topic that has faced recent public scrutiny—the ethical status of quality improvement initiatives. Drawing from one of our cases, the clinical pearl examines the risks of and indications for amniocentesis.
Governmental laws and regulations are analyzed in the health law primer on ERISA's provisions that restrict insurance companies' liability, and in the policy forum on Medicare's "never-events" initiative. The medicine and society piece describes an innovative proposal for reforming health care based on the principles of industrial engineering. Our history-of-medicine and medical humanities articles examine, respectively, the evolution of complex medical systems and the philosophical basis for balancing generalized regulations with individualized exceptions to these rules. Finally, our op-ed author contends that medical education needs to better equip students with knowledge of the laws that affect their day-to-day practice.
Without health care institutions, medical support services, insurance agencies, governmental programs, and regulation of health care, medical practice would be a far more primitive profession conducted in private homes or offices. Without access to the complex technologies and services available in modern medical facilities, the health of the public and of individual patients would inevitably suffer.
Caught between the load of complex medical systems and the basic needs of patients, physicians must figure out how to provide optimal medical care within the structure of health care systems. Should they comply with systems constraints? Should they push to reform them? Or should physicians ultimately take responsibility for restructuring the systems themselves?