American College of Physicians - The Relationship to Other Clinicians
Physicians share a commitment to care for ill persons with an increasingly broad team of clinicians. The team's ability to care effectively for the patient depends on the ability of individual persons to treat each other with integrity, honesty, and respect in daily professional interactions regardless of race, religion, ethnicity, nationality, sex, sexual orientation, age, or disability (57). Particular attention is warranted with regard to certain types of relationships and power imbalances that could be abusive or exploitative or lead to harassment, such as those between attending physician and resident, instructor and medical student, or physician and nurse (58).
Attending physicians and physicians in training
The very title doctor, from the Latin docere, "to teach," implies that physicians have a responsibility to share knowledge and information with colleagues and patients. This sharing includes teaching clinical skills and reporting results of scientific research to colleagues, medical students, resident physicians, and other health care providers.
The physician has a responsibility to teach the science, art, and ethics of medicine to medical students, resident physicians, and others and to supervise physicians in training. Attending physicians must treat trainees with the same respect and compassion accorded to other colleagues. In the teaching environment, graduated authority for patient management can be delegated to residents, with adequate supervision. All trainees should inform patients of their training status and role in the medical team. Attending physicians, chiefs of service, or consultants should encourage residents to acknowledge their limitations and ask for help or supervision when concerns arise about patient care or the ability of others to perform their duties.
It is unethical to delegate authority for patient care to anyone, including another physician, who is not appropriately qualified and experienced. On a teaching service, the ultimate responsibility for patient welfare and quality of care remains with the patient's attending physician of record.
In almost all circumstances, patients should be encouraged to initially seek care from their principal physician. Physicians should in turn obtain competent consultation whenever they and their patients feel the need for assistance in caring for the patient (59). The level of consultation needed should be established first: a one-visit opinion, continuing cooperative care, or total transfer of authority to the consultant. Patients have the option to seek an independent consultation from another physician but may be held financially responsible for their decision.
The consultant should respect the relationship between the patient and the principal physician, should promptly and effectively communicate recommendations to the principal physicians, and should obtain concurrence of the principal physician for major procedures or additional consultants. The care of the patient and the proper records should be transferred back to the principal physician when the consultation is completed, unless another arrangement is agreed upon.
Consultants who need temporary charge of the patient's care should obtain the principal physician's cooperation and assent. The physician who does not agree with the consultant's recommendations is free to call in another consultant. The interests of the patient should remain paramount in this process.
A complex clinical situation may call for multiple consultations. To assure a coordinated effort that is in the best interest of the patient, the principal physician should remain in charge of overall care, communicating with the patient and coordinating care on the basis of information derived from the consultations. Unless authority has been formally transferred elsewhere, the responsibility for the patient's care lies with the principal physician.
The impaired physician
Physicians who are impaired for any reason must refrain from assuming patient responsibilities that they cannot discharge safely and effectively. Whenever there is doubt, they should seek assistance in caring for their patients.
Every physician is responsible for protecting patients from an impaired physician and for assisting an impaired colleague. Fear of being wrong, embarrassment, or possible litigation should not deter or delay identification of an impaired colleague (60). The identifying physician may find it helpful to discuss the issue with the departmental chair or a senior member of the staff or community.
Impairment may result from use of habit-forming agents (alcohol or other substances) or from psychiatric, physiologic, or behavioral disorders. Impairment may also be caused by diseases that affect the cognitive or motor skills necessary to provide adequate care. The presence of these disorders or the fact that a physician is being treated for them do not necessarily imply impairment.
Although the legal responsibility to do so varies among states, there is a clear ethical responsibility to report a physician who seems to be impaired to an appropriate authority (such as a chief of service, chief of staff, institutional committee, state medical board, or regulatory agency). Physicians should aid their impaired colleagues in identifying appropriate sources of help. While undergoing therapy, the impaired physician is entitled to full confidentiality as in any other patient-physician relationship. To protect patients of the impaired physician, someone other than the physician of the impaired physician must monitor the impaired physician's fitness to work. Serious conflicts may occur if the treating physician tries to fill both roles.
It is unethical for a physician to disparage the professional competence, knowledge, qualifications, or services of another physician to a patient or a third party or to state or imply that a patient has been poorly managed or mistreated by a colleague without substantial evidence, especially when such behavior is used to recruit patients.
Of equal importance, a physician is ethically obligated to report fraud, professional misconduct, incompetence, or abandonment of patients by another physician. Professional peer review is critical in assuring fair assessment of physician performance for the benefit of patients. The trust that patients and the public invest in physicians requires disclosure to the appropriate authorities and to patients at risk for immediate harm.
All physicians have a duty to participate in peer review. Fears of retaliation, ostracism by colleagues, loss of referrals, or inconvenience are not adequate reasons for refusing to participate in peer review. Society looks to physicians to establish professional standards of practice, and this obligation can be met only when all physicians participate in the process. Federal law and most states provide legal protection for physicians who participate in peer review in good faith.
Conversely, in the absence of substantial evidence of professional misconduct, negligence, or incompetence, it is unethical to use the peer review process to exclude another physician from practice, to restrict clinical privileges, or to otherwise harm the physician's practice.
Conflicts among members of a health care team
All health professionals share a commitment to work together to serve the patient's interests. The best patient care is often a team effort, and mutual respect, cooperation, and communication should govern this effort. Each member of the patient care team has equal moral status. When a health professional has major ethical objections to an attending physician's order, both should discuss the matter thoroughly. Mechanisms should be available in hospitals to resolve differences of opinion among members of the patient care team.