Physician-Patient Relationship

Medical ethics and evidence-based medicine with Audiey Kao, MD, PhD

In collaboration with the PermanenteDocs Chat

. 18 MIN READ

Moving Medicine

Medical ethics and evidence-based medicine with Audiey Kao, MD, PhD

May 16, 2024

Family medicine physician Alex McDonald, MD and Audiey Kao, MD, PhD, vice president of ethics at the AMA, discuss how ethical principles can help physicians and medical students navigate complex medical decisions, ensuring patient safety and well-being. He also explores the ethical implications of artificial intelligence in health care. This episode was created in collaboration with the PermanenteDocs Chat podcast and is hosted by family physician Alex McDonald, MD.

Speaker

  • Audiey Kao, MD, PhD, vice president of ethics, American Medical Association

Host

  • Alex McDonald, MD, family medicine physician and host of PermanenteDocs Chat, Kaiser Permanente

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Unger: Welcome to Moving Medicine—a podcast by the American Medical Association. Today’s episode was recorded live and produced in collaboration with the PermanenteDocs Chat podcast. It features vice president of ethics at the AMA, Dr. Audiey Kao. He and Dr. Alex McDonald—the host of PermanenteDocs Chat—talk about the intersection of medical ethics and evidence-based medicine. Here’s Dr. McDonald.

Dr. McDonald: Hello, everyone. Welcome to today's PermanenteDocs Chat. I am your host, Alex McDonald. I am very excited for today's discussion. Today we're discussing medical ethics with Dr. Audiey Kao, the VP of Ethics for the American Medical Association. So, Dr. Kao, thank you so much for joining us. So sorry, someone's knocking on my door and interrupting me. So welcome, so much, for joining us. Thank you for being here.

Dr. Kao: Thank you for having me.

Dr. McDonald: Great. So those of you who are here live or watching from LinkedIn Live, please make sure you submit your questions in the Q&A box. Please get these questions in early. Our chats are often very short and high yield, so make sure you get those questions in. Let's just jump right in here. So Dr. Kao, tell us who you are and what you do.

Dr. Kao: So I am the VP for Ethics at the American Medical Association and in that role, I oversee the educational and policy setting activities involving topics and ethics for the AMA. I'm also the editor-in-chief of the AMA Journal of Ethics, which is a peer-review monthly ethics journal that explores topics in medicine and health care.

Dr. McDonald: Wonderful. So clearly, a lot of experience and knowledge to pull from so I'm excited for our chat today. So maybe for those who are not as familiar with the field of medical ethics in general, how would you sort of explain, in some broad strokes, explain what medical ethics is and is not?

Dr. Kao: Yeah. I mean, I think most doctors have heard of this term, "the art and science of medicine." And so, in general, ethics deals with the non-scientific part of the practice of medicine, of good doctoring. And that draws on deep histories within the practice of medicine that go back 2,000 years to Hippocratic oath, and it's really an expression of the values that comprise what good doctoring is. So compassion, empathy, values of that sort.

Dr. McDonald: Yeah. And when I think of ethics, in my mind, I think of doing the right thing—for the patient, for the physician, for the health care industry in general. And then also, the other piece is really trust because trust is so foundational. Without trust, you don't have that patient-physician relationship. And no matter how much data and science you have, it just doesn't work the same way. So, can you tell us how trust is such a critical component to medical ethics?

Dr. Kao: Yeah, trust is a cornerstone of the therapeutic doctor-patient relationship because without that, patients are unlikely to share personally sensitive medical information. And sometimes, trust is all we have in terms of therapeutics for patients. What I mean by that is that there are times when there's not much the science of medicine can do. So just being with the patient, being their companion during their suffering or during the last months and weeks of their life is really emblematic of the art of medicine and the importance of the earned trust that patients have in physicians and the profession as a whole.

Dr. McDonald: Yeah. That brings up sort of a memory for me. I remember I was probably maybe one or two years out of residency and practice, and I had this patient come in who had this horrible back pain and they were seeing specialists in physical medicine and anesthesia and doing epidural injections. They even saw a neurosurgeon. They were having this horrible back pain, and they were on basically all the medications. They were doing physical therapy. And I basically said to them, "Look, I'm sorry. You're doing all the right stuff. There's really not a whole lot I can do for you right now, but how else can I help?" and the patient just sort of looked to me and was like, "Well, you listened to me and that was worth it. That was worth my copay and my coming in for the visit today." And so, I think sometimes, we get caught in this mindset of we have to do something as physicians. But sometimes, we can literally just bear witness and be present with our patients and that's so powerful.

Dr. Kao: No, absolutely. And I think this notion of just being present with your patients when there's not much from the scientific side that one can offer them is really a challenge because I think we're all time pressed in our practice. The 10-minute follow-up visit, the 30-minute new patient visit.

Dr. McDonald: Yeah.

Dr. Kao: Sometimes, it can feel more transactional than relational, and I think that that's where we need to keep focus on that dimension of the doctor-patient relationship. I think.

Dr. McDonald: Yeah. I mean, as a family medicine physician and primary care physician, I could not agree more that, that longitudinal relational-based care is just so much more personally fulfilling and professionally fulfilling for me, and I feel like the patients get a lot more out of it. I have had some patients waiting weeks and weeks to come see me versus seeing somebody in urgent care or one of my colleagues because they know me and they trust me, and so I swear that as an honor in many respects too. So, let's switch gears a little bit here. There's sort of a lot written about maybe this perceived tension between ethics and ethical decision-making versus evidence-based medicine. Do you think there's sort of a tension between those two or are those complimentary? How should physicians think about the relationship between ethics and evidence?

Dr. Kao: Yeah. So, I think ethical decision-making requires that we take into account patients' values and preferences. And so practicing evidence-based medicine should not and does not preclude taking into account patient values. So, I don't view it as necessarily a tension from that standpoint. I do think that for physicians, one of the challenges in the health care space, medicine, practicing medicine is not cookbook. And what I mean by that if is it was, anybody could do it.

Dr. McDonald: Right.

Dr. Kao: And so, the challenge of practicing evidence-based medicine is knowing when those protocols or evidence-based approaches is appropriate for the individual patient in front of you and more importantly when it's not and when you would deviate from evidence-based medicine. And I think it's important for physicians to be clear about why they are following evidence-based practices and more importantly when they are not because when you are not, then you have to be clear about why you don't think the current evidence is either valid or applicable to the individual patient in front of you.

Dr. McDonald: It's interesting. I think a lot of what we do, especially in primary care, I think, is very intuitive. You can't read that in a textbook. You can't look that up online. A lot of it just comes from a lot of experience in terms of, "I think this SSRI is going to help you." There's no evidence that one SSRI is better than another when it comes to treating depression or anxiety and sometimes it's sort of just a gut reaction. When I'm working with residents, sometimes they ask me. They're like, "Well, why'd you pick that one?" and I look at them and I say, "I don't know. It's just my gut reaction. We'll try it and see what happens," and no algorithm could do that, I guess.

Dr. Kao: Yeah. I mean, what you're describing is how, I guess, medicine has been long practiced, right? Clinical experience and judgment, whether it's our N of 1 or N of 2 that we see as physicians. Evidence-based medicine has only been around for about 30, 35 years, and that's well and good because I think we need strong evidence to support the recommendations that we make for our patients. But at the same time, it's not cookbook.

Dr. McDonald: Right. Exactly. I agree with you. Well, and that actually leads me perfectly into my next question regarding AI and medicine. So, a lot of machine learning and augmented intelligence, or artificial intelligence, whatever you want to call it, is really kind of finding its way into every industry. Health care, no different. How do you think that using ethical considerations with the rapid evolution of AI and machine learning is going to impact medicine?

Dr. Kao: Yeah. I mean, I'm tempted to, in real time, ask ChatGPT the answer to your question right now, but obviously I can't.

Dr. McDonald: Oh, let's do it.

Dr. Kao: I can't, but I raise that maybe starting just to think about how AI is going to impact the doctor-patient relationship. From the patient side, as more of these AI chatbots get developed, doctors are going to confront a higher level of visits where patients bring in their ChatGPT response to some question. All of us who've been in practice during the internet age all know the reams of printed out websites that patients bring to us and that's probably going to happen to a very greater degree going forward. And as chatbots get smarter, again, our role as doctors as kind of the learned professional is how to help patients sort through all that evidence or non-evidence that we get. So, I think that is maybe, oftentimes not thought about currently in the AI debate, but it's something that we all experience currently.

Dr. McDonald: Yeah. Sorry, go ahead.

Dr. Kao: Go ahead. Go ahead.

Dr. McDonald: No, I was going to say I sort of describe myself to patients as sort of the interpreter, right? You can read till you're blue in the face, but I can then take that data, interpret it and see how it applies to you as an individual, and then have that shared decision-making about what treatment is best.

Dr. Kao: Right. And then to your larger question about its other impacts, I mean, I think for all of us as physicians, most of us are not going to be involved in the development of AI tools.

Dr. McDonald: Right.

Dr. Kao: Most of us probably aren't even going to be the ones who are going to purchase and deploy the AI tools in our hospitals and practices. And that raises, I think, a lot of important considerations because we're not the developers, nor are we the deployers of these AI tools. So having transparency, what I mean by that is as frontline clinicians and frontline physicians, AI tools can be a black box. How can this AI tool be a valid and useful clinical decision support system? And if you were to ask many developers of AI, they may not even be able to answer how chatbots come up with their answers to questions posed. And that's both revealing in terms of what we as physicians need to hold developers and deployers of AI accountable for, in terms of knowing how algorithms arrive at their decisions, which gets back to your earlier questions about evidence-based, right? What kind of evidence-based do they draw on with these algorithms to arrive at decision support recommendations for physicians. So, I think that's a really important point that needs to be addressed before these AI tools are widely deployed.

Dr. McDonald: Yeah, I completely agree with you. And I think the other piece, too, is you're right. The vast majority of physicians are not going to be involved in the implementation or development of these tools, but I think it's absolutely critical that we do have some physician input as we develop these tools. I can use the example of the electronic medical record. 15 years ago, let's be honest, physicians were not really involved in creating those systems and now they're not very user-friendly for the physician. They're not very user-friendly for the patient. And so just if I can get on my soapbox for a moment, I really think it's critical that physicians and the physician perspective is on the ground floor as we continue to develop these AI tools because they're here whether we like it or not. We're going to have to contend with them so we might as well be at the table as we continue to develop these tools, but that's a bit of a segue.

Dr. Kao: Yeah. No, I couldn't agree with you more. I mean, I think that as the group that's going to take the recommendations from a ChatGPT-like tool, it's important for us to be involved in the development of it as best we can. But as I say, most physicians are not going to have a role in that. And so, it's important for the practicing physician to understand basics about how these algorithms work before they can rely on them, I think.

Dr. McDonald: Yeah. That's very true. And AI is such a huge topic. We've done a couple other chats about that so for those of you listening, shout out. Go look at some of our past podcasts regarding AI and I'm sure we'll do more in the future as those come up. So, make sure you get your questions in if you have any questions. We have just have a few minutes left here. One thing that's always interesting to me is using ethics and using ethical medicine, but also then balancing that with patient safety and patient autonomy and physician and clinician well-being and mental health. Do you have any protocols or ideas regarding balancing ethics with patient safety, with physician wellness?

Dr. Kao: Yeah. How much time do we have?

Dr. McDonald: Right, exactly.

Dr. Kao: So maybe I can take it the most extreme example.

Dr. McDonald: Sure.

Dr. Kao: I mean, all of us have been either directly or indirectly involved in situations where a patient is threatening or potentially threatening himself or the safety of doctors in the health care team, and that's a true ethical conundrum for physicians whose goal is to provide compassionate care. And what I mean by that is when patients are, let's say, so severely agitated that they're threatening themselves and the physical safety of physicians and the health care team, how do you go about applying, what I call, force compassionately? That may sound like an oxymoron, compassionate force, but it's actually critically important to maintain the relationship with the patient. And I would offer a couple of thoughts. As physicians and as leaders of health care teams, during those situations, how we talk with the patient and with the health care team in trying to deescalate those situations is critical.

Dr. McDonald: Yeah.

Dr. Kao: And what I mean by that is the language we use, capturing the situation of the "aggressive" or "disruptive" patient, only starts to escalate the situation. And describing the situation as a patient who may be frightened or frustrated or is having unmet needs seems pretty obvious, but in that moment, it's probably the most important reset a physician can engage in during those situations.

Dr. McDonald: Yeah. Yeah. No, that's certainly, definitely an extreme example and I think it's important to make sure. I sort of think of the analogy of the airplane mask, you got to put your own air mask on first before you help somebody else, and I think we need to make sure that we are not compromising our own values or own safety in an effort to provide real ethical medicine for our patients. And so, I think that's a great example, albeit an extreme one, but I think it certainly highlights some important points. So, we have a couple of questions in the chat here that I want to get to.

Dr. Kao: Sure.

Dr. McDonald: So, one question here: Is there a medical ethical question that you really struggled with as a medical student or a resident or early in your career that now, with experience, you sort of found an answer and can share that advice with those who are newer in practice?

Dr. Kao: So as a student, one of the challenges is what do you do when you observe unethical behavior among your peers and then, more difficult, with people who are more senior to you? And I think that that is difficult for any student to navigate. And I think as you progress in your career ... I mean, all of us are part of a profession, so we self-regulate and how we deal with unethical or incompetent colleagues is a real challenge, right?

Dr. McDonald: Absolutely.

Dr. Kao: But it's something that we need to do. And I think that how one goes about honoring that responsibility of self-regulation and policing myself, it's not easy. And my only practical tip is that it's important to kind of engage that potential person before taking it to the next level. I think that's critically important.

Dr. McDonald: Yeah. No, I think that's a great example. And I think, for me, when I see colleagues who are maybe not practicing what I consider maybe up to what I would want our standards to be here in our practice, I just talk to them and I come to them from a point of caring, right? Not ridiculing them or telling them they did something wrong, but being like, "Hey, I really care about you as a physician. I care about our patients. I care about our practice. How can I help?" And being sort of appreciative in the inquiry, that's something that I found useful, and people are much more receptive to it than sort of saying, "Hey, you did this wrong." Let's be honest. We're all a little type A, we all want to be perfect, and it's hard to have those conversations. But ultimately, those conversations are going to make us all better and it's something that I aspire to in my practice.

Great. Well, this has been phenomenal. I have one last question and it's my favorite question, and one that people kind of struggle with the most. What makes you most proud to be a physician?

Dr. Kao: Well, I've always felt this a privilege that strangers allow us into their lives in such deep and meaningful ways, and so I've held onto that ethic, if you want to call it, in my 35+ years of being a doctor. So, I think that's why I'm proud to be a physician.

Dr. McDonald: Wonderful. And for those listening who want to learn more about medical ethics, where do you recommend they learn more or find more information?

Dr. Kao: So, I mentioned at the outset I'm the editor of the AMA Journal of Ethics, so a little self-promotion here. It's an open access journal so our URL is journalofethics.org. I would also have people go to the AMA Code of Medical Ethics, which provides is a valuable resource for guidance, and that URL is amaethicscode.org.

Dr. McDonald: Great. Well, thank you so much, Dr. Kao, for your time. We really appreciate you joining us and sharing your expertise.

Dr. Kao: My pleasure.

Unger: Subscribe to the PermanenteDocs Chat podcast to never miss an episode and register to take part in upcoming live chats. Visit permanente.org/amadocschat.


Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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