Primary care provider reflections on common themes from special issue on ethical quandaries when delivering integrated primary care

Comments on the articles by Hudgins, Rose, Fifield, & Arnault, (see record 2013-11498-002), Reiter & Runyan, (see record 2013-11498-003), Hodgson, Mendenhall, & Lamson (see record 2013-11498-004), and Kanzler, Goodie, Hunter, Glotfelter, & Bodart (see record 2013-11498-005), regarding the topic of common themes for the special issue on ethical quandaries when delivering integrated primary care. The current author provides brief reflections on each article.

Doctor-patient dialogue--basic aspect of medical consultation

Family medicine is the specialty that provides ongoing primary medical care and improves the health status of the individual, of the family and of the community through preventive, educational, therapeutic and rehabilitation measures. The family doctor often makes the interdisciplinary synthesis, in a flexible manner, either alone or in most cases with interdisciplinary consultation. In the latter case, the family doctor initiates the team work and makes the final evaluation by using the longitudinal follow-up of the disease. The doctor-patient encounter represents the "confrontation" with the greatest moral weight, due to the complexity of the values involved, the status of the doctor in a society, and patient's involvement in decision making. The patient is a person who should be treated with respect, honesty, professionalism and loyalty, whatever the clinical status, severity of illness, mental competence or incompetence. A focus, on an international scale, is represented by the characteristics of a good doctor, family physician included, as the latter is the first link in the network of health services. Each model of consultation varies in a more or less subtle way in priorities assignment, and suggests slight differences regarding the role played by doctor and patient in their collaboration. The qualities of a good family physician include not only the strictly professional competences, that also apply to other medical specialties, but also duties, such as, clearly explaining to patients issues concerning their health, informing them about all the possible preventive measures of diseases, making a diagnosis, initiating and supervising a therapy. Medical responsibility lies at the crossroads between medical science and the conscience of the doctor.

Ethical and legal issues in the clinical practice of primary health care

Since it was conceived, the notion of primary care has been a crucial concept in health services. Most health care is provided at this level and primary care clinicians have an essential role, both in terms of disease prevention and disease management. During the last decades, primary health care has evolved from a traditional paternalistic model, in which patients played the role of passive recipient of care, towards a situation in which patients are partners involved in the decision making-process. This new context opened a considerable number of new ethical and legal aspects, which need to be comprehensively analyzed and discussed in order to preserve the quality of primary health care all around the world. This work reviews the most important ethical and legal issues in primary health care. Legislation issues are explained in the context of the Spanish Health Services.

Teaching and evaluation of ethics and professionalism: in Canadian family medicine residency programs

OBJECTIVE

To document the scope of the teaching and evaluation of ethics and professionalism in Canadian family medicine postgraduate training programs, and to identify barriers to the teaching and evaluation of ethics and professionalism.

DESIGN

A survey was developed in collaboration with the Committee on Ethics of the College of Family Physicians of Canada. The data are reported descriptively and in aggregate.

SETTING

Canadian postgraduate family medicine training programs.

PARTICIPANTS

Between June and December of 2008, all 17 Canadian postgraduate family medicine training programs were invited to participate.

MAIN OUTCOME MEASURES

The first part of the survey explored the structure, resources, methods, scheduled hours, and barriers to teaching ethics and professionalism. The second section focused on end-of-rotation evaluations, other evaluation strategies, and barriers related to the evaluation of ethics and professionalism.

RESULTS

Eighty-eight percent of programs completed the survey. Most respondents (87%) had learning objectives specifically for ethics and professionalism, and 87% had family doctors with training or interest in the area leading their efforts. Two-thirds of responding programs had less than 10 hours of scheduled instruction per year, and the most common barriers to effective teaching were the need for faculty development, competing learning needs, and lack of resident interest. Ninety-three percent of respondents assessed ethics and professionalism on their end-of-rotation evaluations, with 86% assessing specific domains. The most common barriers to evaluation were a lack of suitable tools and a lack of faculty comfort and interest.

CONCLUSION

By far most Canadian family medicine postgraduate training programs had learning objectives and designated faculty leads in ethics and professionalism, yet there was little curricular time dedicated to these areas and a perceived lack of resident interest and faculty expertise. Most programs evaluated ethics and professionalism as part of their end-of-rotation evaluations, but only a small number used novel means of evaluation, and most cited a lack of suitable assessment tools as an important barrier.

Controlling pain and reducing misuse of opioids: ethical considerations

OBJECTIVE

To help family physicians achieve an ethical balance in their opioid prescribing practices.

QUALITY OF EVIDENCE

MEDLINE was searched for English-language articles published between 1985 and 2011. Most available evidence was level III.

MAIN MESSAGE

It is essential to follow practice guidelines when prescribing opioids, except when another course of action is demonstrably justified. In addition, when considering the appropriateness of an opioid prescription, with its many ethical implications, the decision can be usefully guided by the application of the ethical principles of beneficence, nonmaleficence, respect for autonomy, and justice. As well, it is essential to keep current about legal and regulatory changes and provincial electronic registries of opioid prescriptions.

CONCLUSION

Physicians need to ensure that their patients' pain is properly assessed and managed. Reaching optimal pain control might necessitate prescribing opioids. But the obligation to provide pain relief needs to be balanced with an equally important responsibility not to expose patients to risk of addiction and not to create opportunities for drug diversion, trafficking, and the addiction of others. Basic ethical principles can provide a framework to help physicians make ethically appropriate decisions about opioid prescribing.

Findings from a Delphi exercise regarding conflicts of interests, general practitioners and safeguarding children: 'Listen carefully, judge slowly'

General practitioners (GPs) have to negotiate a range of challenges when they suspect child abuse or neglect. This article details findings from a Delphi exercise that was part of a larger study exploring the conflicts of interest that arise for UK GPs in safeguarding children. The specific objectives of the Delphi exercise were to understand how these conflicts of interest are seen from the perspectives of an expert panel, and to identify best practice for GPs. The Delphi exercise involved four iterative rounds with questionnaires completed by an expert panel. Results from each round were distilled and findings sent to panel members until consensus was reached. Panel members shared insights regarding their understanding of conflicts of interest in relation to GPs and safeguarding children and responses when conflicts of interests arise. Findings suggested a broader understanding of conflicts of interest (intrapersonal, interpersonal, interprofessional and interagency), the importance of professional judgement in uncertain situations when both action and inaction have potentially negative consequences and the importance of trust. The Delphi exercise was an effective means to bring together a wide range of professional and disciplinary perspectives on a complex topic. Findings caution against the oversimplification of the conceptual and practical issues, emphasise the importance of professional judgement, and support the development of open and trusting relationships with families and among professionals in health and social care agencies.

Ethics and privacy issues of a practice-based surveillance system: need for a national-level institutional research ethics board and consent standards

OBJECTIVE

To describe the challenges the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) experienced with institutional research ethics boards (IREBs) when seeking approvals across jurisdictions and to provide recommendations for overcoming challenges of ethical review for multisite and multijurisdictional surveillance and research.

BACKGROUND

The CPCSSN project collects and validates longitudinal primary care health information (relating to hypertension, diabetes, depression, chronic obstructive lung disease, and osteoarthritis) from electronic medical records across Canada. Privacy and data storage security policies and processes have been developed to protect participants' privacy and confidentiality, and IREB approval is obtained in each participating jurisdiction. Inconsistent interpretation and application of privacy and ethical issues by IREBs delays and impedes research programs that could better inform us about chronic disease.

RESULTS

The CPCSSN project's experience with gaining approval from IREBs highlights the difficulty of conducting pan-Canadian health surveillance and multicentre research. Inconsistent IREB approvals to waive explicit individual informed consent produced particular challenges for researchers.

CONCLUSION

The CPCSSN experience highlights the need to develop a better process for researchers to obtain timely and consistent IREB approvals for multicentre surveillance and research. We suggest developing a specialized, national, centralized IREB responsible for approving multisite studies related to population health research.