- Email: [email protected]
Ethical mutiny: When the captain of the ship is an outlier
DERMATOETHICS
CONSULTATIONS
Ethical mutiny: When the captain of the ship is an outlier Sphoorthi Jinna, MD,a Jane M. Grant-Kels, MD,a and Jerry Graff, MDb Farmington, Connecticut, and Ocean View, Delaware
CASE SCENARIO After completing his Mohs micrographic surgery fellowship, Dr A (Aggressive) joined a small dermatology specialty practice in the Midwest. His referral base grew, and he was kept busy doing Mohs cases for recurrent or aggressive nonmelanoma skin cancers (NMSCs). He also performed excisions for smaller melanomas. Over time, he became the owner of the practice and hired a few dermatologists to complement those remaining in the practice. One of the newest employees, Dr EG (Easy Going), a board-certified dermatologist with 10 years of private practice experience, began noticing that the other practice dermatologists were referring all of their biopsy-proven NMSC cases to Dr A for Mohs. They seemed not to perform excisions or destructions by curettage and electrodessication. Dr EG asked a patient new to him in the practice about previous skin cancers and learned that this patient was told to have the Mohs procedure for a 4-mm squamous cell carcinoma in situ on the extensor forearm. Because the patient could not see or feel any residual growth after the biopsy, the patient decided to observe the site and not have the Mohs procedure done. It was now 3 years since the biopsy, and there had been no recurrence of the squamous cell carcinoma at the site. Dr EG then asked his colleagues about the protocol in the practice and learned that they were required by Dr A to refer all NMSCs to him for Mohs because ‘‘it provides the highest cure rates.’’ Familiar with the American Academy of Dermatology (AAD) guidelines for Mohs micrographic surgery, Dr EG believed he could not participate in the modus operandi of this practice. Upon questioning his colleagues about the AAD guidelines, it became clear that the practitioners were aware of the appropriate use criteria. Dr EG should: A. Resign from the practice and seek employment elsewhere. B. Encourage his practice colleagues to adhere to the established guidelines and join Dr EG in confronting Dr A. C. Confront Dr A on his inappropriate overuse of Mohs micrographic surgery. D. Report Dr A to the state medical board. E. Remain in the practice and treat the NMSCs on his patients based on the AAD guidelines.
DISCUSSION This case highlights the ethical dilemma inherent in becoming an employed physician in a practice whose owner encourages unethical behavior. From the Department of Dermatology, University of Connecticut Health Center,a and retired private practice dermatologist, Ocean View.b Funding sources: None. Conflicts of interest: None declared. Correspondence to: Jane M. Grant-Kels, MD, Department of Dermatology, University of Connecticut Health Center, 21 South Rd, Farmington, CT 06032. E-mail: [email protected].
1218
Dermatology guidelines are generated to specify acceptable clinical practices. What is a dermatologist’s obligation upon learning that those guidelines are not being followed in their practice? J Am Acad Dermatol 2017;76:1218-20. 0190-9622/$36.00 Ó 2016 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2016.11.054
J AM ACAD DERMATOL VOLUME 76, NUMBER 6
Given the ethical principle of justice and the limited resources in our current health care system, the AAD, American College of Mohs Surgery, American Society for Dermatologic Surgery, and American Society for Mohs Surgery created appropriate use criteria for Mohs micrographic surgery in 2012.1,2 Even before these guidelines were penned, most dermatologists would agree that not all NMSCs require Mohs micrographic surgery, especially a 4-mm squamous cell carcinoma in situ on the extensor forearm. What is Dr EG’s responsibility to his patients and to the health care system in general in this scenario? It would appear that in this particular private practice, owned and administered by Dr A, patient autonomy to grant informed consent is being breached by not explaining various treatment options for NMSCs. Instead, the therapeutic decision was being mandated for them paternalistically and all patients were being referred to the owner of the dermatology group, the Mohs surgeon. Therefore, in our case scenario, Dr EG’s right to practice according to his best clinical judgment and the current standards of care is being taken from him. Dr EG is struggling with the principles of beneficence and nonmaleficence. What is Dr EG’s responsibility to the other clinicians in the practice
ANALYSIS OF CASE SCENARIO Choice A, in our opinion is not the optimal decision for Dr EG. Resigning from this group may alleviate the dilemma for Dr EG but does not address the behavior exhibited by the other practice providers. In our opinion, Dr EG has an ethical obligation to address the principles of autonomy and justice that are being violated by the members of this practice, particularly Dr A. If Dr EG is required to comply with the policies or cannot effect change among his colleagues, it is an appropriate next step to leave the practice. Choice B, encouraging his practice colleagues to adhere strictly to the widely accepted AAD guidelines, is the best initial choice. Shedding light on the overuse of Mohs as potentially detrimental to both the individual patient and health care in general may be enough for some providers to become compliant with guidelines. If Dr EG could convince several of his fellow colleagues to follow the standards of care and to stand up to Dr A, it would give him greater leverage to change Dr A’s practices than approaching him alone. This would be an appropriate first step before choice C or D.
Jinna, Grant-Kels, and Graff 1219
who are complying with Dr A’s mandate to refer all NMSCs for Mohs micrographic surgery no matter their location or clinical and histologic features? There are many ethical questions to ponder. Why are these other well-trained dermatologists acceding to Dr A’s demand? Possibly, they are concerned that they might lose their employment in this practice. Why does Dr A make this demand on his employed clinicians? Is it avarice or his sincere belief that Mohs is the treatment of choice for all skin cancers because of the high cure rate and tissue sparing? Finally, is it ethical for Dr EG to be only responsible for how he treats his own patients, or must he attempt to stop this unethical practice in his group? Any situation in which employees believe they are coerced by their employer to behave blindly outside the bounds of accepted standards of care can lead to trouble. Employed physicians may be concerned about their continued employment if they were not to comply with the recommendations. It becomes even more difficult when the other employees are in compliance with the owner’s requests. Everyone wants to be perceived as a team player. Despite all these conflicting demands, physicians need to remember their overarching primary duty to their patients.
Choice C, confronting Dr A, must be part of the solution if change were to be effected. Although encouraging his colleagues to adhere to Mohs guidelines is worthwhile, doing so without confronting Dr A is not likely to resolve the issues. Because Dr A is aware of the guidelines, confronting him is likely to be contentious; however, Dr EG’s 10 years of clinical experience might carry significant weight with Dr A. If this confrontation does not cause a change in Dr A’s behavior, Dr EG should strongly consider removing himself from the unethical work environment. Choice D, reporting Dr A to the state medical board, would be inappropriate as a first step. Dr A’s abusive and outlying practices border, or even cross the line into, health care fraud, both in intent and practice. They are likely to draw the attention of commercial insurers or state and federal authorities at some point. Nonetheless, before whistle blowing, an attempt to bring awareness to both Dr A and the other dermatologists of the practice should be undertaken. If after approaching these physicians, no changes are made, then this is a future option. A warning alone that this is Dr EG’s next course
1220 Jinna, Grant-Kels, and Graff
of action might cause some of the other providers to take a stand against Dr A’s policy. Choice E, remain in the practice but follow the Mohs appropriate use criteria guidelines for his own patients may seem reasonable, but such
BOTTOM LINE A physician employee who finds himself or herself in a practice that does not conform to the standards of care of our specialty and engages in unethical behavior must be true to his or her ethical core. Clearly guidelines are not being followed by Dr A’s practice, placing Dr EG in the difficult position of standing up for his own ethics to the senior physician/owner and colleagues. Nonetheless, Dr EG should not participate in this unethical and fraudulent behavior.
J AM ACAD DERMATOL
JUNE 2017
a decision violates Dr EG’s moral obligation to stop this fraud on the practice’s patients and on the health care system. Furthermore, by remaining in this practice, Dr EG risks damage to his reputation.
REFERENCES 1. Ad Hoc Task Force, Connolly SM, Baker DR, et al. AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery. J Am Acad Dermatol. 2012;67:531-550. 2. Connolly SM, Baker DR, Coldiron BM, et al. AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery. Dermatol Surg. 2012;38:1582-1603.
CONSULTATIONS
Ethical mutiny: When the captain of the ship is an outlier Sphoorthi Jinna, MD,a Jane M. Grant-Kels, MD,a and Jerry Graff, MDb Farmington, Connecticut, and Ocean View, Delaware
CASE SCENARIO After completing his Mohs micrographic surgery fellowship, Dr A (Aggressive) joined a small dermatology specialty practice in the Midwest. His referral base grew, and he was kept busy doing Mohs cases for recurrent or aggressive nonmelanoma skin cancers (NMSCs). He also performed excisions for smaller melanomas. Over time, he became the owner of the practice and hired a few dermatologists to complement those remaining in the practice. One of the newest employees, Dr EG (Easy Going), a board-certified dermatologist with 10 years of private practice experience, began noticing that the other practice dermatologists were referring all of their biopsy-proven NMSC cases to Dr A for Mohs. They seemed not to perform excisions or destructions by curettage and electrodessication. Dr EG asked a patient new to him in the practice about previous skin cancers and learned that this patient was told to have the Mohs procedure for a 4-mm squamous cell carcinoma in situ on the extensor forearm. Because the patient could not see or feel any residual growth after the biopsy, the patient decided to observe the site and not have the Mohs procedure done. It was now 3 years since the biopsy, and there had been no recurrence of the squamous cell carcinoma at the site. Dr EG then asked his colleagues about the protocol in the practice and learned that they were required by Dr A to refer all NMSCs to him for Mohs because ‘‘it provides the highest cure rates.’’ Familiar with the American Academy of Dermatology (AAD) guidelines for Mohs micrographic surgery, Dr EG believed he could not participate in the modus operandi of this practice. Upon questioning his colleagues about the AAD guidelines, it became clear that the practitioners were aware of the appropriate use criteria. Dr EG should: A. Resign from the practice and seek employment elsewhere. B. Encourage his practice colleagues to adhere to the established guidelines and join Dr EG in confronting Dr A. C. Confront Dr A on his inappropriate overuse of Mohs micrographic surgery. D. Report Dr A to the state medical board. E. Remain in the practice and treat the NMSCs on his patients based on the AAD guidelines.
DISCUSSION This case highlights the ethical dilemma inherent in becoming an employed physician in a practice whose owner encourages unethical behavior. From the Department of Dermatology, University of Connecticut Health Center,a and retired private practice dermatologist, Ocean View.b Funding sources: None. Conflicts of interest: None declared. Correspondence to: Jane M. Grant-Kels, MD, Department of Dermatology, University of Connecticut Health Center, 21 South Rd, Farmington, CT 06032. E-mail: [email protected].
1218
Dermatology guidelines are generated to specify acceptable clinical practices. What is a dermatologist’s obligation upon learning that those guidelines are not being followed in their practice? J Am Acad Dermatol 2017;76:1218-20. 0190-9622/$36.00 Ó 2016 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2016.11.054
J AM ACAD DERMATOL VOLUME 76, NUMBER 6
Given the ethical principle of justice and the limited resources in our current health care system, the AAD, American College of Mohs Surgery, American Society for Dermatologic Surgery, and American Society for Mohs Surgery created appropriate use criteria for Mohs micrographic surgery in 2012.1,2 Even before these guidelines were penned, most dermatologists would agree that not all NMSCs require Mohs micrographic surgery, especially a 4-mm squamous cell carcinoma in situ on the extensor forearm. What is Dr EG’s responsibility to his patients and to the health care system in general in this scenario? It would appear that in this particular private practice, owned and administered by Dr A, patient autonomy to grant informed consent is being breached by not explaining various treatment options for NMSCs. Instead, the therapeutic decision was being mandated for them paternalistically and all patients were being referred to the owner of the dermatology group, the Mohs surgeon. Therefore, in our case scenario, Dr EG’s right to practice according to his best clinical judgment and the current standards of care is being taken from him. Dr EG is struggling with the principles of beneficence and nonmaleficence. What is Dr EG’s responsibility to the other clinicians in the practice
ANALYSIS OF CASE SCENARIO Choice A, in our opinion is not the optimal decision for Dr EG. Resigning from this group may alleviate the dilemma for Dr EG but does not address the behavior exhibited by the other practice providers. In our opinion, Dr EG has an ethical obligation to address the principles of autonomy and justice that are being violated by the members of this practice, particularly Dr A. If Dr EG is required to comply with the policies or cannot effect change among his colleagues, it is an appropriate next step to leave the practice. Choice B, encouraging his practice colleagues to adhere strictly to the widely accepted AAD guidelines, is the best initial choice. Shedding light on the overuse of Mohs as potentially detrimental to both the individual patient and health care in general may be enough for some providers to become compliant with guidelines. If Dr EG could convince several of his fellow colleagues to follow the standards of care and to stand up to Dr A, it would give him greater leverage to change Dr A’s practices than approaching him alone. This would be an appropriate first step before choice C or D.
Jinna, Grant-Kels, and Graff 1219
who are complying with Dr A’s mandate to refer all NMSCs for Mohs micrographic surgery no matter their location or clinical and histologic features? There are many ethical questions to ponder. Why are these other well-trained dermatologists acceding to Dr A’s demand? Possibly, they are concerned that they might lose their employment in this practice. Why does Dr A make this demand on his employed clinicians? Is it avarice or his sincere belief that Mohs is the treatment of choice for all skin cancers because of the high cure rate and tissue sparing? Finally, is it ethical for Dr EG to be only responsible for how he treats his own patients, or must he attempt to stop this unethical practice in his group? Any situation in which employees believe they are coerced by their employer to behave blindly outside the bounds of accepted standards of care can lead to trouble. Employed physicians may be concerned about their continued employment if they were not to comply with the recommendations. It becomes even more difficult when the other employees are in compliance with the owner’s requests. Everyone wants to be perceived as a team player. Despite all these conflicting demands, physicians need to remember their overarching primary duty to their patients.
Choice C, confronting Dr A, must be part of the solution if change were to be effected. Although encouraging his colleagues to adhere to Mohs guidelines is worthwhile, doing so without confronting Dr A is not likely to resolve the issues. Because Dr A is aware of the guidelines, confronting him is likely to be contentious; however, Dr EG’s 10 years of clinical experience might carry significant weight with Dr A. If this confrontation does not cause a change in Dr A’s behavior, Dr EG should strongly consider removing himself from the unethical work environment. Choice D, reporting Dr A to the state medical board, would be inappropriate as a first step. Dr A’s abusive and outlying practices border, or even cross the line into, health care fraud, both in intent and practice. They are likely to draw the attention of commercial insurers or state and federal authorities at some point. Nonetheless, before whistle blowing, an attempt to bring awareness to both Dr A and the other dermatologists of the practice should be undertaken. If after approaching these physicians, no changes are made, then this is a future option. A warning alone that this is Dr EG’s next course
1220 Jinna, Grant-Kels, and Graff
of action might cause some of the other providers to take a stand against Dr A’s policy. Choice E, remain in the practice but follow the Mohs appropriate use criteria guidelines for his own patients may seem reasonable, but such
BOTTOM LINE A physician employee who finds himself or herself in a practice that does not conform to the standards of care of our specialty and engages in unethical behavior must be true to his or her ethical core. Clearly guidelines are not being followed by Dr A’s practice, placing Dr EG in the difficult position of standing up for his own ethics to the senior physician/owner and colleagues. Nonetheless, Dr EG should not participate in this unethical and fraudulent behavior.
J AM ACAD DERMATOL
JUNE 2017
a decision violates Dr EG’s moral obligation to stop this fraud on the practice’s patients and on the health care system. Furthermore, by remaining in this practice, Dr EG risks damage to his reputation.
REFERENCES 1. Ad Hoc Task Force, Connolly SM, Baker DR, et al. AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery. J Am Acad Dermatol. 2012;67:531-550. 2. Connolly SM, Baker DR, Coldiron BM, et al. AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery. Dermatol Surg. 2012;38:1582-1603.