- Email: [email protected]
The role of doctors in managing scarcity
European Journal of Internal Medicine 27 (2016) e9
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Letter to the Editor The role of doctors in managing scarcity Keywords: Health care Needs of patients Available resources
The paper by Macchi and Pavan [1] reaffirms that sustainable publicly funded healthcare systems depend on a mature recognition of the necessity to manage scarcity. The moral importance of preventing and treating diseases and disability with effective health care systems derives from the way in which protecting normal functioning contributes to protecting opportunity and preserving the individual ability to participate in the political, social and economic lives of their society. It is therefore of the utmost importance to have an universalistic health care system. In recent years this need has been undermined by the constant reduction of the resources necessary to maintain an acceptable standard of public health care. From a physician's point of view the practice of medicine in our times is beset with unprecedented challenges in all modern societies. The legitimate needs of patients, the resources available to meet them and the increasing dependence on market forces to design health care systems are a combination of factors that doctors must learn to tackle. Steven Brint argues that “without a strong sense of the public and social purposes served by professional knowledge, professionals tend to lose their distinctive voice in public debate” [2]. This is exactly what has happened in all developed countries and is one of the main reasons why doctors are so unhappy [3]. The debate about health care has been dominated by financial, economic and political interests and physicians, individually and collectively, have lost any role in promoting and conducting any rethinking of our health care systems [4]. How can they ask for a leading role in the public debate on medicine and health care if not by reaffirming two of the responsibilities outlined in the professional charter: the commitment to a fair distribution of finite resources and the principle of social justice [5,6]? The needs of individual patients and the cost effective management of the available resources must be balanced. Therefore it is a precise duty of the physician to avoid unnecessary and costly tests and procedures that can diminish the resources available to others and sometimes also harm the patient. The ethical difference between parsimonious medicine and rationing is
clear [7]. Both tend to reduce resource use and waste but while the first requires principles of distributive justice absolutely necessary in circumstances of resource scarcity but sometimes difficult to fully understand, the second rests on the principles of doing no harm and attending to the good of patients and is much closer to the daily chores and practice of doctors. This implies a drastic reduction of the so called defensive medicine that is estimated in Italy to be around 14 billion Euros a stark 10% of the total public financing of the health care system. This can be achieved only with a different approach to the so called medical malpractice or medical errors for instance through a no blame system that favours both patients through a cost effective and rapid reimbursement and physicians through a system that avoids direct financial losses. The role of doctors in managing scarcity is to strengthen medical professionalism to restore medicine's distinctive voice and help society to maintain some kind of universalistic health care system. Conflict of interests The authors state that they have no conflicts of interest. References [1] Macchi L, Pavan A. Managing a research hospital at the time of a global economics crisis: cruising between Scylla and Charybdis. Eur J Intern Med 2015;26:377–8. [2] Brint S. In an age of experts: the changing role of professionals in politics and public life. Princeton, NJ: Princeton University Press; 1994. [3] Smith R. Why are doctors so unhappy? BMJ 2001;322:1074–5. [4] Swick HM. Toward a normative definition of medical professionalism. Acad Med 2000;75:612–6. [5] Brennan T, Blank L, Cohen J, et al. Medical professionalism in the new millennium: a physician charter. Project of the ABIM Foundation, ACP–ASIM Foundation, and European Federation of Internal Medicine. Ann Intern Med 2002;136:243–6. [6] Brennan T, Blank L, Cohen J, et al. Charter on medical professionalism. Medical professionalism in the new millennium: a physicians' charter. Lancet 2002;359:520–2. [7] Tilbur JC, Cassel C. Why the ethics of parsimonious medicine is not the ethics of rationing. JAMA 2013:309.
Sergio Barbieri Unit of Clinical Neurophysiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy Tel.: +39 338 1646710. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.ejim.2015.09.003 0953-6205/© 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
28 August 2015
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Letter to the Editor The role of doctors in managing scarcity Keywords: Health care Needs of patients Available resources
The paper by Macchi and Pavan [1] reaffirms that sustainable publicly funded healthcare systems depend on a mature recognition of the necessity to manage scarcity. The moral importance of preventing and treating diseases and disability with effective health care systems derives from the way in which protecting normal functioning contributes to protecting opportunity and preserving the individual ability to participate in the political, social and economic lives of their society. It is therefore of the utmost importance to have an universalistic health care system. In recent years this need has been undermined by the constant reduction of the resources necessary to maintain an acceptable standard of public health care. From a physician's point of view the practice of medicine in our times is beset with unprecedented challenges in all modern societies. The legitimate needs of patients, the resources available to meet them and the increasing dependence on market forces to design health care systems are a combination of factors that doctors must learn to tackle. Steven Brint argues that “without a strong sense of the public and social purposes served by professional knowledge, professionals tend to lose their distinctive voice in public debate” [2]. This is exactly what has happened in all developed countries and is one of the main reasons why doctors are so unhappy [3]. The debate about health care has been dominated by financial, economic and political interests and physicians, individually and collectively, have lost any role in promoting and conducting any rethinking of our health care systems [4]. How can they ask for a leading role in the public debate on medicine and health care if not by reaffirming two of the responsibilities outlined in the professional charter: the commitment to a fair distribution of finite resources and the principle of social justice [5,6]? The needs of individual patients and the cost effective management of the available resources must be balanced. Therefore it is a precise duty of the physician to avoid unnecessary and costly tests and procedures that can diminish the resources available to others and sometimes also harm the patient. The ethical difference between parsimonious medicine and rationing is
clear [7]. Both tend to reduce resource use and waste but while the first requires principles of distributive justice absolutely necessary in circumstances of resource scarcity but sometimes difficult to fully understand, the second rests on the principles of doing no harm and attending to the good of patients and is much closer to the daily chores and practice of doctors. This implies a drastic reduction of the so called defensive medicine that is estimated in Italy to be around 14 billion Euros a stark 10% of the total public financing of the health care system. This can be achieved only with a different approach to the so called medical malpractice or medical errors for instance through a no blame system that favours both patients through a cost effective and rapid reimbursement and physicians through a system that avoids direct financial losses. The role of doctors in managing scarcity is to strengthen medical professionalism to restore medicine's distinctive voice and help society to maintain some kind of universalistic health care system. Conflict of interests The authors state that they have no conflicts of interest. References [1] Macchi L, Pavan A. Managing a research hospital at the time of a global economics crisis: cruising between Scylla and Charybdis. Eur J Intern Med 2015;26:377–8. [2] Brint S. In an age of experts: the changing role of professionals in politics and public life. Princeton, NJ: Princeton University Press; 1994. [3] Smith R. Why are doctors so unhappy? BMJ 2001;322:1074–5. [4] Swick HM. Toward a normative definition of medical professionalism. Acad Med 2000;75:612–6. [5] Brennan T, Blank L, Cohen J, et al. Medical professionalism in the new millennium: a physician charter. Project of the ABIM Foundation, ACP–ASIM Foundation, and European Federation of Internal Medicine. Ann Intern Med 2002;136:243–6. [6] Brennan T, Blank L, Cohen J, et al. Charter on medical professionalism. Medical professionalism in the new millennium: a physicians' charter. Lancet 2002;359:520–2. [7] Tilbur JC, Cassel C. Why the ethics of parsimonious medicine is not the ethics of rationing. JAMA 2013:309.
Sergio Barbieri Unit of Clinical Neurophysiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy Tel.: +39 338 1646710. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.ejim.2015.09.003 0953-6205/© 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
28 August 2015