- Email: [email protected]
Why a new section dedicated to ethics in the JAAD?
COMMENTARY
Why a new section dedicated to ethics in the JAAD? Jane M. Grant-Kels, MD,a and Lionel Bercovitch, MDb Farmington, Connecticut, and Providence, Rhode Island
H
ave you ever had a patient with a malignancy refuse treatment? Have you ever seen a patient that received care from one of your colleagues that seemed shockingly substandard and wondered if you should report it—and if so, to whom? Have you ever been asked to be an investigator in what seemed like a bogus postmarketing study, paying you $1000 to fill out paperwork on each patient you start on the drug? Have you ever noticed what looked like a skin cancer or a melanoma on the skin of a stranger and wondered what to say? Has any patient of yours ever demanded a biologic drug for what seems like fairly mild psoriasis? Has any patient ever asked you to code an excision for an asymptomatic lesion of cosmetic concern so that insurance will pay for the procedure? Have you ever given a patient a manufacturer’s discount card for an expensive branded steroid even though the generic—albeit in a nonproprietary vehicle—is much less expensive and likely as well tolerated and effective? We are clinicians, entrepreneurs, scholars, researchers, managers, employers, small businesspersons, lifelong students, and professionals. As dermatologists, we are faced with countless ethical and professional dilemmas such as the above, which often require us to make split second decisions or act reflexively without the luxury of time to engage in serious analysis and moral reflection. We are practicing in a complex environment that has become even more so as a result of government intervention, limited resources coupled with increasing demands for expensive new technology and cutting-edge biologic therapies, ever-changing From the Departments of Dermatology, University of Connecticut Health Center,a Farmington, and the Warren Alpert Medical School of Brown University,b Providence. Funding sources: None. Conflicts of interest: None declared. Reprints not available from the authors. Correspondence to: Lionel Bercovitch, MD, Department of Dermatology, Warren Alpert Medical School of Brown University, 593 Eddy St, APC-10, Providence, RI 02903. E-mail: [email protected]. Published online November 29, 2010. J Am Acad Dermatol 2011;64:432-3. 0190-9622/$36.00 ª 2010 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2010.11.002
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powerful information technology, increasing cultural diversity, increasingly intrusive regulatory oversight, medicolegal assaults, as well as conflicting demands on our time by our patients, our institutions, our staffs, and our families. The era of the dermatologist practicing in a small independent practice without computerized billing and electronic health records is rapidly becoming a nostalgic memory. Changes in technology occur faster than our ethical standards can adapt; electronic communication and teledermatology are but two examples. Direct-to-consumer advertising and information overload related to the Internet have created new ethical challenges relating to patient autonomy. New business models, including managed care, ambulatory surgical centers, boutique practices, and medispas have all created potential conflicts of interest and dramatic shifts in the delivery of dermatologic care. Genomics and personalized medicine, genetic testing, and new reproductive technologies and their attendant ethical controversies are no longer hypothetical. And both society and our regulatory bodies are more vigilant and less tolerant of lapses in professionalism. As hard as it is for experienced dermatologists to stay current and adapt to an ever-changing world with diminishingly plastic nervous systems, dermatology trainees face a special set of challenges. They are dealing with issues while in training that previous generations of dermatologists could not even have conceived. Conflicts of interest in the workplace relating to interactions with drug companies and other vendors; new rules dealing with working conditions in graduate medical education; formal documentation of training and core competencies; privacy issues; the rapidly changing and evolving nature of dermatology practice and the job market; and huge student loan debt all simultaneously weigh heavily upon our greatest resource and the future of our specialty. All of these factors have combined to create novel ethical challenges and moral and professional dilemmas. Behaviors that we have come to take for granted as being the norms in contemporary dermatology have often not been subjected to critical ethical analysis with any regularity in the dermatology literature. Things that we might always have
J AM ACAD DERMATOL VOLUME 64, NUMBER 2
taken for granted as ‘‘the way things are’’—for example, gifts from industry, lavish entertainment at major conferences, even pens and notepads—are now regarded as improper. Even such seemingly innocuous practices such as accepting gifts or donations from patients or dispensing drug samples in the office are facing scrutiny. For all of these reasons, it is time for our specialty to have a venue to address contemporary ethical and professional issues. We are therefore soliciting and welcoming two types of submissions: short, casebased articles and dermatoethics consultation requests. Short, case-based articles (up to 1750 words and 10 references) should begin with a case scenario illustrating the ethical or professionalism issue to be discussed, with a multiple choice question offering the reader four possible actions to deal with the
Grant-Kels and Bercovitch 433
problem presented (distinct from the continuing medical education [CME] questions that follow the article), followed by a balanced discussion of the subject, with special focus on the ethical issues, and an analysis of the case based on the multiple-choice options presented along with the author’s recommended resolution. Each article should be accompanied by two multiple-choice questions so that CME credit can be awarded upon successful completion. The questions should examine an understanding of the concepts presented in the paper. Dermatoethics consultation requests should be short cases or scenarios for commentary and analysis. These will be selected for print or online commentary written by the editors or invited experts. The success of this new journalistic venture depends on your participation. We look forward to receiving your submissions!
Why a new section dedicated to ethics in the JAAD? Jane M. Grant-Kels, MD,a and Lionel Bercovitch, MDb Farmington, Connecticut, and Providence, Rhode Island
H
ave you ever had a patient with a malignancy refuse treatment? Have you ever seen a patient that received care from one of your colleagues that seemed shockingly substandard and wondered if you should report it—and if so, to whom? Have you ever been asked to be an investigator in what seemed like a bogus postmarketing study, paying you $1000 to fill out paperwork on each patient you start on the drug? Have you ever noticed what looked like a skin cancer or a melanoma on the skin of a stranger and wondered what to say? Has any patient of yours ever demanded a biologic drug for what seems like fairly mild psoriasis? Has any patient ever asked you to code an excision for an asymptomatic lesion of cosmetic concern so that insurance will pay for the procedure? Have you ever given a patient a manufacturer’s discount card for an expensive branded steroid even though the generic—albeit in a nonproprietary vehicle—is much less expensive and likely as well tolerated and effective? We are clinicians, entrepreneurs, scholars, researchers, managers, employers, small businesspersons, lifelong students, and professionals. As dermatologists, we are faced with countless ethical and professional dilemmas such as the above, which often require us to make split second decisions or act reflexively without the luxury of time to engage in serious analysis and moral reflection. We are practicing in a complex environment that has become even more so as a result of government intervention, limited resources coupled with increasing demands for expensive new technology and cutting-edge biologic therapies, ever-changing From the Departments of Dermatology, University of Connecticut Health Center,a Farmington, and the Warren Alpert Medical School of Brown University,b Providence. Funding sources: None. Conflicts of interest: None declared. Reprints not available from the authors. Correspondence to: Lionel Bercovitch, MD, Department of Dermatology, Warren Alpert Medical School of Brown University, 593 Eddy St, APC-10, Providence, RI 02903. E-mail: [email protected]. Published online November 29, 2010. J Am Acad Dermatol 2011;64:432-3. 0190-9622/$36.00 ª 2010 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2010.11.002
432
powerful information technology, increasing cultural diversity, increasingly intrusive regulatory oversight, medicolegal assaults, as well as conflicting demands on our time by our patients, our institutions, our staffs, and our families. The era of the dermatologist practicing in a small independent practice without computerized billing and electronic health records is rapidly becoming a nostalgic memory. Changes in technology occur faster than our ethical standards can adapt; electronic communication and teledermatology are but two examples. Direct-to-consumer advertising and information overload related to the Internet have created new ethical challenges relating to patient autonomy. New business models, including managed care, ambulatory surgical centers, boutique practices, and medispas have all created potential conflicts of interest and dramatic shifts in the delivery of dermatologic care. Genomics and personalized medicine, genetic testing, and new reproductive technologies and their attendant ethical controversies are no longer hypothetical. And both society and our regulatory bodies are more vigilant and less tolerant of lapses in professionalism. As hard as it is for experienced dermatologists to stay current and adapt to an ever-changing world with diminishingly plastic nervous systems, dermatology trainees face a special set of challenges. They are dealing with issues while in training that previous generations of dermatologists could not even have conceived. Conflicts of interest in the workplace relating to interactions with drug companies and other vendors; new rules dealing with working conditions in graduate medical education; formal documentation of training and core competencies; privacy issues; the rapidly changing and evolving nature of dermatology practice and the job market; and huge student loan debt all simultaneously weigh heavily upon our greatest resource and the future of our specialty. All of these factors have combined to create novel ethical challenges and moral and professional dilemmas. Behaviors that we have come to take for granted as being the norms in contemporary dermatology have often not been subjected to critical ethical analysis with any regularity in the dermatology literature. Things that we might always have
J AM ACAD DERMATOL VOLUME 64, NUMBER 2
taken for granted as ‘‘the way things are’’—for example, gifts from industry, lavish entertainment at major conferences, even pens and notepads—are now regarded as improper. Even such seemingly innocuous practices such as accepting gifts or donations from patients or dispensing drug samples in the office are facing scrutiny. For all of these reasons, it is time for our specialty to have a venue to address contemporary ethical and professional issues. We are therefore soliciting and welcoming two types of submissions: short, casebased articles and dermatoethics consultation requests. Short, case-based articles (up to 1750 words and 10 references) should begin with a case scenario illustrating the ethical or professionalism issue to be discussed, with a multiple choice question offering the reader four possible actions to deal with the
Grant-Kels and Bercovitch 433
problem presented (distinct from the continuing medical education [CME] questions that follow the article), followed by a balanced discussion of the subject, with special focus on the ethical issues, and an analysis of the case based on the multiple-choice options presented along with the author’s recommended resolution. Each article should be accompanied by two multiple-choice questions so that CME credit can be awarded upon successful completion. The questions should examine an understanding of the concepts presented in the paper. Dermatoethics consultation requests should be short cases or scenarios for commentary and analysis. These will be selected for print or online commentary written by the editors or invited experts. The success of this new journalistic venture depends on your participation. We look forward to receiving your submissions!