Practicing Physical Medicine and Rehabilitation in an Ethical Manner

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Most medical students accumulate substantial debt and earn little to no income. Residency and fellowship training programs offer relatively modest stipends, usually not amounting to what most trainees need both to live on and also to repay their accumulated debt. Therefore, when trainees finally complete the period of deferred-income appreciation, it is no surprise that they begin paying much more attention to the economic aspects of practice. After all, this is the time when they should finally be able to earn a “decent” income, either by receiving a salary from an institution or established practice, getting fee-for-service payments from patients, or some combination of these earning mechanisms. Given the economic pressures that young physicians face, it is natural for them to begin considering the economic consequences of their career and professional choices as they enter the active workforce. They quickly become much more sensitized to the fact that how one practices and the decisions one makes clinically will have economic consequences, not only for patients and the institutions that serve them, but also for themselves.

Yet, I have rarely met a physician who was drawn to medicine (or physiatry more specifically) primarily for the earning potential as opposed to the emotional and intellectual satisfactions associated with the specialty. In this regard, I believe that many younger individuals make the conscious decision that they will be giving up a more highly compensated career choice in favor of a more modestly rewarding one when they choose to enter the field of physical medicine and rehabilitation (PM&R). The reasons that physicians cite to explain their choice of PM&R as a specialty frequently relate to personal experiences with a friend or family member with a serious disabling condition, a preference for the establishment of long-term relationships with patients, a desire for a more balanced lifestyle without extensive call schedules intruding on personal time, and an interest in patients as people rather than organs with diseases. It is the latter reason that distinguishes PM&R from most other medical specialties and justifies the real privilege of becoming certified in this specialty by the American Board of PM&R.

The setting that one chooses for his or her career also reflects personal values and style. People who prefer doing things themselves without delegating or relying on others tend to gravitate towards independent practices that are not burdened with organizational bureaucracy. Individuals who gain more satisfaction from immediate responses to their medical decision making are likely to prefer musculoskeletal practices in which diagnosis, treatment, and response frequently follow a more rapid pace than the changes one sees in in-patient rehabilitation. But regardless of the practice setting, physicians have fiduciary obligations to multiple parties: the patient, the institution or group in which they practice, the third party paying the bill, society as a whole, and themselves.

Frequently, tension may exist between what is in the best interests (or agendas) of these various parties and these stresses may result in ethical challenges. Because physiatrists deal with patient problems in the domains of Activity and Participation, as well as Disease and Impairment (to use the World Health Organization conceptual framework), we are uniquely likely to be confronted by struggles our patients are having with insurance companies, government agencies, and public institutions that involve the use of financial resources. The nature of PM&R often leads the physiatrist to struggle with decisions that juxtapose business and clinical choices, leading to ethical dilemmas.

For example, in my personal practice, I have been asked by patients to prescribe drugs, devices, equipment, supplies, or some special treatment that were not of my own initiative. I have been asked to alter the prescribed frequency of drug dosages to help a patient get insurance coverage for a longer-lasting supply of appropriate medications; patients have requested replacement equipment to have convenience backups available and asked me to prescribe them even though their current equipment was still functional; and I have even been asked to write medical permissions to get a student exempted from buying a college meal plan by claiming she needed to be on a medically prescribed diet, when the truth was that she found the plan to be too expensive and the food too distasteful. (Sound reminiscent of your own college dormitory life?) In each of these cases, although I appreciated the desires and wishes of my patients, I felt obligated to decline these requests because they crossed the line that I thought existed between creative problem solving and prevarication.

In each of these examples, the real issue was an economic one. Who bears the cost of desired goods or services, the patient or the obligated third party? I had no personal economic interest in these issues, only an ethical standard to uphold and my professional integrity to protect. To my knowledge I have not “lost” any of the patients to whom I had to say no, but that certainly could be a consequence. We all know that patients shop for doctors who will be more compliant with their desires.

Physiatrists also are faced with the opportunity to make clinical decisions that may benefit the doctor more than the patient. How many electrodiagnostic studies have been recommended and performed not so much to clarify a diagnosis as to provide a revenue opportunity? Is the decision to perform an injection of an intramuscular myoneural blocking agent versus a peripheral nerve with phenol to manage spasticity determined on the basis of best practice or best economics? Is the choice to perform a fluoroscopically guided spinal injection for pain management versus a trial of conservative modalities and drugs always made because it is in the patient's best interests or the doctor's? Everyday clinical decisions can clearly be influenced by economic consequences.

Therefore, it appears to me that economics are at the heart of many of the ethical dilemmas faced by practitioners of PM&R. We are a bit less likely to be dealing with the grander issues of end-of-life care, discontinuation of life-sustaining treatments, and the like, but we are more likely to face challenges on the basis of economic pressures. After all, many of our patients are the “high rollers” in the health-care system. They have chronic diseases; long-term needs for expensive treatments; therapies, equipment and devices, and are frequently outliers in the costs they incur for needed care.

Much of this tension exists because of the strange trichotomy of health-care financing we live with on a daily basis: the patient, the provider, and the payer (the notorious “third party”). We are so used to the intervention of a clinically disinterested party in our health-care transactions that we have become desensitized to the bizarre nature of this triad. If you have ever tried to explain to a businessman from another country how our system works, you have had to explain that:

In my experience, having a conversation like that with a retailer or banker only leads to head shaking and comments from them like “you need a single-payer national health-care system.”

Business transactions with patients become confusing and cause problems in part because different value systems are being expressed. For example, if 2 alternate courses of treatment are likely to produce a similar outcome and reduce pain, but the less expensive one takes substantially longer (and the patient is in pain for substantially longer), is the cost difference “worth it?” To the insurer, it might not be, but to the patient, most likely it is! Therefore, the perceived value of a service depends on how personal it is, as well as the objective outcome. Although the rate at which an outcome is achieved is quite meaningful to the patient, payers seem to be relatively disinterested in that factor.

Another reality in U.S. health care is that patients expect perfection in treatment and outcomes. Mistakes or just bad outcomes may result in professional liability lawsuits. In fact, it is frequently the practice that when a suit is filed, anyone with a medical degree who can be even remotely associated with the case may be named. Therefore, the fear of litigation may drive a physician to be overly cautious or overuse tests in an effort to anticipate imagined future challenges. The duty a physician feels to protect his or her own interests may be at odds with what the payer or institution might think of as “the right thing to do.”

Public policies may also put a physician in an ethical dilemma. Consider the Medicare policy of trying to minimize the use of inpatient rehabilitation hospitals or units for single joint replacement patient care. By seemingly deliberately confusing the conditions of eligibility for a hospital or unit (the 60% rule) with medical necessity criteria for coverage for an individual patient, Medicare has placed ethical pressure on the physician to argue against the many forces that seek to prevent admitting some of these clinically needy patients. In this case, the physician's decision to admit a patient potentially places the inpatient rehabilitation hospitals or units in jeopardy of a subsequent denial of coverage, regardless of what is in the patient's best interest.

In our current health-care delivery system, dealing with real-world practice on a day-to-day basis and trying to resolve ethical dilemmas is in effect, a reconciliation of what are the best interests of the patient, the host institution, and the payer. In my experience, there are not always easy answers to these challenges, but I have found that considering these issues as ethical dilemmas can be helpful as a frame of reference.

To address these types of concerns, I have found the following principles to be helpful:

In the more than 35 years that I have been practicing PM&R, I have found that one is faced with tensions between clinical and economic interests on a daily basis, and that it is hard to stay invigorated and invested in working through all the myriad issues. What has renewed me, however, has been reminding myself of the patients, and the terrible pain, suffering, or stress with which they endure. My responsibility (as I have seen it) has been to try to help make a difficult situation a little less so and to provide the best support and assistance possible within the bounds of appropriate professional conduct. Practicing PM&R is truly a pleasure and a privilege, and all parties are best served when one consciously strives to maintain awareness of the ethical principles that should contribute to good decision making.

• † Disclosure: nothing to disclose