Transcript casa-4-ventura-ethics-compressed

The Primary Spine Practitioner
and Ethics
John Ventura, DC, DABCO
NQF, musculoskeletal committee
USBJI, board member
CMS, technical expert panel
University of Rochester, School of
Medicine
Disclosures/COI
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Spine Care Partners, LLC
Primary Spine Provider Network, LLC
Member of ACA, NYSCA, APHA, NASS
National Quality Forum, musculoskeletal committee
United States Bone and Joint Initiative, board
Center for Medicare/Medicaid Services, technical expert
panel for Physician Quality Reporting System
30 yrs in full time clinical practice
 17 yrs clinical instructor family medicine University of
Rochester School of Medicine
 16 yrs clinical instructor New York Chiropractic College
 4 yrs assistant clinical professor D’Youville College
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Ethics
The discipline of dealing with what is good and bad, right
and wrong
 The discipline of dealing with moral duty and obligation
 The principles of conduct governing an individual or
group
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Secular and Religious contexts
Santa Claus Is Coming To Town
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“so be good for goodness sake”
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“you better not shout, you better not cry, you better not
pout, I’m telling you why”…0r Else!
Descriptive Ethics
Describing what people think about morality
 Not so much about the moral choice made, but how the
person came to make that choice
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- many think stealing is bad, but it is OK to download
music off the internet
Normative Ethics
Establishes what is moral for populace based upon
behavior
 Describes how person’s ‘ought’ to behave
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- strive to help our patients
- first do no harm
Metaethics
Asks what morality is..
How people determine for themselves what is moral
behavior, and is influenced by…
- religion (ie. Ten Commandments)
- peers
- culture
- fear
- guilt
What is the nature of ethical properties?
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Which path will you take?
A Framework for Universal Principles of Ethics
by L. Colero
University of British Columbia
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Personal Ethics
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Professional Ethics
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Global Ethics
Centre for Applied Ethics
*Each area operates within context of the other areas*
 The underlying premise is unconditional love and compassion.
 Apply to all cultures, faiths, professions, philosophies.
 How does my behavior affect the well being of others?
Personal Ethics
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Concern for the well being of others
Respect for the autonomy of others
Trustworthiness and honesty
Willing compliance with the law (except civil disobedience)
Basic justice (being fair)
Refusal to take unfair advantage
Benevolence
Preventing harm
Global Ethics
Global justice (international law)
 Society before self
 Social responsibility
 Environmental stewardship
 Interdependence
 Responsibility for the ‘whole’
 Reverence for place
These principles are simply recurring patterns of ethically
responsible behavior that our conscience can use as landmarks.
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Professionals and
Professional Ethics
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Impartiality (objectivity)
Openness (full disclosure)
Confidentiality
Due diligence (duty of care)
Fidelity to professional responsibilities
Avoiding potential or apparent conflict of interest
example:
A patient informs you that they are
depressed and they are considering suicide
- Confidentiality (professional ethics) in
conflict with preventing harm (professional
and personal ethics)
“Let the buyer…………
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Merchant: caveat emptor
“let the buyer……………..beware”
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Health Professional: credat emptor
“let the buyer……………..trust”
Chiropractic profession
and
Ethical issues
Our problem….TRUST
In 1990, the McLean County (Illinois) Chamber of
Commerce's Professional Committee surveyed a
population of people (12% of which were chiropractic
patients) with the following results:
only stockbrokers scored lower on a scale of
trustworthiness than chiropractors,
over 45% of those surveyed felt chiropractic ethics were
below average
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The problem continued…..
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Canada Speaks survey, held in 2002 and
again in 2006, chiropractic trustworthiness
improved from 15th place to 12th place
(49% of those surveyed felt chiropractors
to be trustworthy), but still well below
medical physicians (80%) and nurses (87%)
The problem continues……Gallup Poll
So how do we gain TRUST?
Cultural Authority
the ability to define your professional truth
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Legitimacy
- technical expertise, scientific principles
- shared professional standards
- standardized training
Competency
- collegiality
- cognitive approach
- moral attributes (patient centered)
American Chiropractic Association
code of ethics
Upholds the fundamental principle that the
paramount purpose of the chiropractic
doctor's professional services shall be to
benefit the patient
Adhere to highest standards of excellence
Follow best practices
Follow all governmental rules/regulations
Dr/Pt relationship based upon trust, respect
and cooperation
 Dr should not mislead the patient in any
manner
 Dr should protect the patient’s confidentiality
 Provide information and facilitate
understanding so that patient can make an
informed decision
 Dr must not exploit the trust of the patient
(sexual, Stark)
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Dr must refer to others when patient will
benefit
 Never neglect or abandon the patient
 Cannot deny care to a patient based upon
race, religion, creed, gender, sexual
preference, handicap
 Work with others for public health(reduce
morbidity, increase function, increase
longevity, reduce health care costs)
 Advertising is truthful and accurate
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Doctors must protect the public and the
profession by reporting acts which are
illegal, unprofessional, incompetent,
unethical to the appropriate authorities
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The challenge here is to determine what is:
Unprofessional
Incompetent
Unethical
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International Chiropractic Association
code of ethics
Basically the same as that of the ACA
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The overriding objective of these
principles is for the doctor of chiropractic
to render the greatest possible service
and care to mankind.
Consider the well-being of the patient.
The primary effort and ultimate goal
should be for "the greatest good” of the
patient.
Allied Health Professional Council of SA
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Principles of Medical Ethics
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Respect for persons dignity each person
Beneficence pt’s need supercede dr’s
Rights of the individual rights of individual paramount
Autonomy do not coerce the pt
Integrity behavior consistent with moral attributes
Truthfulness honesty
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Principles of Medical Ethics cont’d
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Confidentiality keep info confidential
Compassion empathize
Justice treat everyone equally
Recognition of diversity respect differences
Professional competence continually improve
Community public health focus
Justice: Equal versus Equitable
Remuneration: what do we say?
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The health and welfare of the patient should always be
paramount and expectation of remuneration or lack thereof shall not in
any way affect the quality of service rendered to the patient.
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The doctor of chiropractic should support proper activities designed to
enable access to necessary chiropractic care on behalf of
individuals who are unable to pay reasonable chiropractic fees or who
are otherwise legally destitute.
Remuneration
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What is reasonable?
What is usual and customary?
Who determines these definitions?
Example
CPT 97012: spinal decompression
(non-covered lumbar spine treatment)
- Dr A charges the patient (US) $45/visit
- Dr B charges the patient (US) $200/visit
Is doctor A undervaluing the service?
Is doctor B being unethical?
Example
Diagnosis: recurrent lumbar disc syndrome
- Dr A charges the patient (US) $45/visit and
recommends X3/week for 4 weeks
- Dr B charges the patient (US) $6,000 paid in advance for
1 year of care
Is doctor A undertreating the patient?
Is doctor B being unethical?
Advertising
Truthful
-in NY cannot claim professional
superiority that cannot substantiate
-cannot offer guarantees
-must qualify doctor degree as
chiropractor
 Avoid scare tactics/intimidation
- “you could end up in a wheelchair”
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Poisoning The Well
New York State Rules:
unprofessional conduct
NY State Dept. of Education/board for
chiropractic
Defines Unprofessional Conduct (what are
professional ethics)
- exploiting the patient for financial gain
- receiving‘kickbacks’
- violating patient confidentiality
- exceeding scope of practice of state license
Ethics and decision making
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Knee MRIs more likely to be negative when ordered
by an MD who has ownership stake in the MRI
facility. (MP Lungren Radiology 2013)
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Doctors are required to provide disclosures/conflict
of interest for lectures and publications, not
necessarily with patients (PODs for surgical devices,
pharma relationships)
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However there is upside to industry support:
more consistent quality and innovation
Ethics and decision making cont’d…..
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AUTO REPAIR
◦ Bring your car in to check out engine
◦ Consumer: caveat emptor
◦ Incentive: find something wrong, do more service
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HEALTH CARE
◦ Bring your body in to check out ‘engine’
◦ Consumer: credat emptor
◦ Incentive: find something wrong, do more service
Ethics and decision making cont’d…..
Dr tells parent that childhood immunizations
cause autism and should be avoided.
Dr offers elective fusion surgery for herniated
disc but doesn’t offer conservative therapy
options.
One business..4 questions, 3 actions
Is the action legal?
 Does it comply with our values?
 If you do it, will you feel bad?
 How will it look in the newspaper?
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If you know it is wrong, don't do it!
 If you're not sure, ask.
 Keep asking until you get an answer.
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S Perle 2007
Ethics and the Primary Spine Provider
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Must be well versed in all treatment options
Shared decision making
◦ The diagnosis
◦ All available treatment options for this condition, including natural
history of the disorder
◦ The treatment option you recommend and the potential harms
◦ Patient’s values, health hx, preferences, social hx
◦ The evidence supporting your treatment option
Thanks to…….
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The articles of Stephen Perle, DC
http://www1bpt.bridgeport.edu/~perle/ethics
Access to Quality Spine Care
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All people should have access to high quality spine care
◦ Developed countries (probably too much access)
◦ Developing countries (almost no access)
WORLD SPINE CARE: helping people with spinal disorders
in underserved communities throughout the world
SHOSHONG PROJECT
Botswana
RANTHAMBHORE PROJECT
INDIA
Providing care for 250,000 people
in 32 villages
Magu Project
Tanzania
Providing care for 500,000 people
Moca Project, Dominican
Republic
Getting involved
1. Find out more
2. Tell others Word of mouth, websites, social media
3. Make a donation
The statement of your support is as important as your donation
4. Become a Volunteer
• Fund raising events, corporate/foundation
support
• Start a social fundraising campaign
• Research, education and program
development
• Administration
• Special skills
Getting involved
5. Become a Volunteer (Cont.)
Primary spine care clinician
- Willing to spend 6 weeks, 3 months, 6 months or a year at a
WSC center
- Capable of finding the financial support for their participation
Medical specialist and surgeons
- Willing to do site visits and needs assessments
- Willing to spend 2 weeks providing specialist or
surgical care
YOU CAN MAKE A DIFFERENCE
This is a volunteer organization.
It can only provide help to others
if those in privileged positions
are willing to provide time,
expertise and funding.
Please Join Us
www.worldspinecare.org
"A conclusion is the place where you got tired of
thinking."
So, THANK YOU