Conduct an Ethics Audit
Gauge the moral fiber of a practice before
you join. Asking the
right questions now may prevent sticky situations in the future.
right questions now may prevent sticky situations in the future.
Finding a good job requires more than
negotiating the best salary, benefits and practice size.
Physicians would do well to heed the lesson from cautionary
tales now associated with Enron and WorldCom: The ethical
culture of an employer matters. And the more you know about a
practice’s ethics before accepting a job offer, the less
likely you’ll be to find yourself in a situation you
regret.
Linda K. Trevino, PhD, and
Katherine A. Nelson address this issue in their book, Managing Business Ethics: Straight Talk About
How to Do It Right (John Wiley and Sons Inc., 2004).
“We think of professionals as having
strong standards, but when dealing with reward and compensation
systems, those ethics can be hard to hold onto,” Trevino
points out. “It’s a good idea to ask your physician
colleagues or potential colleagues what it’s like to
practice medicine at the practice you’re considering. Do
the management systems there allow them to practice in the way
that they want to? Are there time limits on patient visits?
What are the consequences if a physician goes over an HMO
administrator’s head to provide care? Professionals such
as physicians often have a great deal of autonomy, and have
expectations that they will be supported by their employer
[regarding the decisions they make], but this may not be the
case. Before you get hooked on an opportunity and maybe even
move your family to a new area, it’s important to clearly
understand the business side of the practice.”
“An interview is
not where you go to sell yourself,” she says.
“You’re there to see if they’re right for
you; they want to see if you’re right for them.”
Before you begin your
job search, says Trevino, do some soul searching.
“You must ask yourself, ‘What are my values?
What am I willing to lose my job over?’ ”
Preliminary homework
Early in a physician’s career, the
most likely starting point will be with a small practice of
probably one to five physicians, says Harvey Waxman, MD, the
chief of cardiology for the University
of Pennsylvania Medical Center Presbyterian in Philadelphia.
“You may not see
formal policies in place when it comes to ethics,” he
says. “What may be most relevant in this type of practice
is how the physicians resolve conflict. It’s a good idea
to do a little background checking before you interview. If
you’re living in the area, find out what the
group’s reputation is. Of course, this information may
not be that easy to come by. If there are only two cardiology
practices in town, for example, the other practice may not be
willing to say good things about the competition. But the
nurses at the hospital where the doctors have privileges always
know the scoop. They are a great resource for background
information.”
For positions in
larger organizations or in academia, information on the
employer’s business practices and reputation may be found
on line. Often all it takes it typing the organization’s
name into a search engine to find out all about its history.
You may even be able to find information about former employees
and where they are presently working, so that you could contact
them for an informational or “background”
interview.
Asking the tough questions
Of course, certain questions will need to
be asked directly of your potential employer during the
interview. How you ask these questions is key, says Kay, the
author of Interview Strategies That Will Get You the
Job You Want (Betterway Books, 1996).
“There are a
couple of times during the interview when you could ask these
sorts of questions,” Kay says. “If the interviewer
is in the zone of ‘Here’s what we do, here
are how many patients we see...’ use that as an in. You
may interject, ‘How do you do that? What systems are in
place to keep things running smoothly?’”
The other opportunity
to gather more information, obviously, is when the interviewer
turns the interview back over to you, asking, “Do you
have any questions for me?”
Kay’s strategy:
Ask direct, yet appropriate questions. Write down your
questions beforehand and have them ready to refer to at this
point in the interview. According to Kay, “One way to
begin is with something like, ‘I’m sure you want a
good fit for you as well as for me...’ and you can ask
about their practice philosophy and whether there is a
structure in place to ensure it,” she says.
As stated in the “ACP
Ethics Manual” (Ann. Int. Med.
1998; 128:576-597; available at
www.acponline.org), “The physician’s first and
primary duty is to the patient.” There are several parts
of a practice that, if not run well, could compromise this
basic ethical tenet. The following questions help assess the
means a practice applies to reach its desired ends.
How many patients are physicians here
expected to see? One of the
most important components of practice philosophy is how many
patients a physician is expected to handle per hour or per day,
says Waxman.
“You need to
balance what you are capable of doing with what a practice
wants you to do,” he says. “Some doctors can handle
a large patient load and still do a great job. But when people
tend to be spread too thin, patient care suffers.”
Kay agrees. “You
should definitely ask about patient load and customer service
policies. A bottom-line-only practice would be a very
frustrating place to work.”
Has malpractice been an issue for this
practice? Even if an
interviewer says that the physicians in the practice see many
patients with few problems, it’s a good idea to find out
about its malpractice claim history. You can find malpractice
history and disciplinary action on record at the state medical
association, often available on line through the
association’s Web site. But whatever you discover during
research before the interview, it’s a good idea to get
the interviewer’s take on it.
If the interview is
going well and you feel comfortable, Waxman recommends asking
in a way such as, “Malpractice is really tough these
days. Has this practice had any problems with it?”
Waxman says,
“Number one, malpractice problems indicate that the
doctors there have poor communication with their patients at
best. Number two, if you join a practice where malpractice has
been an issue, the high insurance premiums will affect your
income.”
Does this practice have written guidelines
to follow regarding referral acceptance and testing?
Another major issue, Waxman says, is
specialists over-testing patients to generate revenue.
Stanley Goldfarb, MD, the
senior vice chair for the department of medicine at University
of Pennsylvania Hospital,
agrees, cautioning that certain forms of practice management
are not only unethical, but illegal.
“The issue of
testing and churning is really, really troubling,”
Goldfarb says. “We need to ask ourselves, when does this
morph into inappropriate care? And when it comes to the issue
of referring, when doctors refer for money, it’s illegal.
There are national guidelines that must be followed in this
regard. So when you’re considering a practice
opportunity, lay out your principles. Ask about the
practice’s guidelines for preventive care.”
Potential influences on clinical
judgment cover a wide range and include financial incentives
inherent in the practice environment (such as incentives to
over utilize in the fee-for-service setting or underutilize in
the managed care setting), drug industry gifts, and business
arrangements involving referrals. Physicians must be conscious
of all potential influences and their actions should be guided
by appropriate utilization, not by other factors. A fee paid to
one physician by another for the referral of a patient,
historically known as fee-splitting, is unethical. It is also
unethical for a physician to receive a commission or a kickback
from anyone, including a company that manufactures or sells
medical instruments or medications that are used in the care of
the physician’s patients. Physicians should not refer
patients to an outside facility in which they have invested and
at which they do not directly provide care.
What type of training do the doctors here
take for coding and billing correctly? The third major component of an ethical practice
is its billing system. Goldfarb says. “If you’re
not billing to the level of care, you will go to jail. So
during the interview, ask what training the doctors have taken
for coding billing correctly. If they go to medical
association-sponsored training sessions regularly, that’s
great. If they have never trained in this area, you’ll
know they have a problem and this is not a good practice to
consider joining.”
How do the physicians here stay up-to-date
in their field? A desirable
practice will encourage its physicians to attend CME programs
sponsored by state or local medical associations. Beware the
practice in which pharmaceutical company sponsored courses are
the norm for continuing education, Goldfarb warns, as this
could create a conflict of interest.
Does this practice participate in phase
four clinical trials? Phase
four clinical trials (those conducted after the drug is on the
market) may be proposed by a pharmaceutical company to study a
drug’s effect on people not included in the initial
clinical trials. The company compensates the doctors who
participate in these trials with the hopes that the physicians
will prescribe the drug later. If this system does not sit well
with you, you’ll want to know about it before joining the
practice, Goldfarb says.
Trevino, the chair of the
department of management and organization at the Penn State
Smeal College of Business,
points to a physician she knows who shuns pharmaceutical
company involvement in his practice altogether. He does not
allow sales reps into his practice, period.
“He says he
doesn’t want to get his information about drugs from
them,” Trevino says. “He will read journals or go
on line for information instead.”
Goldfarb disagrees
with this stance.
“There’s
nothing wrong with letting a drug company sales rep visit the
office,” he says. “It can be a good way to learn.
Of course, I always ask a lot of questions and tend to be
somewhat skeptical. I personally won’t use a new drug
unless it is the only way to get a desired result. But
it’s not unethical to listen to what the rep has to say.
As the saying goes, you can take someone dancing without
breaking your marriage vows.”
Does this practice have investments,
financial holdings, or business connections with hospitals or
other entities? “I recently
saw a sign on the wall in one practice, saying, ‘We have
a financial interest in such and such diagnostic facility, but
you have no obligation to use that facility if you prefer
another one,’” Trevino says. “I was impressed
by that. Certainly, as a physician, you may ask about a
potential employer’s investments or business connections.
Then you can decide whether you, too, are willing to buy into
those relationships.”
This issue, too, is
summarized in the “ACP Ethics Manual:”
Physicians may... invest in or own health
care facilities when capital funding and necessary services are
provided that would otherwise not be made available. In such
situations, in addition to disclosing these interests to
patients, safeguards must be established against abuse,
impropriety, or the appearance of impropriety. Physicians may
invest in publicly traded securities. However, care must be
taken to avoid investment decisions that may create a conflict
of interest or the perception of a conflict of interest.
The acceptance of individual gifts,
hospitality, trips, and subsidies of all types from the health
care industry by an individual physician is strongly
discouraged. The acceptance of even small gifts has been
documented to affect clinical judgment and heightens the
perception (as well as the reality) of a conflict of interest.
While following the guideline of the London-based Royal College
of Physicians,’ “Would I be willing to have this
arrangement generally known?” physicians should also ask,
“What would the public or my patients think of this
arrangement?”
Harvey Waxman, MD, the chief of cardiology
for the University of Pennsylvania Medical Center Presbyterian
in Philadelphia, suggests asking about the practice’s
malpractice history. “Number one, malpractice problems
indicate that the doctors there have poor communication with
their patients at best. Number two,… the high insurance
premiums will affect your income.”
photo/ ©2004
Don Tracy
