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OB/GYN Editorial AUGUST 2005
At Least Gregor Samsa
Knew He Was an Insect:
A Survival Guide for Physicians Who Care for Female Patients
Frank A. Chervenak, MD;
Laurence B. McCullough, PhD
In Franz Kafka’s story The Metamorphosis, protagonist
Gregor Samsa awakes one day to discover that he has become
an insect.1 All at once his world has been turned upside
down. We worry that today’s physicians may have a lot
in common with Gregor Samsa. In the context of changes in
payment of physicians and the liability insurance crisis,
we suspect that on a bad day, readers of The Female Patient wonder whether they have indeed become insects about to be
stomped by managed care and plaintiffs’ attorneys.
The authors have described four types of progressive dysfunction in health care
organizations that shape day-to-day practice.2 This editorial offers practical
suggestions on how to survive such dysfunction without going crazy, becoming
a helpless insect on the verge of extinction, or abandoning professional integrity.
Professional integrity is a virtue—ie, a trait or habit of character—that
should define every physician. Such integrity was codified in the system of medical
ethics developed by John
Gregory, an eighteenth-century Scottish physician-ethicist. Professional integrity
requires physicians to practice medicine to standards of intellectual and moral
excellence. Intellectual excellence means that practice should be based on the
application of the best available evidence to each individual patient. Moral
excellence means placing the patient’s health-related interests first,
while keeping self-interest secondary.3
The first step away from professional integrity occurs when the physician begins
to see patients as potential threats rather than women who need excellent medical
care. For example, patients may question recommendations about the use of postmenopausal
estrogen therapy based on what they have read on Internet Web sites. Some patients
may threaten to initiate litigation if their pregnancy does not go well. The
ethical challenge is that such threats can cause the physician to lose sight
of the primacy of the obligation to the female patient. The ethical remedy
is to recognize this change at the outset and actively resist the creeping
cynicism that can result.
The second step away from professional integrity occurs when physicians engage
in self-deception about their professional integrity. For example, a physician
can come to believe that performing an unnecessary cesarean delivery is best
for one patient, and then become so convinced for all subsequent patients.
This can lead to a kind of “Wonderland” climate where one’s
judgments no longer bear any relationship to integrity. The ethical challenge
is that physicians can thus incrementally drift away from intellectual and
moral excellence without being aware of doing so. The ethical remedy is to
take an active role in continuous quality improvement of one’s own practice.
This can be time-consuming, but is a small price to pay.
The third step away from professional integrity occurs when physicians have the
Kafkaesque experience of being held accountable to standards that have nothing
to do with clinical reality. For example, a physician who is sued for an adverse
pregnancy outcome, despite meeting excellent standards of care, confronts a
plaintiff’s expert who cites “standards” dissociated from
the realities and limitations of prospective clinical management. The ethical
challenge is not to succumb to the imposition of an alien reality, especially
when the liability carrier is pressing for a settlement. The ethical remedy
is to refuse such pressures and resist the distortion of accepted standards
of care.
The final step away from professional integrity occurs when physicians experience
contradictory pressures in clinical practice. For example, a managed care plan
may refuse to pay for diagnostic testing, advocating a practice standard of
inadequate testing. At the same time, the professional liability crisis often
pushes physicians toward a standard of overtesting. This is a postmodern world,
in which clashing standards all claim ultimate authority. The ethical challenge
is to recognize that such irreconcilable claims are not authoritative unless
they meet evidence-based standards. The ethical remedy is to vigorously embrace
evidence-based medicine as crucial for maintaining professional integrity.
Physicians are professionals, not insects. They should not acquiesce to
becoming insects, even in the face of powerful forces. The privilege of caring
for female patients provides a powerful antidote to the preventable drift
of medical practice into cynical, Wonderland, Kafkaesque, and postmodern
deviations from professional integrity. The beauty of caring for the female
patient is well worth the fight to preserve professional integrity.
Frank A. Chervenak, MD
Editorial Advisory
Board Member |
Laurence B. McCullough, PhD
Professor of Medicine and
Medical Ethics and Associate Director for Education, Center for Medical Ethics
and Health Policy, Baylor College of
Medicine, Houston, Tex. |
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References
- Kafka F. The Metamorphosis. Corngold S, trans-ed. New York, NY: Bantam Doubleday Dell Publishing Group; 1987.
- Chervenak FA, McCullough LB. The diagnosis and management of progressive dysfunction of health care organizations. Obstet
Gynecol. 2005;105(4):882-887.
- McCullough LB, Chervenak FA. Ethics in Obstetrics and
Gynecology. New York, NY: Oxford University Press; 1994.
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