Endometriosis Foundation of America 2014
Professional responsibility: An essential dimension in the management of endometriosis
- Frank Chervenak, MD
Victor, it is a special thank you, it is an honor to be here. You have been a mentor to me and to so many people in this room. I have more comments to say about you but I will save that for my last slide. I will save that for my last slide.
I echo, Tamer, what everyone has said. In my travels I see it is so easy for things to fall apart but so hard to build something up. It is truly a thing of beauty to see what you have built up here. I have to give you a round of applause, congratulations.
I must say it is a special pleasure to see some friends that I have not seen in decades, to see wonderful people, to be on this panel. I just pray that we have not just gotten older but we are all a little bit wiser over the years as we have travelled.
I was a little bit filled with trepidation when Victor asked me to speak on this topic. This is not my usual topic. Those of you who know me know I am maternal fetal medicine, obstetrics. I enlisted the help of Debby Taubel, a superb physician in my department to help sharpen the clinical focus and Larry McCullough the philosopher I have worked with for over 30 years.
I came to realize that indeed ethics is an essential dimension of endometriosis. We will see if I convince you of that in the few minutes we have. There are clinical/ethical challenges in endometriosis that affect the appropriate diagnostic workup and the appropriate clinical management. Concerning the diagnostic workup everyone faces patients with a diagnosis of endometriosis with no documentation and inappropriate workup. Patients who have been worked up with negative results but symptoms persist and diagnosis has been given notwithstanding. Patients who insist that their self-diagnosis is correct, despite the absence of findings. I think everyone in this room who deals with these patients knows these are common issues when it comes to diagnosis.
Clinical Management: when it comes to management patient choice, sometimes demand, for medical or surgical management that is completely non-indicated; patient request for narcotics, new or continued, and risk of addiction with no documented benefit; patients who accept management plan but do not allow enough time for the plan to become effective, they are pressuring us to get it done quickly; and patients who are seeking secondary gain, such as justifying absence from work or school or for disability claims.
As you can see, and I am sure there are many, many more issues, when it comes to diagnostic issues with endometriosis or management issues, ethics is an essential dimension. In order to unwrap this let us very, very succinctly go over some tools of ethics. We will touch upon beneficence, respect for autonomy, professional integrity and conflicts of interest.
Beneficence comes from the Latin, it is nothing holy or benediction. It is a secular ethical principle and it means to do good. We have an ethical obligation to identify, recommend and provide clinical management that is reliably expected in deliberative, evidence-based, rigorous, transparent and accountable clinical judgement to result in outcomes with a net clinical benefit for the patient. Medically reasonable means it is technically possible and meets this test. The patient's preferences, by themselves, do not establish that diagnostic or clinical management is medically reasonable. This is a problem I face in obstetrics all the time. Just because a patient wants something does not make it medically reasonable. It is the same in gynecology just because a patient wants something does not mean we should do it. Sometimes we just say no.
Respect for autonomy is another core ethical principle. Informed consent empowers the patient with the information that she needs to exercise her autonomy in an informed fashion. We identify and present medically reasonable alternatives to the patient. And sometimes we recommend only one medically reasonable alternative if it is the only one when it is clinically superior.
I cannot resist. I know many in this room heard Harry's excellent presentation, Tamer's. You love history so I cannot resist it is the century anniversary of my own institution of the birth of informed consent in the United States. It was in 1914 the famous Schlonedorff decision by the United States Supreme Court and this is worth the moment discretion so please allow this. I love this society there is a strong current of history. Mrs. Schloendorff went to her doctor with a pelvic mass. The physician at my hospital, then the New York Hospital, did an exam under anesthesia and felt the pelvic mass and made the medically correct decision. He said let me open her up and take the mass out because to wake her up and to get consent for this would be too risky. Back then there was only ether anesthesia and it would put her life at risk. Mrs. Schloendorff was not happy she said, "Wait a minute you didn't get my consent". This went all the way up to the Cardosa Supreme Court and it laid the grounds for informed consent today. So this...respect for autonomy in the United States is based in large part on that landmark Schloendorff decision a century ago this year.
Professional integrity - something we speak about where we practice medicine, conduct research and teach to standards of intellectual and moral excellence. Intellectual excellence means we submit to the discipline of deliberative clinical judgment. Not the bombastic anecdotes of old. Moral excellence, protection and promotion of the patient's health related interest is the primary concern and self-interest systematically secondary. We are going to come back to this when we talk to John Gregory later.
Responsible management of conflicts of interest - every one of us has conflicts of interest in the practice of medicine. Conflict is between the professional responsibility to provide medically reasonable diagnosis and management and self-interest on the other hand. What are these: Economic conflicts of interest, please we all have a legitimate interest to do financially well and non-economic conflicts of interest, convenience, avoiding aggravation, something I watch in obstetrics with unnecessary caesarians.
Professionally responsible management of conflict of interest requires adherence to professional integrity. Again, the overriding consideration - the patient's interest comes first over our interests. We have legitimate interests but the patient's interest comes first.
Okay, with this very quick background how is this relevant to endometriosis? Let us first talk about diagnosis. The risk of incomplete workup it is sometimes more convenient for the physician to treat symptoms rather than work up their causes and design the appropriate treatment plan. Of course not for any one of us in this room but we all know doctors that sometimes do this. On the other hand there is risk of excessive work up. Biopsies are not optimally performed resulting in preventable repeated biopsies. This can sometimes be financially beneficial to the doctor.
When a highly reliable histological diagnosis can be safely made all the principles I just put forward beneficence, autonomy, integrity recommend should coalesce. And it should be done.
Negative results rule out endometriosis. Again, that is an important issue. It should be ruled out when it is not there and then you work up other issues, including psychiatric work up if it is indicated. Adhering to this approach will responsibly manage economic and non-economic conflicts of interest. Focus will be on the patient and not secondary gain.
Let us go to management very succinctly. Management based on symptoms puts the patient at risk of psychosocial harm. The iatrogenic risks of mistreatment: under treatment or over treatment. Management based on symptoms puts the patient at risk of preventable stress and anxiety of the prolonged "diagnostic hunt". Some of you have patients referred to you as a result of this. There is a risk of loss of trust in physicians and medical care because of this diagnostic hunt that has gone on too long. Management based solely on symptoms, without establishing a diagnosis when it is obtainable violates professional integrity.
Beware of responding to vulnerable patients with false promises of success, especially patients with concurrent mental disorders such as anxiety or depression. And some of the patients with endometriosis have this. To use a word that is rarely spoken in these circles, humility, and it needs to be remembered. We need to remember our limitations, whether it is obstetrics or gynecology. Professional integrity requires educating patients about our limits, especially in complex conditions such as endometriosis.
Let us touch upon pain issues. Pain is a report in the central nervous system accompanied by awareness. There is a professional responsibility to prevent and effectively manage unnecessary pain. Pain is unnecessary when it is not required as an effective treatment for part of the patient's condition. Again, beware of poorly managed conflicts of interest. Treating pain to keep the patient happy and coming back for the physician's financial self-interest, some of you may have seen physicians who do this. Treating pain to shorten the patient visits and minimizing other contacts for convenience is again clearly a violation. The beneficence and integrity based responsibility to prevent iatrogenic risks of inappropriate pain management. Again, there is the issue of abuse in addiction from analgesia. Supporting patients who need to live with chronic pain that cannot be safely eliminated assures that the needs of the patients are met often with a multi-disciplinary approach. And again, be aware of one's limits and make the appropriate referral when necessary.
I want to close, and I think it is especially appropriate at this time in 2014 where we are situated with medicine today and I will close with history and I will stay on time Victor!
I want to go back to who we consider the father of professional medicine, Dr. John Gregory. I want to go back to 18th century Great Britain. John Gregory lived in a time when medicine was a mess in Great Britain. It was a fierce competition among a wide variety of physicians, surgeons, midwives, quacks and the doctor at the time he, almost always he then, cared about making money. Gregory and Percival had revolutionary concepts. The physician should remain scientifically, ethically and clinically competent. They should protect and promote the health-related and other interests of the patient as the primary interest - a revolutionary concept. I want to emphasize that this did not come from Hippocrates, this was 18th century Great Britain, Gregory and Percival. And preserve and strengthen medicine as a public trust.
This is what professionalism emanated with. These concepts of professionalism, the good news is, rapidly spread throughout the world. They were translated into many languages and indeed fortunately influenced America greatly. Indeed, they influenced us here with our first AMA code of ethics.
As I promised, I am going to stay on time. I want to close with a picture. I dedicate this to you Victor. This is from the time of John Gregory and this embodies our specialty, obstetrics and gynecology and indeed embodies, and I look to you Victor, you embody what John Gregory would call for is what we should strive for in our field. Here we see the ideal ¬¬¬¬anlage of modern obstetrics and gynecology. You see on one side the man with the technologic advance of the time, the forceps, there was no caesarian section. Forgive me Harry, laparoscopy was not even thought about at that time forgive me, not even on the horizon. But forceps was the technological advance for obstetrics and gynecology but that was not enough. It was melded with the virtues of the midwife. The compassion, the integrity, the self-sacrifice, the self-effacement, the virtues Gregory annunciated.
I want to close with this image. And again Victor, I come to you as a model, I know you are the best and I know that most people in this room know you, that you embody this concept and this is what we should strive for - the technologic excellence to push the science forward more and more but not to forget the ethical and human virtues that are so essential to our profession.
I say thank you Victor and Tamer for the opportunity to present to this wonderful group. Thank you so much.