I had an interesting telephone conversation with a physician who was doing a locum for a specialist colleague. The specialist had chosen to limit a practice to a subset of the entire population – those with suspected malignancies. The physician who called me was questioning if this was ethical. He was concerned that the patients not seen could in fact have something which would go undetected.
Similarly, when reviewing feedback from our recent standards consultation, a couple of comments pertaining to the After-Hours Access to Care standard, suggested that being available to current patients beyond a certain point would limit a physician’s ability to see other patients – patients who are already waiting on long wait lists.
These two events brought to mind the balance between individual and group responsibilities. The College and the courts concentrate on individual responsibilities. Physicians have a fiduciary responsibility to each patient and we expect physicians to act in the best interest of individual patients. The argument that it might be acceptable to provide sub-standard care to one patient in order to provide care to others does not fly. As physicians, we must all look after one patient at a time; all for one.
Such a fiduciary focus sometimes poses a challenge for physicians when there are not enough resources to do everything one wants to do. This would be a challenge for all resource allocation decisions. For example, on the macro-level, governments need to decide how much to allocate to health care versus road construction. One step deeper, they need to allocate health care resources between social housing and transplant availability. These are the meso-allocation decisions. Physicians get involved at the micro-level. They make micro-allocation decisions such as deciding which patient gets the next transplant or whether or not to reorder a CT scan for a patient. Are there unlimited resources to back up these decisions? No. Thus, physicians do have a responsibility to triage.
When faced with waiting lists, it is acceptable to limit practices in a global sense. Although you cannot limit your practice on the basis of ‘prohibited grounds’ such as sex, ethnicity and so forth, you can limit your practice based on your expertise and the needs of the population. What is most important is to be fully transparent to everyone about your limitations. Thus, back to the example above, it is acceptable to limit a practice to patients with a higher pre-test probability of benefiting from care, i.e., those with a higher likelihood of having a malignancy. This is triaging. Yes, there will be times when patients not seen would have benefited from care. This however does not imply blame back to the physician but rather a responsibility to look at the algorithms he or she used to triage to ensure the process is as robust as possible.
Transparently triaging allows other members of the profession and the wider healthcare team to better allocate their resources. We all have a responsibility to allocate resources based on best evidence. The Alberta Medical Association’s Choosing Wisely initiative and Toward Optimized Practice (TOP) program are both excellent examples of what we as physicians collectively must do to provide excellent care to the population. We must use our resources wisely and thoughtfully. Ordering tests ‘just in case’ will sometimes cause more harm than good, especially with low incidence diseases. In these cases, the high number of false positives in pursuing such investigations can cause unnecessary costs and more worrisome, harm to patients. By thoughtful, evidence-informed management of our patients, we can all better allocate resources broadly and reasonably; this is how we can be one for all.
Whether we are the physicians or the population in need of care, we all have a responsibility to wisely use our resources. This reflects the reality of everyone working together as a stable society where though we all have rights, we equally all have responsibilities.
All for one and one for all, united we stand divided we fall