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The Ethical Dilemma of Following Your Instincts

During the last week of my clinical rotation in family medicine, my attending advised me and the accompanying medical student that going forward, the health providers of the clinic must limit their scope of care for patients who present for annual examinations. This decision, made the previous day in a board meeting with the clinic’s administration, meant that under no circumstances could we deviate from the “Annual Exam” template curated for the practice that revolves around medication reconciliation and routine health maintenance items such as United States Preventive Services Taskforce (USPSTF) screenings and Centers for Disease Control and Prevention (CDC) immunizations. We were to steer clear of “new onset” concerns. As we absorbed the policy’s implications, tension pervaded the room as we concluded our pre-huddle and began the day.

Our first patient, a middle-aged female, presented for her annual examination. For this patient, I initiated the visit alone. During the collection of an otherwise routine history, the patient reported that lately, she had been undergoing increased stress attributed to the COVID-19 pandemic, working at home and serving as primary caregiver for her husband, who was recovering from a stroke. In light of our earlier directive and uncertain of how deeply I should pursue these concerns, I noted this finding to the attending, and we saw the patient as a team.

As the visit was wrapping up, the patient complained of chest discomfort she had been experiencing lately, and I looked to my attending for guidance. At first, explaining the institution’s new policy changes limiting the scope of care, my attending strongly advised the patient to schedule another visit to address these symptoms because they deserved more time. But as the patient further described a chest tightening she experienced during a recent “panic attack,” my attending, following her instincts and disregarding the mandates she had just that day been given, probed into the patient’s complaint. She ordered an electrocardiogram, the results of which confirmed her suspicion: The patient had suffered a myocardial infarction and was advised to obtain further evaluation in the Emergency Department. 

In medical school didactic courses, we are repeatedly instructed to carefully listen to the patient as this will lead to the diagnosis. My attending did just that while also drawing on her training and experience to promptly and accurately diagnose our patient’s condition.  But, in medical school, we receive no instruction on how to confront the challenges of upholding the Hippocratic Oath when it conflicts with real world economic policies that negatively impact patient care. The case of this patient presenting in the setting of these new policies displayed such a dilemma.

My attending, however, tackled this head-on by placing her patient’s welfare ahead of costs and profit margins and scolding of the administration. Yet, how many patients will suffer poorer health care outcomes due to the strict enforcement of the recent policy change which, in this patient’s case, would have delayed treatment of her cardiovascular condition with potentially dire or fatal consequences? This issue is particularly critical for female patients and even recognized by the American Heart Association because their clinical presentation and pathophysiological mechanism of disease deviates from the norm, leading to a higher rate of misdiagnosis, longer hospitalizations, higher in-patient mortality rates and a readmission rate of up to 30%. The implementation of economic policies which have turned the profession of medicine into a business enterprise further worsen health care for women because statistically, they are less likely than men to receive adequate medical care, especially regarding cardiovascular disease. Our patient clearly illustrated this.

How can we improve women’s health care outcomes? A near-term solution to this problem does not appear within reach. Nevertheless, after seeing my attending unflinchingly confront these challenges rather than yield to external pressures that conflict with her moral obligation, I believe that if we project humanity in our service and care, grounded by our oath, we can tackle these disparities one patient at a time. Possible efforts may include longer patient interactions that allow for physicians to listen with intention and optimize care or even applying a systematic quality improvement strategy such as the Plan-Do-Study-Act approach that optimizes processes by cyclic testing, assessing and refining a modification. I am ever grateful for the opportunity to have trained with this attending and will carry this lesson with me throughout my training and professional life. I vow to practice medicine with “patient-centered care” as my focus and to empower and be an advocate for my patients.

Image credit: Stethoscope and money on white (CC BY 2.0) by wuestenigel

Allison Chin Allison Chin (1 Posts)

Contributing Writer

Florida International University Herbert Wertheim College of Medicine

Allison Chin is a fourth-year medical student at Florida International University Herbert Wertheim College of Medicine in Miami, FL in the class of 2023. In 2017, she graduated from the University of Miami with a Bachelor of Science in biochemistry and nutrition, along with minors in chemistry, psychology and art. She was inducted in the Arnold P. Gold Humanism Society and awarded the President Volunteer Service Award and the Florida Board of Medicine Medical Student Recognition Award in 2022. She enjoys custom card making, yoga, painting, and discovering new red wines and dark chocolate in her free time. After graduating medical school, Allison would like to pursue a career in Internal Medicine.