Ethics of fees and medical service contracts
Gonzalo Herranz, department Bioethics, University of Navarra
Session at the School Medicine, University of the Andes
Santiago, Chile, March 24, 1993, 11:30 a.m.
Conflicts of interest and commercial conduct
In search of a solution: informed consent for fees
2. The ethics of medical service contracts and wages
Ethical standards regarding the contract
The ethics of work and hierarchical function
Salaried physicians and financial incentives
Professor Juan Cox has made a special effort to discuss a topic with you this morning topic , at first glance, may not seem particularly appealing, but which, upon closer inspection, is extremely revealing and even stimulating. Medical fees certainly have important ethical implications.
The history of doctors' relationships with their patients' money or with the public treasury contains, alongside brilliant examples of individual self-sacrifice and collective altruism, scandalous cases of greed and meanness. A fairly popular stereotype is that of the three-faced Aesculapius, who appears as an angel when he comes to heal the patient, as a god when he cures him, but who is transformed into a demon when he demands payment of his fees.
As testimony to the irremediable humanity of doctors, rich in virtues and not immune to vice, we find in both the minor history of medicine and in general literature portraits of generous doctors alongside others who are mean and miserly; moving examples of selflessness alongside repulsive anecdotes of greed. Here are a couple of examples among the many that literature offers us. In The Brothers Karamazov, Dostoevsky presents us with two portraits: that of Dr. Herzenstube, a selfless, humble, and original village doctor, and that of a doctor from the capital, satisfied with his science, arrogant in his haughtiness, and greedy for profit. One is "a man with a compassionate, humanitarian heart, who treats his poor patients... without asking them for anything, who visits their miserable huts... and discreetly leaves them money so they can buy the medicines he prescribes." The other, the famous specialist called from Moscow, not only dressed with solemn affectation and spoke in a loud, hollow voice, but also, when speaking, emphasized the syllables of abstruse scientific words; he felt out of place, and did not hide it, in the poor house of the Snegurovs, whom, as humble people, he openly despised. His visit those around him with the impression that he had come "only in search of a hefty fee." In his In Search of Lost Time (1913–1922), Marcel Proust masterfully sketches Dr. Dieulafoy, the prototype of the elegant distinction with which those eminent doctors of yesteryear, whose reputation was based almost exclusively on enquiry homes enquiry the rich enquiry dying, covered their sacra auri fames, and there perform the ritual of assuring the grief-stricken relatives that, unfortunately, death was now inevitable. "With majesty, wrapped in his tailcoat, the Professor entered the room, his countenance sad but free of affectation, without uttering a word of condolence that might seem insincere... After examining my grandmother... he whispered a few words in my father's ear... he bowed respectfully to my mother, and made a perfect exit, accepting with infinite naturalness the Closed envelope Closed was slipped into his hand. He gave the impression that he had not even seen it, so great was the skill the conjurer with which he made it disappear."
The two cartoons undoubtedly have an air of antiquity about them, and fortunately, they are outdated. The socialization of medicine has brought, along with many great benefits and some inevitable drawbacks, the blessing of removing from the lives of many doctors the temptation to enrich themselves through their profession. Today, the majority of doctors, whether out of necessity or virtue, put their economic interests second to their more or less dedicated service to their patients.
And yet, within the National Health Services and in private internship , there is still a risk of inappropriate behavior in subject fees, contracts, and salaries. It is therefore not surprising that the topic to concern those of us who are dedicated to professional ethics in medicine and that the Codes of Medical Ethics and Deontology continue to include a chapter or, at least, a few articles dedicated to the subject. And, curiously, relatively little is said about this deontology.
To give some structure to my presentation this morning, I will divide the subject two parts. First, I will give a general analysis of the deontological doctrine on fees as an element of the doctor-patient relationship in internship medical internship . I will then offer some reflections on the ethics of the contracted doctor and the financial compensation for which he or she leases their services to a public or private healthcare institution. Let us begin, then, by talking about the
All modern codes of professional conduct include ethical guidelines on doctors' fees. This is test everywhere the issue needs to be illuminated by ethics, even if it is considered a subject . The Code of Medical Ethics and Deontology in force in Spain devotes an entire chapter to it, although, symbolically, it is the last of those that comprise it. And the same is true of the Principles of Medical Ethics for Europe: the rules on fees are relegated to the article .
In the 1986 edition of the Code of Ethics of high school Chilean high school , articles 40 to 43 and 49 deal with fees and, despite some differences in nuance, are consistent with European ethical tradition. I will use them as a guide to comment on the ethics of fees.
To begin with, article of the Code of Ethics strongly imposes the obligation of professional courtesy: It states that physicians are prohibited from charging fees for the care of their colleagues, parents, spouses, and children when such care is paid for out of the physician's own pocket, and they are obliged to provide timely and careful care.
In turn, the physician receiving care, either personally or from one of the family members mentioned above, must pay for the corresponding supplies for the services that require them.
My first reaction to this article one of envy: the ethical institution of professional courtesy no longer appears in the Code currently in force in Spain. The article described and recommended it—it did not impose it—was unfortunately removed, perhaps as a result of recent criticism of this tradition, specifically criticism that professional courtesy is often linked to lower quality medical care.
It is therefore advisable to have a clear understanding of the nature and extent of this fraternal custom, so that it does not paradoxically become an opportunity to practice class medicine class a threat to professional friendship.
The custom has become established as sample collegial friendship and in response to the distinction that it means for a physician when another colleague entrusts him with the care of his own health and that of his closest relatives. This obliges both parties to act with extreme delicacy, but also with complete naturalness.
Naturalness consists of accepting that the sick doctor or his sick relatives have the right to receive normal and ordinary attendance in all respects—timely and careful, according to the Chilean Code—that is, of the same quality and skill that provided to other patients. The fact of not paying fees cannot delay the call to the colleague or the response to the call. Patients therefore have every right to skill time and skill . It is unreasonable, for fear of causing inconvenience, to postpone calling a colleague, as this could dangerously delay a necessary intervention.
The doctor who is called will always feel fully gratified by the privilege of serving his colleague. However, he must claim full responsibility for the case and will not allow a vague and diffuse distribution of responsibility to be established between himself, the doctor who called him, or other colleagues who, out of friendship, spontaneously offer their opinion. As in any other status , a single physician must assume full responsibility for the case, and under no circumstances should chaos in care or patient disobedience be allowed.
The article that only fees are exemption. The attending physician must claim payment for the materials used in examinations and treatments, as it would be unfair, rather than discourteous, to force the colleague, who has devoted time and effort, to pay for them out of his own pocket. Similarly, the same courtesy requires that the necessary steps be taken to ensure that both fees and expenses are covered by the relevant insurance company, in the event that the physician or those dependent on him or her are entitled to compensation.
article is very dense. In addition to reaffirming two fundamental ideas, namely that fees must be fair in amount and that medicine is a service activity and not a business guarantees results, it deals with the unethical nature of the dichotomy and the payment of commissions for referring patients to specialists. It states: The physician's right to fair remuneration or compensation for services rendered to the patient is independent of the results of the treatment. It is strictly prohibited to charge and/or pay another physician for referring or submission , even when the latter is necessary and beneficial to the patient's health. Similarly, any member or group of members who pay or charge commissions—dichotomy—for receiving or referring patients and complementary tests will be guilty of serious misconduct. For its part, article establishes that in the absence of a contractual agreement between the parties, the value of the fee shall be determined by the physician, in agreement various factors related to the medical act in question, the patient's partner status, and the prestige and experience of the professional.
Professional fees are part of the medical act. In the grade invoice are not issued invoice technical procedures, but rather for work and, above all, for the moral responsibility of the physician. In theory, the medical act is not subject to economic valuation: it is priceless. Physicians are symbolically compensated with fees, which must therefore be dignified and fair.
Dignity in fees does not refer only to the quantitative aspect, as I will discuss below. It refers above all to the circumstances of moderation and tact that should surround them. Although they occupy a secondary place in the doctor-patient relationship, they cannot be considered something annoying and of inferior status. When asked by the patient, the physician should state the amount of his or her fees. The budget the requested care should specify which part corresponds to the fees for the physician's services and which part corresponds to the estimated expenses (hospital stay, medications, materials, services). The physician should also inform the patient of the social organizations that can help with the payment of medical expenses. There is nothing wrong with the internship of delegating the setting and collection of fees to secretaries or nurses. However, the physician should not refuse to deal with this issue personally with patients who so desire.
Within ethical limits, physicians must take certain circumstances into account when setting their fees: the services they have provided, their skill prestige, the patient's financial situation, and the circumstances of the case. The importance of their services depends on their technical complexity and the skill , the risk of the procedure, and the time employee it.
Some important social and cultural factors also influence fees: higher fees are charged in certain regions, social classes, or medical specialties.
The amount of fees that a particular doctor usually charges serves, to a certain extent, to spontaneously select, from above and below, the social strata to which the patients who come to him belong. However, although this practice is socially accepted, it cannot become a rule , as it would give rise to unethical behavior: a doctor who systematically refuses enquiry poor or insolvent enquiry in his enquiry would demonstrate that he is dominated by class prejudice in his internship . In his internship , the doctor has a general moral obligation, out of human solidarity and his commitment not to discriminate between his patients, to admit some indigent patients to his office. And if, once the doctor-patient relationship has begun, due to the unforeseen evolution of the illness, the fees initially calculated fall far short of those actually accrued, it is the doctor's duty to continue providing their services, even if the patient cannot pay for them immediately.
There are behaviors that are considered normal in other professions but would be considered inappropriate or unworthy in medicine. It is unethical to charge fees in advance, even when performing a high-cost procedure. This rule has been confirmed by court rulings in some European courts, including the French committee State and the Spanish Supreme Court. In the United States, it has even been said that certain surgeons subject patients who are about to undergo surgery to preoperative bloodletting.
Nor is it compatible with the dignity of the profession for a doctor to extort money from a patient in financial difficulty, demanding immediate payment of debts or payments in kind, or proceeding to seize their assets by court order, or hiring the services of debt collectors or agencies specializing in collecting from defaulting debtors. Furthermore, they must be tolerant of patients who forget to pay them and must not refuse to treat them again because of this. In rural areas, in agreement local traditions and economic cycles of abundance and scarcity, doctors will accept gifts in kind as compensation for their professional services, sometimes of more symbolic than monetary value.
There are ethical limits on the amount of fees. Moderation in fees is, at least in Spain, a statutory obligation, as manifest abuse of the grade constitutes a minor offense. Any physician who, through negligence or intentionally, exceeds the grade must, upon complaint by the patient, agree to reduce it to a reasonable level.
On the other hand, doctors are required to accept the minimum fees established by the competent bodies. Violating this rule also rule a minor offense. The setting of minimum fees is based on the need to protect professional decorum and maintain a certain social appreciation for the work of doctors. Doctors are prohibited from reducing their fees below a critical minimum level, as fees are a symbol of the human and technical quality of the individual doctor and of the entire profession. The respect that doctors owe themselves prevents them from asking work derisory work for their work The respect they owe their colleagues prohibits them from engaging in skill with them and, so to speak, declaring a price war on them.
On some occasions, fees must be regulated by an all-or-nothing law: it is incomparably more dignified to offer one's services free of charge to those who cannot afford them than to demand an undignified and paltry stipend. The doctor is free to demand payment of his fees or not. He can even demand them and then return them. For reasons of kinship, friendship, charity, or collegial solidarity, the doctor should provide his services free of charge. But when he does so, he must fulfill one essential condition: that between the internship and paid internship , there should be no difference in the quality of care or in the respect he owes the patient.
There is an intraprofessional problem of distributive justice, which is the asymmetry of fees: a chronic and irritating problem. It is traditional for doctors in different specialties to charge very different fees. For a work less than an hour, such as fitting a pacemaker or performing arthroscopy, a doctor may charge fees that far exceed those earned by another doctor, such as an internist, for a long and demanding work workshop To put it bluntly, there is too much difference between doctors who do things and think little (those who in the United States are called proceduralists, who, for example, work in surgical specialties or diagnostic imaging technologies) and doctors who listen, think, and advise (the contemplatives: family doctors, internists, pediatricians, psychiatrists).
This unfair status should be resolved through ethical progress within the profession, which, judging by the evidence available to us, does not seem easy. This is attested to by the reception of work by William C. Hsiao, of the Harvard School of Public Health, on the relative value scale of work the resources that physicians of different specialties invest in each medical act. After several years work to design a scale that took into account the human cost of interventions (time, mental effort, skill , physical effort, and psychological stress), overhead costs (materials and resources consumed, including professional insurance policy ), and the costs required for the physician's Education and training , Hsiao and his collaborators reached conclusions that caused an enormous outcry. Their relative value scales, which were reproducible, consistent, and applicable for determining the relative amount of work different specialists, revealed that some physicians (surgeons and pathologists, for example) would have to drastically reduce their fees, while others (primary care physicians, internists) would have to increase them. It is easy to imagine where the detractors and enthusiasts of Hsiao's proposed system stood. It was assumed that, if the scales were applied, beneficial effects for patients (and, one suspects, for the doctors themselves) would soon become apparent: fewer surgical interventions as surgeons would be less incentivized, and less rush in consultations with internists and general practitioners.
Another issue related to the fairness of fees is the dichotomy. The ethical prohibition on paying commissions and secretly dividing fees is intended to ensure that, in the practice of their profession, doctors will never abuse their position of power to exploit patients. As article succinctly states, only the distribution of fees based on partnership the provision of services and corresponding responsibility is permitted. When a patient is treated by several physicians, each of them, in the exercise of their freedom and independence, must indicate the amount of their emoluments and issue the corresponding grade . This approach has obvious advantages: it eliminates the danger of anonymity that always threatens team medicine, promotes individual responsibility towards the patient, makes the management and tax obligations of each physician more transparent, and avoids conflicts between colleagues when distributing fees.
In its ethical structure, the hidden fee splitting is almost always an injustice. First of all, it is an injustice if it leads to an increase in the regular fees by an additional amount: the amount which is submission precisely as a commission to the colleague. The injustice is even greater if it leads to over-prescription or to superfluous indications for diagnostic ( laboratory, radiological, various specialities) or therapeutic (surgical, rehabilitative, psychotherapeutic) procedures.
We cannot forget that the dichotomy is much more than a minor mischief whereby some doctors agreement others to attack the patient's wallet. The very existence of dichotomy is a serious assault on medical ethics, as the doctors who practice it no longer put the patient's interests first, but rather their own financial gain: patients are sent not to the most competent colleague, but to the one who provides the most generous commissions. The patient then often pays more money for a lower quality service. This may go unnoticed for some time, but it eventually comes to light, with the consequent discredit for the doctors involved and for the entire profession. Giving and receiving commissions are equally unfair actions, which tend, by their very nature, to become a stable element in the relationship between colleagues. The dichotomy establishes a state of injustice. Upright doctors who reject the dichotomy are left in a status economic inferiority compared to others who are less qualified. The latter, who are more venal, get more work participating in the dirty game of kickbacks.
Some doctors believe that this dichotomy is justified and even serves as a remedy for certain irregularities. They say, for example, that the submission a commission by the surgeon to the primary care physician who referred the patient for surgery is fair compensation for the aforementioned asymmetry in fees. But it is morally unacceptable to claim that one injustice can be remedied by another injustice.
Conflicts of interest and commercial conduct
The first paragraph of article of the Chilean Code states that physicians are prohibited from accepting and receiving any kind of payment that could constitute commercial collusion in professional care, such as from pharmacies, opticians, laboratories, or manufacturers of orthopedic devices. They are also prohibited from selling medicines, prostheses, or similar items.
This is a rule : medicine is not a business. Codes and statutes prohibit all types of commercial behavior that seek to provide physicians with certain unfair or improper advantages, whether in cash or in kind. Except in exceptional circumstances due to the physical inability of patients to access a pharmacy, doctors may never sell medicines directly to their patients. And, even then, they must take legal or administrative precautions to ensure and make it clear that the doctor does not obtain any financial advantage from providing these drugs.
The forms that marginal corruption, collusion, and cronyism can take are extremely varied: gifts of objects of varying value; invitations to meetings aimed at promoting new products, which include meals and a symbolic fee, but which are sometimes extended to include trips to exotic locations and stays in luxury hotels paid for by pharmaceutical or medical equipment companies; commissions on the prescription of certain drugs or prostheses, etc. All of this tends to weaken the critical judgment of some doctors who are susceptible to the temptation of money, who end up prescribing not exclusively for the good and interest of their patients, but for their own.
This selfish impurity is evident in modern forms of commercialism: in some countries in Europe—and I suppose also in Latin America—there are many well-equipped centers for diagnostic imaging, special therapies, or advanced clinical biology laboratories, in whose creation and operation several doctors participate. It is understandable that these doctors have a positive interest in having these techniques available to better diagnose and treat their patients, but it is equally easy to understand that their decisions to perform costly diagnostic tests or to institute highly sophisticated treatments may be influenced by their interest in obtaining a financial benefit commensurate with the economic cost of the venture. Studies have been published showing that physicians who are co-owners of these centers generate significantly higher expense tests and treatments than their colleagues who are free of this conflict of interest.
It is a shame that such things happen and that they are staunchly defended by quite a few of our colleagues. They destroy the prestige of the profession for their own gain. Because, at the end of the day, what they are doing is not simply offering their patients their professional opinion on the best way to diagnose and treat the disease. What they do is cloud their professional judgment with considerations of profit: in cases of real doubt, or self-induced doubt, they systematically lean toward what benefits them financially. They take advantage of the fact that, in internship , although many decisions must be made in uncertainty, it is necessary to try to overcome this uncertainty in order to practice a kind of mitigated diagnostic persistence that lines their pockets.
In search of a solution: informed consent for fees
Naturally, the climate of affirming patient autonomy has reached the field of fees. Haavi Morreim has proposed that doctors and patients should be more explicit when discussing the Economics medical care. The physician should be completely frank and disclose the price of each service, any conflicts of interest that may limit his or her loyalty to the patient, any financial assistance that the patient can obtain through his or her mediation, and the methods and terms that the patient can use to make the payment for medical services more bearable. Only when the patient is fully informed can he or she give consent. Thanks to these transactions, Morreim hopes that the doctor-patient relationship will become more transparent and immune to insincerity and manipulation.
This is clearly a very lofty ideal. There are a thousand ways in which doctors can "woo" paying patients, thereby creating an artificial medical need, a consumerism of luxury medicine. And there are deterrents that doctors can use to keep less affluent or unwanted patients away from their offices. In pursuit of profit, doctors can offer services to privileged segments of society, prominent professional groups, and residents of high-end residential areas. They can promise them attention , indulge their dietary whims, gratify their desires for psychopharmacological hedonism, and legitimize the aberrant ideas about the cause and mechanisms of their health held by the well-to-do hypochondriac. All of these things are done for economic reasons, as they would not grant attention to patients with limited resources.
2. The ethics of medical service contracts and wages
In contrast to the theory and internship medical fees and their abundant moral pathology, the specific ethics of medical service contracts, like those of medical salaries, are still largely to be developed. This is logical, since medical contracts and salaries have gravitated much more toward the field of law (labor, union, and civil) than toward medical ethics; more toward the realm of protest actions than toward ethical reflection.
The power wielded by the employers of salaried physicians is considerable, whether it be the omnipotent modern state and its ministries of health and social security; large, sprawling companies, some of them multinationals, providing attendance or health insurance; or, finally, colleagues who largely control the civil associations created to practice medicine in group. This power becomes particularly formidable in certain circumstances: when the state, by creating and administering a national health system that covers practically 100% of the population, becomes the sole employer, a monopolist, of the medical workforce. Or when medical unemployment is very high and an almost proletarianized work market is created, with abundant cheap labor and very modest demands. Many doctors then have no choice but to submit to medical service entities that easily exploit them. I am aware of temporary contracts signed by young doctors in Spain which, based on government regulations to combine employment training for unemployed young people, subject doctors to abusive rules regarding working hours, salaries, mobility, stability, incentives, and conditions for contract renewal, contracts that mortgage the professional future of those who sign them. These contracts contain clauses that prohibit, for a period of several years, any professional practice that could compete with the business activity, and they enforce this through economic reprisals that the candidate accept. It is very difficult for salaried doctors to negotiate on their own for better moral, technical, and salary conditions in these work contracts, as discontent is seen as disruptive and they can be replaced very easily.
The demands of justice and the ethical notion of respect for doctors and their dignity must inform negotiations to set salaries and financial compensation scales for the various medical procedures established by private insurance companies or agreed upon in agreements with national health services. There is always the possibility, often immediate, that employers or health authorities will demand selfless and heroic conduct from doctors, in the certainty that they will always put the interests of the patient before their own. On occasion, situations may arise that are unacceptable or incompatible with professional dignity, in which a doctors' strike is necessary to remedy the poor state of facilities, equipment, and services, or to demand an increase in doctors' salaries to the minimum amount compatible with the human and social dignity of salaried doctors. However, the doctor's strike is a topic incredibly rich in ethical nuances, which I prefer not to go into.
Ethical standards regarding the contract
Much of the ethical regulation of salaried medicine seeks to prevent situations, whether permanent or temporary, in which doctors who hire out their services are placed in a position of inferiority. Thus, the committee of European Community Doctors has promulgated ethical texts that aim to guarantee the ethical independence and job security of salaried doctors. The 1970 Luxembourg Declaration, which expands on the 1967 Nuremberg Declaration, in which the committee develops article . article of the Treaty of Rome from a medical-professional point of view, on the conditions for practicing medicine in European Community countries, states that physicians must have, guaranteed by law, by contract or by agreement from agreements between the profession and representatives of the institutions, the conditions of incorporation and dismissal that guarantee their professional independence; that such independence would not be possible if salaried physicians began their degree program inadequate or questionable conditions of appointment, or saw the stability of their employment weakened, so that they could be dismissed by unilateral decision, without the mediation of an advisor body advisor of delegates of the physicians involved and representatives of the public or private entity in which they work.
Subsequently, the same committee of EC Doctors, together with the association of Hospital Doctors, approved the Charter of Hospital Doctors in 1985, which, in addition to emphasizing the above concepts, states that the selection of candidates must be based on employment conditions employment guarantee the stability of doctors in their position, as well as their financial independence and social protection. Hospital doctors are entitled to remuneration or fees commensurate with work and the importance and social dignity of the doctor, which ensure their financial independence [...] The basic salary must be accompanied by supplements that include essential social benefits and, in particular, paid vacations, sick leave and convalescence leave, disability compensation, pensions, and periodic adjustments to the cost of living.
In view of these guidelines, it is understandable that it is rule or ethical rule in most EU countries that work contracts work to doctors must be submitted to high school for approval. The French Medical Association provides its members with model contracts that they must adhere to when signing contracts. The General Statutes of the Spanish Medical Association, for their part, establish that work contracts work be submitted for approval by high school . This is the best way to ensure, among other things, compliance with article .4 of the Code of Ethics and Professional Conduct, which states that the Associations shall not authorize the formation of groups in which any of their members could be exploited by others.
There is a B between these requirements demanded in Europe and those established by rule Chilean rule Ethics (1986), which states in article that professional agreements between colleagues must be strictly complied with, even if they do not comply with legal and customary formalities. Those that are important must be in writing; but professional ethics require that, even if they have not been, they must be complied with as if they were contained in a public document. It is wonderful to see how the verbal contract retains all its binding force here, which presupposes unlimited credit trust credit the goodness of professional relationships. But I think it would be desirable to add a minimum of ethical security to that trust.
The problem is not solely or fundamentally one of ensuring financial remuneration that allows doctors to lead a dignified life free from stress: it is necessary to create work conditions work guarantee salaried doctors a fully ethical existence, with the necessary autonomy, freedom, and responsibility; that respect the professional aspirations and human and labor rights of each individual; and that, ultimately, make work Degree compatible Degree with their extra-professional obligations and duties. There are contracts that, in themselves, are capable of destroying the family life and legitimate extra-professional aspirations of physicians.
This is a problem of vast proportions. For example, the growing feminization of the medical profession is a well-known fact. With the exception of the United Kingdom, very few countries have taken seriously the creation of specific work conditions work female doctors that are compatible with their aspirations to marry, start a family, have children, and play their irreplaceable role in family life. Organizers of services continue to hold overly simplistic ideas about the inferiority ofpart-time schedule part-time to full-time work. The forced imposition of employment disproportionately harms women, creates sexist discrimination that is inappropriate in our time, and impoverishes the profession, which loses many high-quality vocations. By violently imposing harsh labor standards on female doctors who are mothers, we also end up "enslaving" other members of the profession.
The ethics of work and hierarchical function
The correct ethics of work seek to preserve the independence, and consequent responsibility, of each member of the group intact, and to create hierarchical relationships that are compatible with and protective of the professional and human dignity of all of them.
work must be based on individual responsibility. The Spanish Code states that the moral independence of the physician does not disappear or diminish simply because they work in group. Institutional ethics are universal and apply to all forms of professional practice. In all circumstances, physicians retain their independence and freedom to prescribe. They can never act anonymously in front of their patients. To symbolize their staff responsibility, they shall sign their name on the notes they make in their patients' medical records and on the orders they prescribe for them.
The main purpose of the aforementioned contract approval is to ensure that, in work teams, there are no owners and servants, employers and mercenaries. group founding document group specify in sufficient detail the rights and obligations of each of its members: participation in overhead costs, authority over staff , conditions for use of facilities, work schedules, areas of specific responsibility, file systems, on-call schedules, substitutions, and vacations, etc.
Hierarchical organization is a functional necessity, but its substance is ethical, as it is the legitimate way to create order and efficiency in a group people who have to work together. Today, fortunately, much is demanded of those who govern, who must earn the support of the governed on a daily basis. management must be based on moral and scientific authority, on the ability to work, on the rationality of orders, and on respect for subordinates. Authority must be conceived as a service to others, not as an opportunity to rule despotically. Respect for ideological diversity is an essential element of good management .
Salaried physicians and financial incentives
In the work salaried physicians, there are plenty of opportunities to obtain some unfair marginal benefits. When salaries barely cover financial needs, the temptation to give in to certain financial incentives can be very strong.
Referring patients from public healthcare to private practices or defrauding the government or insurance companies in collusion with patients are typically criminal acts. If salaried physicians work in an organization that invoice medical procedure, they may be under considerable pressure from management to invoice . If they work in an entity that is paid by a capitation system, they are encouraged to act as gatekeepers and unfairly ration medical services. In either case, giving in to management's invitations usually provides, along with the sympathy of the system's economic managers, a award . But in either case, the patient is the loser. Salaried physicians in an institution are obliged to reject, through their upright conduct, all such perverse financial incentives and to favor ethical incentives.
Finally, it is worth asking whether it is possible to work in salaried medicine without falling into mediocrity or indifference. It is sometimes very difficult not to give in to the temptation to take the path of least resistance and settle for a mercenary mentality.