Marianne L. Burda, M.D., Ph.D.
Wexford, Pa.
[email protected] 

Clinical ethics activities (education, consultations, policy development, and closing ethics quality gaps) traditionally occur in the hospital and inpatient settings where the sickest patients and the most ethically challenging issues and cases are usually located. But medicine is increasingly emphasizing shifting patient care to the outpatient setting and physician's office whenever possible. According to the Centers for Disease Control 2010 National Ambulatory Care Survey, one billion physician office visits occurred that year.¹ The advent of Accountable Care Organizations, patient centered medical homes, insurance reimbursement based on quality instead of quantity of care, telemedicine, and continued advancements in pharmaceuticals and technologies all contribute to this trend.² Even as clinical ethics programs struggle to gain an active and visible presence in some hospital and inpatient settings, they must keep up with the changes occurring in health care and expand to the next frontier — the physician's office. Crucial conversations and decisions about which potentially life-saving treatment and care patients pursue or decline frequently take place in the physician's office. Many day-to-day routine office activities include ethics issues physicians and office staffs may never think about, for example, conflicts of interest associated with the sale of medications and products to patients. Physician office staffs, especially if located off the main health system campus or employed by a private physician practice, can be somewhat isolated and unaware of where to turn when value conflicts arise. Educational opportunities may be few and far between. Office quality and safety initiatives may not include identifying and closing ethics quality gaps, resulting in missed opportunities to improve the overall quality of care for patients.

This paper outlines a clinical ethics program for the physician's office setting, drawing on office safety and quality initiatives as development sources. The physician's office clinical ethics program consists of three parts: education, implementation, and evaluation, each of which will be discussed in detail. Unique barriers and challenges to implementing physician's office clinical ethics programs include the number of offices, their varying locations and schedules, the diversity of staffs and specialties, and the ownership of physician practices. Utilization of technology, media, and other creative tools to help overcome these challenges and barriers, especially with providing ethics education, will be described. 

The concept of outpatient clinical ethics appeared in the literature in the 1980s, with the focus on ethical issues physicians encounter in the outpatient setting and their ability to recognize and evaluate them.³ One study found about one-third of internal medicine office patients had ethical problems that influenced their health care.⁴ The authors of the study concluded these findings established "a rational basis for the development of curricula and research agendas concerning ethical problems in primary care offices."⁵ In 1989, La Puma and Schiedermayer published "a taxonomy of outpatient clinical ethics problems" based on three categories – problems of dual loyalty, problems of communication, and problems of professional and social responsibility.⁶ Felder, almost doubling the size of the list, expanded the taxonomy in 2002. Examples of additional ethics issues on Felder's list include informed consent, confidentiality, justice considerations, and conflicts in values.⁷ The 1989 and 2002 taxonomies include ethics issues found in both the hospital and physician's office setting. 

Outside of an article calling for a code of ethics in the ambulatory care setting in 1995,⁸ outpatient ethics was not really addressed in the literature again until 2002 when The Journal of Clinical Ethics devoted an entire issue to the subject. In this issue, Potter and Kaiser stated: "Attending to outpatient ethics will clarify, redirect, and energize bioethics … Outpatient ethics is the next stage of evolution in bioethics, as it has grown from the clinical setting of the hospital, to the organizational level of corporate healthcare, and now out into the human community where everyday existence is lived."⁹ 

Quality and safety initiatives evolved from the clinical hospital setting, to healthcare organizational levels, and into the outpatient setting and physicians' offices, with the goals of improving patient care and processes. Payment from healthcare insurers, in some instances, is based on physician office practices meeting various qualities of care metrics. Safety initiatives, for example, include formal programs by national medical organizations, such as the American Congress of Obstetricians and Gynecologists (ACOG) and the Safety Certification in Outpatient Practice Excellence (SCOPE) program.¹⁰ These initiatives can also cover clinical ethics issues. For example, SCOPE includes informed consent processes, patient rights, and conflicts of interest as part of the physician's office safety evaluation.¹¹ But merely incorporating ethics into office quality and safety initiatives is not sufficient. Crucial ethics issues, such as conflicts of values, may be missed relying only on quality and safety programs for a physician's office's clinical ethics program. A separate, comprehensive physician's office clinical ethics program directed at all staff members is required. 

But barriers exist to the implementation of a physician's office clinical ethics program. While integrated health systems can require employee participation in clinical ethics office programs, no regulatory standard compels private physician practices to initiate this type of program. Unlike quality and safety, accreditation by professional organizations and financial incentives from insurance companies are not currently available to entice healthcare systems and private practice physicians to participate in a physician's office clinical ethics program. Time equals money in the office setting, as the primary source of revenue consists in patient encounters and procedures. Physician practices can have multiple locations, with some at a significant distance from the affiliated health system's main campus and each other. Office staffs have diverse duties, backgrounds, and education levels. Staff members may have limited knowledge of and contact with health system ethics programs, except for required compliance-based activities. 

A comprehensive physician's office clinical ethics program should begin with education, focusing on clinical ethics issues found in the office setting and ethics resources available to physicians' offices. Education for all types of physicians' offices can include healthcare ethics principles, theories, values, and issues applicable to all specialties. In addition, education about ethics committees and clinical ethics consultations, how to access the health system's ethics resources, and how to identify and close ethics quality gaps should be taught. Additional educational programs can focus on case-based topics or issues specific to each medical specialty (neurology, psychiatry, etc.) or a certain position in the office (nurse, billing, etc.). Physician's offices may combine educational activities with other parts of the health system, other offices of the same medical specialty, or in the same physical location. 

Creativity will be required in many cases to ease staff members' ability to participate, minimize time away from patient activities, and promote engagement for staff. One such solution is utilizing technology and communication tools. Teleconferencing, webinars, call-in lines, and online education programs can connect staff with clinical ethics experts and education programs in other locations without requiring travel. Simulation of cases and scenarios depicting specific ethics issues using mannequins, standardized patients, and web-based virtual patients can engage and assist staff in learning how to identify and resolve ethics issues. An example of this is a web-based virtual patient case that educates office staff on advance directives and end-of-life planning. Computer access is the only equipment required to participate in this form of education. Staff can do these cases on their own or with other staff members. Media, literature, and art can also be used to actively engage physician's office staff in clinical ethics education. An office or department book club exploring pertinent ethics issues illustrated in different books, for example, is well suited to teleconferencing or call-in formats. 

Implementing physician's office clinical ethics programs requires support from the physician's practice itself, the affiliated health system, and on a larger level, professional medical organizations and regulatory/accreditation agencies, especially to overcome the previously mentioned barriers. One possible implementation strategy involves health systems providing physicians' office clinical ethics programs to both affiliated private physician practices and integrated physician offices, as high quality ethics programs in the office setting will prevent many inpatient ethics issues in the future. Local efforts can include health system ethics personnel reaching out to the office staff, such as visiting office sites and assessing their needs, the ethics issues they encounter, and personally inviting them to participate in a physician's office clinical ethics program. Ethics personnel and office staff can partner with other departments in the health system, such as information technology and education, to link offices and ethicists. Offices can also reach out to local universities or health systems besides their own for access to ethicists and ethics resources, along with exploring the ethics resources provided by local medical societies and national medical organizations. For example, the American Medical Association's and Veterans Health Administration's ethics resources, programs, and publications are available online and at little or no cost.

Hospital ethics committees and consult services can include office staff personnel as members, ensuring ethics issues unique to the physician's office are addressed, along with creating a more inclusive atmosphere to encourage physicians' office staff to bring forth ethics concerns and request consults. Health system ethicists and ethics committees can also assist staff in the development of office ethics policies, such as informed consent, withholding and withdrawing of treatment, conflicts of interest, etc.

An ethics quality program to close gaps between best ethics practices and current ethics practices in the physician's office can be incorporated into the office's overall quality program. Problems in the health care setting typically have both quality and ethics components. The goal is for staff to recognize that ethics is as important as technical competence and customer service.¹² Office staff may already be improving ethical practices without realizing it or establishing it as the main goal. A large oncology practice in Kansas City, for example, discovered its quality improvement initiatives, such as prevention of errors, evaluation and improvement of pain management and end-of-life care, led to a commitment to ethical practice by the staff.¹³ 

The visible support of the leadership of each individual physician's office and its affiliated health system are key to the successful implementation of a physician's office clinical ethics program. Leadership should promote and champion the program. Leadership should provide appropriate personnel, finances, and other needed resources required to support and grow the program. The office and health system cultures are also crucial for the program's success, with leadership setting the tone. Leaders at the physician's office and health system levels should foster an organizational environment and culture that makes it easy for all staff to do the right thing.¹⁴ The physician's office culture should not be based on reward and punishment, but should be value-based, empowering employees to identify, discuss, and resolve ethical issues.¹⁵ 

Other methods for obtaining buy-in and participation from physicians and office staff include no charges or fees for the affiliated health system ethicists' time and expertise, educational programs, and technology used to access these programs. Clinical ethicists and ethics activities should accommodate physician's office staff schedules to minimize interference with patient care. Providing continuing educational credits for appropriate staff members also offers incentive for participation. Increasing patients' awareness of the importance of ethics to health care personnel's providing high quality, safe care can also promote physician office participation and propel ethics to the forefront of patient care. Many safety initiatives and programs were initiated by or partner with patients, such as the Josie King Foundation.¹⁶ 

Acknowledging participation by physician's offices in a clinical ethics program may also prompt increased buy-in. ACOG's SCOPE program certifies ob/gyn offices that meet the program's standards and criteria, recognizing them on the organization's website and in its academic journal.¹⁷ Although physicians' offices cannot be certified in this same manner from an ethics perspective, acknowledging publicly their participation in a physician office clinical ethics program by providing a certificate of participation to display and listing them in the affiliated health system publications (hospital and community newsletters) and websites, may provide incentive for individual offices to participate, especially if practices see their competition participating. 

Physicians' offices owned by an integrated health system can mandate participation in a clinical ethics program, but this excludes practices that are privately owned. Of course, mandates by accrediting and regulatory agencies would force participation regardless of who owns the physician practice. 

Ethics programs should also adopt the saturation-training model used in safety, which holds changes in culture and behaviors may occur when enough learners are educated in a skill in a short period of time.¹⁸ Based on this model, if only one or two staff members participate regularly in a physician's office ethics program and the rest do not, the individuals who participate may not put into practice the clinical ethics knowledge they acquire. However, if all staff members receive clinical ethics education and incorporate clinical ethics knowledge into their daily work, then it becomes the new norm and the new way of doing things for everyone who works in that physician's office. When new individuals join the staff, they will quickly learn that ethical practices and participation in a clinical ethics program are the norm for that physician's office.¹⁹ 

Like quality and safety programs, a physician's office clinical ethics program requires ongoing evaluation. Individual physician's offices can designate an individual (manager, physician, etc.) to oversee the program and gather information for evaluation. This individual can liaison with the health system ethicist; schedule, assign and track completion of ethics education assignments for staff; lead and evaluate the development and implementation of ethics office policies and procedures; and lead and evaluate ethics quality initiatives. Individual physician's office staff members' evaluations can include an ethics component to assess their ethics knowledge and provide information for future clinical ethics program planning. Patient surveys and data collection, similar to that used in other health care quality initiatives, can also identify issues for ethics programs to address and evaluate the impact of the clinical ethics program. 

The same as hospital clinical ethics programs, physicians' office clinical ethics programs can provide numerous benefits to staff members, patients, and the health care organization. These include improved patient communication, shared decision-making, patient and staff satisfaction, productivity, quality of care, and safety. A comprehensive clinical ethics program can also safeguard the practice's future. Additional benefits include decreasing unwanted care, utilization of resources, and future value conflicts.²⁰

The decades-long shift of health care to the outpatient and physician's office setting rather than the inpatient hospital setting continues, with no reversal of this trend in sight. Therefore, despite the barriers present, clinical ethics must follow patients and health care professionals to the physician's office environment and establish vibrant, comprehensive physician's office clinical ethics programs as called for in the literature in the 1980s and again in 2002. Likewise, health system and physician's office leadership must partner with clinical ethicists and clinical ethics programs to implement and support these efforts. Only then will health care personnel truly provide all patients with high quality, safe medical care and treatment.

Notes
^1. CDC, "2010 National Ambulatory Medical Care Survey," accessed at www.cdc.gov/nchs/ahcd.htm, accessed 3/24/2014
^2. Michael Felder, "Outpatient Ethics: 'And the Walls Came Tumbling Down,'" The Journal of Clinical Ethics, 13, no. 4(Winter 2002): 282-283.
^3. Marian Gray Secundy, "Ethical Dilemmas in Office Practice: Physician Response and Rationale," Journal of the National Medical Association, 77, no. 12 (1985): 999.
^4. Julia E. Connelly and Steven DalleMura, "Ethical Problems in the Medical Office," JAMA, 260, no. 6 (August 12, 1988): 815. 
^5. Ibid.
^6. John La Puma and David L. Schiedermayer, "Outpatient Clinical Ethics," Journal of General Internal Medicine, 4 (September/October, 1989): 413.
^7. Felder, p. 285.
^8. Isaac D. Montoya and Alan J. Richard, "The Case for a Code of Ethics in an Ambulatory Care Setting," Journal of Ambulatory Care Management, 18, no. 3 (1995):68-76.
^9. Robert Lyman Potter and Christy Kaiser, "Bringing Moral Order to the Ordinary: Outpatient Ethics Takes Shape," The Journal of Clinical Ethics, 13, no. 4 (Winter 2002): 274.
^10. American Congress of Obstetricians and Gynecologists Safety Certification in Outpatient Practice Excellence for Women's Health, http://www.scopeforwomenshealth.org, accessed March 29, 2014.
^11. Ibid. 
^12. Ellen Fox, Bette-Jane Crigger, Melissa Bottrell, and Paul Bauck, IntegratedEthics, "Ethical Leadership: Fostering an Ethical Environment & Culture," Veterans Health Administration National Center for Ethics in Health Care, p. 15.
^13. John E. Hennessy and Marcus Neubauer, "Quality Improvement and Ethics: Performance Improvement in an Oncology Practice," The Journal of Clinical Ethics,13, no. 4 (Winter 2002): 353-358.
^14. Fox et al., Ethical Leadership, pp. 13-14.
^15. Ibid, pp. 13-15.
^16. Josie King Foundation, www.josieking.org, accessed 3/29/2014.
^17. ACOG SCOPE.
^18. Timothy C. Clapper and Grace M. Ng, "Why Your Team STEPPS Program May Not Be Working," Clinical Simulation in Nursing, 9, no. 8 (2013):e288
^19. Ibid.
^20. IntegratedEthics, "A Brief Business Case for Ethics," www.ethics.va.gov/businesscase.pdf, Veterans Health Administration National Center for Ethics in Health Care, accessed 3/29/2014

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