The delivery of cardiovascular care is rapidly evolving in tandem with professional obligations of clinicians, requiring a new paradigm of ethical and professional standards for clinicians to follow, according to an American Heart Association (AHA)/American College of Cardiology (ACC) Consensus Statement on professionalism and medical ethics published in both Circulation and the Journal of the American College of Cardiology.
“The 2020 [AHA] and [ACC] Consensus Conference on Professionalism and Ethics comes at a time even more fraught than the eras of the previous 3 meetings,” the authors wrote. As the COVID-19 pandemic sweeps the nation, in conjunction with social justice-focused protests and a divisive political climate, “…there could be no better time to review and take a fresh perspective on medical ethics and professionalism in the light of established norms and current stressors.”
The most recent AHA/ACC-sponsored medical professionalism and ethics conference took place on October 19 and 20, 2020. During this meeting, numerous medical and professional organizations came together to address the “practical management” of both professional and ethical behavior by cardiovascular clinicians and scientists. The two sponsoring organizations have, according to authors, a long history of formally addressing medical ethics and professionalism issues.
This year’s conference included a diverse slate of 61 participants, 41.2% of whom were women, 7.9% of whom were Black, and 4.8% of whom were Hispanic, an improvement on prior conferences.
The goal of this conference was to reevaluate the current tenets of medical professionalism and ethics, updating them as necessary to reflect the current state of the nation.
“The tenets of medical ethics, the principles and commitments of medical professionalism, and the specific obligations of medicine’s social contract form the basis of this joint AHA/ACC study of medical ethics and professionalism in the 21st century,” the authors wrote.
Currently, the tenets of medical ethics focus on 4 main domains: respect for autonomy, beneficence, nonmaleficence, and justice. Similarly, the principles of professionalism include patient-focused guidance and include primacy of patient welfare, patient autonomy, social justice, professional competence, honesty with patients, patient confidentiality, maintenance of appropriate relations with patients, and improvement of quality of care, as well as improvement of access to care, just distribution of finite resources, and upholding scientific standards through the application of scientific knowledge.
Consensus conference attendees came together to evaluate these tenets and principles, then published the current report to summarize the discussions and recommendations that came out of the conference. Five task forces were formed, each focusing on a different area of interest. The results of each task force’s discussions are summarized below.
Task Force 1
Task Force 1 focused on conflict navigation, including relationships with industry and conflicts of interest in the areas of teaching, publications, peer review, research data, technology, and expert testimony. The Task Force developed a 4-step process that is essential for practitioners who are considering creating conflicts of interest and how to manage them: full disclosure, assessment of relationships, management, and oversight.
Not all relationships with industry represent a conflict of interest, but disclosure of these relationships should be mandatory in educational and publication settings.
Associational interests — interests that arise from “an individual’s formal or informal, nonfinancial participation in or relationship with an organization or individual” — should also be fully disclosed and carefully evaluated to determine potential conflicts of interest.
In general, payments consisting of a single instance that totals less than $500 may not need to be labeled as a relationship with industry or a conflict of interest.
For publications, comprehensive relationship data should be collected for both individuals and institutions involved in research. Disclosures of financial conflicts of interest should reflect the types of relationships and the role of each individual clinician involved in the research.
Individual organizations should maintain requirements for “ethical, truthful, clear, science-grounded, and conflict-free medical testimony” in both civil and criminal litigation. Practical mechanisms should be established for peer review of medical testimony.
Task Force 2
Task Force 2 focused on diversity, equity, inclusion, and belonging — in particular, how to optimize cardiovascular health care, research, and education while eliminating bias, discrimination, harassment, and racism. Injustices in both the medical profession and in society, the task force noted, require “increased attention to the quality of the workforce.”
“A growing appreciation of the essential importance of diversity in achieving excellence and recognition of the widespread prevalence and consequences of a range of behaviors and inequities from implicit bias, to discrimination and harassment, to structural sexism and racism, demands action,” they wrote.
The task force began by creating general concepts of diversity, equity, inclusion, and belonging, noting that these concepts are “collectively and individually essential” to excellence, and should be included in all aspects of health care, from research to education to business.
Immediate goals include achieving diversity among trainees, workforces, and leadership, ensuring freedom from bias, discrimination, and harassment, and ensuring equity, inclusion, and belonging while eliminating structural racism and sexism. These efforts, however, should be evidence-based and utilize a systems approach to ensure that change is associated with measurable outcomes.
Additional discussions dealt with specific accountabilities and special groups. Task force members noted that educators in particular have a responsibility to “ensure diversity among those entering the cardiovascular community” while eliminating bias, harassment, and racism in schools and training programs. Senior educators and leadership should work to provide professional development, mentorship, and sponsorship to marginalized members of the community.
To ensure that these measures go beyond the perfunctory, diversity metrics should be continuously assessed and improved upon, and based on best practices. Because training is essential for these efforts to succeed, programs and interventions that work toward eliminating bias, harassment, racism, and sexism should be encouraged, funded, conducted, and published.
Task Force 3
Task Force 3 discussed the topic of how to enhance clinician well-being. Typically, the professionalism of health care providers has “centered predominantly around the high standards of altruism that are to be upheld by clinicians.” Although this standard remains, it has been recognized that clinician well-being is essential to meeting patient needs — particularly as clinicians are facing unprecedented challenges that lead to stress, such as consolidation of medical practices, increased productivity expectations, reduced reimbursements, electronic health record (EHR) requirements, and legislative and regulatory requirements, among others.
“Burnout…is classified as an occupational phenomenon, not as a medical condition,” the authors wrote. “Burnout and reduced satisfaction with work-life integration are more prevalent in physicians compared with other US working adults.”
The task force began by discussing strategies at the organizational level to promote physician well-being; the first of these tenets states that health care organizations must “actively support and be accountable for the psychosocial health of their workforces.” Any investments in clinician well-being research, and any interventions, should be directed toward creating work environments where clinicians can thrive.
Well-being should also be addressed among trainees and researchers, with training programs providing appropriate preventive and responsive mental health care resources. The creation of a confidential ombudsperson program would allow the confidential reporting of mistreatment, as well as access to resources for support and restitution.
To reduce the burden associated with EHRs, health information technology vendors and developers should ideally collaborate with clinicians, researchers, and other necessary vendors to improve EHR usability and interoperability. They must also work in conjunction with health care organizations and employers to improve practice efficiency and reduce the time and effort required for EHR documentation.
Equally as important is the identification of the “disruptive physician” — a physician who engages in disruptive behavior within a team or organization. Health care systems should develop programs to educate physicians about what constitutes disruptive behavior, as well as on their responsibility to act as professional and respectful team members. Physicians should be encouraged to be “upstanders,” not bystanders, when disruptive behavior is encountered.
Clinicians should also be taught to recognize potentially impaired physicians, as well as the process to confidentially report any concerns. Intervention plans should be developed on an individualized basis for each care setting, and programs should be accessible and aimed at rehabilitation and safe reentry into practice.
One important caveat noted is that there are multiple laws, policies, and regulations in place that “contribute to the administrative burden placed on clinicians, including clerical documentation, measuring and reporting quality metrics, prior authorization forms, licensure requirements, and board certification,” the authors wrote. “Healthcare policy makers, regulatory bodies, and accreditation groups should identify, reduce, or eliminate policies, rules, and procedures that provide minimal or no value to patient care.”
Another caveat is the stigma associated with seeking mental health help, which should be reversed both in general and within the health care profession.
Task Force 4
Task Force 4 discussed the topics of patient autonomy, privacy, and social justice in health care by focusing on 3 specific areas “relevant to contemporary biomedicine”: patient autonomy as it relates to clinical decision making; privacy, data access, and transparency associated with the expansion of research and proliferation of electronic biomedical data resources; and social justice in medical education and clinical practice.
Respect for patients, they noted, “requires an acknowledgment of their autonomy and the importance of the alignment of their care with their goals and values,” particularly as the balance between paternalism and autonomy evolves. Informed consent is both ethically and legally required, but it is insufficient for ensuring patient autonomy.
Patient-centered care is “grounded in the ethical principle of autonomy and has a sound basis in legal, moral, and human rights theories,” they wrote. Shared decision making requires both patients and physicians to make a decision together that is based on best practices, evidence, and patient goals and preferences.
To ensure the highest levels of data privacy, transparency, and access, participants in research studies must receive clear communication from investigators on the objectives of biomedical research. Investigators should ideally declare study objectives in a public forum before initiation, removing the temptation to publish only those findings that are aligned with interests of sponsors or investigators.
EHR access should also be improved; as it stands, the barriers to access can undermine patient engagement and education. Organizations that provide health care should refrain from sharing patient data with external partners for reasons that do not include improving clinical care.
It is a reality of the health care system that nearly 80% of a person’s health is determined by the socioeconomic conditions of their environment. These social determinants of health lead to inequalities in health care and outcomes, and work must be done to address the mechanisms behind these determinants.
Allyship plays an important role in both providing patient care and addressing systemic inequalities, and it is a key to overcoming health disparities and achieving equity among patients.
Ultimately, medical care should be patient-centered and transparent. Education about social justice, race, and racism is vital to ensure the highest level of patient care possible. However, some cases may involve competing ethical principles, such as when beneficence, nonmaleficence, and justice “supersede the importance of autonomy and privacy,” potentially requiring modification to these guidelines.
Task Force 5
Task Force 5 discussed modern health care delivery challenges, particularly those related to care delivery systems. Medicine, they wrote, is experiencing “unprecedented change driven by scientific and technological advances, combined with evolving healthcare delivery systems.” These challenges require the highest moral imperative and ethical principles to solve.
When engaging in new models of care delivery, clinicians should strive to balance patient interest and resource stewardship with transparency, quality, shared decision making, and patient-centricity. Clinicians must, in the face of a transition from fee-for-service toward value-based care, “recognize and weigh the conflicting risks of overtreatment vs undertreatment.”
Patient-centered care should be prioritized in the face of quality metrics in pay-for-performance programs, and guideline-recommended, evidence-based treatment should always be considered in conjunction with patient preferences and goals. Health policy intended to improve value should be supported by high quality evidence that leads to improved outcomes, and quality, outcomes, and patient experience should be given the highest priority.
When creating clinical documentation, clinicians should capture the patient’s problems, history, and decision making in language that is “accurate, current, respectful, consistent, confidential, secure, and transparent.”
Summing Up: Evolution and Consistency
“Delivery of cardiovascular care to people and communities continues to evolve rapidly, whereas professional obligations to patient-centricity must remain consistent,” the statement authors wrote. “The transformation of care delivery models and the complexities of new technologies mandate increased attention and careful introspection in relationship to professionalism and ethics.”
“It is the responsibility of each individual, as well as our professional communities, to continually evaluate the degree to which such standards are maintained and met,” they concluded.
Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.
Benjamin IJ, Valentine CM, Oetgen WJ, et al. 2020 American Heart Association and American College of Cardiology Consensus Conference on professionalism and Ethics: A consensus conference report. Circulation. Published online May 11, 2021. doi:10.1161/CIR.0000000000000.963