Efforts to teach and evaluate humanistic qualities in physicians in residency training are marred by ambiguous goals. The humane physician can be characterized by four distinct qualities: technical competence, humanistic attitude, knowledge of humanistic concepts, and humanistic behavior. Education in the humanities can foster humanistic attitudes, but it cannot promise to lead to changes in behavior. Likewise, although formal training in communication teaches the skills necessary for humanistic behavior, without an understanding of humanistic concepts these skills may not serve medical or moral ends. Evaluation of the humane physician must also include modalities that test attitude, knowledge, and behavior. Testing one characteristic does not ensure competence in other areas; knowledge of the requirements for informed consent, for example, does not guarantee one's ability to discuss this concept effectively with patients. In this article, we suggest ways to combine the humanities and communication skills in the clinical setting and we emphasize both the training and the evaluation of humane physicians.
Health maintenance organizations (HMOs) are providing an increasing proportion of medical care in the United States. Characteristics of these organizations such as cost containment, incentives to reduce spending by practitioners, and barriers to access for clients raise significant ethical concerns. This paper considers how these features of the HMO withstand ethical scrutiny and what may be done to prevent abuse. Generally, the challenges to the moral integrity of physicians practicing in HMOs are neither intractable nor in all cases unique, although special arrangements may have to be made to ensure that ethical standards are upheld. Independent practice associations pose particular problems. Finally, whether or not an HMO is a for-profit enterprise is a significant consideration.
Cost pressures and changes in the health care environment pose ethical challenges and hard choices for patients, physicians, policymakers, and society. In 2000 and 2001, the American College of Physicians, with the Harvard Pilgrim Health Care Ethics Program, convened a working group of stakeholders--patients, physicians, and managed care representatives, along with medical ethicists--to develop a statement of ethics for managed care. The group explored the impact of a changing health care environment on patient-physician relationships and how to best apply the principles of professionalism in this environment. The statement that emerged offers guidance on preserving the patient-clinician relationship, patient rights and responsibilities, confidentiality and privacy, resource allocation and stewardship, the obligation of health plans to foster an ethical environment for the delivery of care, and the clinician's responsibility to individual patients, the community, and the public health, among other issues.
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