Physician Conceptions of Responsibility to Individual Patients and Distributive Justice in Health Care

Abstract

PURPOSEPhysicians' values may be shifting under managed care, but there have been no empirical data to support this claim. We describe physician conceptions of responsibility to individual patients and distributive justice in health care, and explore whether these values are associated with type of managed care practice and professional satisfaction. METHODSWe mailed a questionnaire to 500 primary care physicians from 80 outpatient clinics in 11 managed care organizations (MCOs) who were participating in 4 studies designed to improve the quality of depression care in primary care. RESULTSWe received 414 responses (response rate 83%). Twenty-eight percent of physicians strongly agreed that their main responsibility was to the individual patient rather than to society (strong sense of responsibility to individual patients). Physicians with a strong sense of responsibility to individual patients were older (43% of physicians older than 50 years reported a strong sense of responsibility to individual patients, compared with 26% of physicians aged 36 to 50 years, and 21% of physicians younger than 35 years, P = .009) and tended to practice in network-rather than staff-model MCOs (33% of physicians in network-model MCOs reported a strong sense of responsibility to individual patients compared with 24% in staff-model MCOs, P = .077). Scores on a scale measuring egalitarian conceptions of distributive justice within the health care system were similar for physicians regardless of whether they reported a strong sense of responsibility to individual patients. When we controlled for physician and practice characteristics, physicians with a strong sense of responsibility to individual patients and physicians with higher scores on an egalitarian scale were more likely to be very satisfi ed overall with their practices (adjusted odds ratio [AOR] = 2.23, 95% confi dence interval [CI], and AOR = 1.18, 95% CI, respectively).CONCLUSIONS Physicians with a strong sense of responsibility to individual patients are older and less likely to practice in staff-model MCOs. Stronger commitment to an egalitarian health care system and a strong sense of responsibility to individual patients are independently associated with greater practice satisfaction among physicians. The impact of these values on patient care should be a priority for future research and the subject of professional education and debate.

Controlling Health Costs: Physician Responses to Patient Expectations for Medical Care

“…Previous research has clearly demonstrated that physicians' perceive a tension between their responsibility to practice cost-consciously and their ability to serve their patients' best interests, 13,[17][18][19] which often manifests in a desire to fulfill their patients' expectations. 5,[14][15][16] Our data suggest that physicians do consider resources in the daily care of patients, but some may be more adept at balancing this tension than others.…”

“…14,15 For example, more than onethird of U.S. physicians would order a magnetic resonance image (MRI) for back pain in response to patient request even when the MRI was unnecessary. 16 Surveys of California physicians, 17 primary care physicians, 18 and oncologists 19 reflect similar tensions between physicians' perceived responsibility to practice cost-consciously and their desire to satisfy their patients' expectations.…”

Medical Students’ Knowledge and Attitudes Toward Female Sex Workers and Their Occupational Risk Factors

“…24 Medical students and physicians may deeply value acknowledgment of patient needs, adherence to personal moral values and/or promotion of social justice, all in variable orders of priority. [25][26][27] COMBI action plans, historically successful for vector-borne disease prevention (Available at: http://www.tropika.net/review/061001-Dengue_Behaviour_change/article.pdf, updated 2006; cited 2014 May 30), are also applicable for other family and community health initiatives and may improve sexual and reproductive health outcomes by reconciling health care provider interests with the health needs of female sex workers. 28 Our results suggested that student attitudes were polarized mostly by personal moral beliefs (self-identified religiousness) and the legal environment (legality of prostitution in the country of intended medical practice), rather than by other variables such as age, number of years in medical school and previous education in social determinants of health or occupational health.…”

The moral psychology of rationing among physicians: the role of harm and fairness intuitions in physician objections to cost-effectiveness and cost-containment

“…Yet, “bedside rationing” has been criticized for being exclusively utilitarian [ 13 ] and at odds with multi-faceted conceptions of justice [ 14 - 17 ]. Moreover, many physicians feel that their foremost professional obligation is to advocate for their individual patients, without regard to the broader questions regarding cost and resources [ 18 ]. To date, there has been little empirical research that might begin to explain why some physicians embrace CER and cost-effectiveness analysis and others resist them.…”