Primary care ethics is the study of the everyday decisions that primary care clinicians make, such as: how long to spend with a particular patient, how to reconcile their own values and those of their patients, when and where to refer or investigate, how to respect confidentiality when dealing with patients, relatives and third parties. [citation needed]All these decisions involve values as well as facts and are therefore ethical issues. These issues may also involve other workers in primary healthcare, such as receptionists and managers.
Primary care ethics is not a discipline; it is a notional field of study which is simultaneously an aspect of primary health care and applied ethics. De Zulueta argues that primary care ethics has ‘a definitive place on the ‘bioethics map’, represented by a substantial body of empirical research, literary texts and critical discourse (2, 9, 10). The substantial body of research referred to by De Zulueta (9) has a tendency to be issue-specific, such as to do with rationing(11), confidentiality, medical reports, or relationships with relatives.
Much of the literature on primary care ethics concerns primary care physicians. The term primary care physician is synonymous with family practitioner, or general practitioner; meaning a medically qualified clinician who is the first point of access to health care, with general responsibilities which may but do not necessarily include child health or obstetrics and gynaecology. Other primary care clinicians; nurses, physiotherapists, midwives, and in some situations pharmacists may face similar issues, and some (confidentially, prioritisation of patients) may also involve administrative staff. In some healthcare systems primary care specialists may also encounter many of these issues.
The place of primary care ethics in bioethics
Although the ethical decisions made in primary care are often as less dramatic than those in high-tech medicine (1), their cumulative effect may be profound (2), because of the vast number of health care encounters which take place in primary care, (approximately 400.3 million in England in 2008 alone (3, 4) ). Each of these involves ethical judgements, occasionally difficult, often straightforward; often deliberate but more often unconscious. Also, since primary care is often the first step in the patient journey, small decisions made then may make big differences later on. Most of the bioethical literature however deals with tertiary medicine, and much less attention is paid to the daily concerns of primary care physicians and members of the primary care team (5).
In countries with well developed primary health care, patients often stay with the same practice for many years, allowing practices to gather a large amount of information and to develop personal relationships over time. Patients often see the same clinician for a variety of problems, at once or at different times. Whole families may see the same doctors and nurses, who may also be their friends and neighbours. These factors affect moral decisions in primary care, and raise ethical dilemmas which might not occur often in secondary and tertiary medical care (6, 7). Moreover, the transfer into the community of services previously provided in hospital (such as specialist chronic disease management and mental health) may lead to the ethical dilemmas arising which were previously only encountered in secondary care (8).
Spicer and Bowman argue that the ‘tertiary’ level ethical problems that dominate so much of the debate about healthcare ethics, such as genetics, cloning, organ donation and research, are experienced entirely differently in primary care. Moreover, what might be argued to be core moral principles, such as autonomy and justice, may be reinterpreted when viewed through the lens of primary care (13). Toon, by contrast argues such re-interpretations are not exclusive to general practice and primary care. Doctors in other specialities (such as psychiatry, rheumatology, HIV medicine, or where specialists take primary responsibility for a patient’s health care over a considerable period) may perform what he terms the interpretative function, but when they do so, they are acting as generalists and practising generalism (14). The extension of this argument is that it is not just good primary care physicians who are aware of the ethics of the everyday, but good clinicians (15).
Values of primary care
According to Toon (16), doctors in primary care are charged with three tasks:
1. To deliver the best possible, evidence based medical care to patients who have physical or mental illnesses that can be understood and treated or cured within a biomedical framework
2. Insofar as it lies within their power, to help prevent avoidable illness and death in their patients
3. To help those who are or who believe themselves to be ill to cope with their illnesses, real or feared, to the best of their ability and so to achieve their maximum potential as human beings.
The first two tasks largely involve understanding the patient as a biopsychosocial system that the doctor is seeking to influence, whilst the third involves seeing the patient as a fellow human being in need. Reconciling these tasks is not easy.
Gatekeeping
In many health-care systems patients can only see specialists by referral from doctors in primary care, a system which restricts access to secondary care and is often called “primary care gatekeeping”. Although historically in some countries this developed as a mutually beneficial arrangement between specialists and primary care doctors, rather than from a desire to improve patient care, it is widely recognised that it benefits both individual patients and the health care system. Individual patients benefit from having a personal doctor who can integrate their health care and view their problems together rather than in isolation, and who can protect them from over-investigation and over-treatment -which Toon characterises as the 'furor therapeuticus' of specialist medicine (16). Patients as a whole benefit because the system ensures that expensive secondary care resources are spent on those who have the greatest need.
Some people however are concerned that gatekeeping can damage the doctor-patient relationship, since the doctor cannot act solely in the interests of the individual patient (17). Others have questioned whether this is ever possible, even without gatekeeping. Much depends on the system within which gatekeeping operates, and how great the pressures are on the primary care doctor not to refer, and how strong the incentives, personal, professional and financial are for or against referral. All are agreed that “positive gatekeeping” in which doctors are rewarded for encouraging patients to have unnecessary or dubious procedures, as exists in many private systems, is unethical, and that avoiding unnecessary treatment (therapeutic parsimony) is desirable. Heath has pointed out that the primary care doctor has influence over two other “gates” between illness and health, and between self care and professional care (18).
Certification and confidentiality
It is traditional in many countries that primary care doctors issue certificates to allow patients to be absent from work for reasons of sickness. In some countries such certificates are required even for one day’s absence from work, and this can form a considerable part of the primary care doctor’s workload. In other countries these certificates are only needed for longer periods of illness. In either case this can function can pose ethical problems for doctors as they try to reconcile a duty to do the best for the patient, a duty not to lie to employers, and the need to maintain the doctor patient relationship for professional and/or financial reasons.
Many people want information on patients’ health, and are prepared to pay for it. Insurance companies, employers, social agencies such as the police and the courts and many other bodies have interests in the health status of individuals. The primary care physician is often best placed to provide this information, but doing so can pose ethical problems, particularly in respect of confidentiality. Although patients may sign a consent form to allow information to be released, this consent is not always free, since the patient is often in a position where it would be difficult to refuse, and/or it is not informed, in that patients are often given forms to consent to the release of medical records without what this means being properly explained to them. Doctors can face a conflict of interest in this situation, since they can benefit financially from the fees paid for the release of such information. This poses a difficult ethical conflict as the doctor tries to “serve two masters”; the patient who has a right to confidentiality and the employer or other agency that is paying for the information. Confidentiality has been identified as a key concern to general practitioners in the UK and has been described as one way in which they display their commitment to patient-centeredness (19).
Access and use of time
As the first point of contact with health services, primary care doctors have particular responsibilities with respect to access. Patients typically and understandably want to see the doctor of their choice at the time and place of their choosing, without waiting, and for the length of time they feel they require; however it is rarely possible for all these conditions to be met. The decisions that doctors make about how best to reconcile these conflicting demands by appointment arrangements, arrangements for emergency consultation etc. have a strong ethical as well as practical component.
So too do decisions doctors make about the allocation of their time and resources between different problems and different patients. The three aspects of general practice are mentioned above but even within these doctors make choices that are ethical. One doctor may give priority to the care of patients with diabetes, another to women’s health, and a third to psychological problems and so on.
In some countries it is common place for doctors to strike – in others this is seen as unethical. This again depends on the values that doctors espouse, and in this case in particular on doctors' understanding of the nature of the doctor patient relationship.
The doctor, the patient and the family
A characteristic feature of primary care is that doctors’ often care for several patients who are related to each other. They also often care for a number of individuals and families who live and/or work in close proximity, and whose lives are intimately related to each other. Particularly though not exclusively in rural areas, the same applies to the doctor and to his staff. This can be a considerable strength of general practice, since doctors gain a fuller understanding of the social context in which their patients live and become ill. It can also pose ethical problems, however particularly in conflicts between duties to different individuals – family members, employers and employees, and even between friends, when the illness of one affects the life or health of another. Confidentiality can also be a problem, as patients may not understand or accept that information given to the doctor by one family member may not be divulged to others.
Respect for confidentiality, and maintaining confidence amongst patients that confidentiality is respected can be difficult not just for doctors but also for other members of their staff in such situations.
Analysing ethical issues in primary care
As in other aspects of applied ethics, different approaches may be used to understand these problems; they may be seen in terms of the rights and duties involved in medical practice, or how to maximise the good through the work clinicians do, or in terms of the virtues needed to flourish as a clinician or a patient. Deciding which moral framework to apply brings primary care ethics into contact with meta-ethics and epistemology. There is increasing interest in the empirical study of primary care ethics, often using qualitative research methods, which raises important metaethical and methodological questions about the relationship between facts and values.
In understanding the significance of informed consent, quite often, medical teams will work alongside an experienced medical advocate so as to meet the patients needs in achieving medical autonomy.
Toon P. The centrality of interpretation to generalism. In: RCGP, editor. Submission to RCGP commission on Generalism ed. London; 2011.
Pinching A. All good doctors (Personal communication). In: Toon P, editor. London; 1998.
Toon P, Chapter 8: Ethics and family medicine, in Mathers NJ (Editor in Chief), Maso G, Bisconcin M. European Textbook of Family Medicine. Passoni Editore. Milan; 2006
Medicine is the science and practice of caring for a patient, managing the diagnosis, prognosis, prevention, treatment, palliation of their injury or disease, and promoting their health. Medicine encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness. Contemporary medicine applies biomedical sciences, biomedical research, genetics, and medical technology to diagnose, treat, and prevent injury and disease, typically through pharmaceuticals or surgery, but also through therapies as diverse as psychotherapy, external splints and traction, medical devices, biologics, and ionizing radiation, amongst others.
Medical psychology or medico-psychology is the application of psychological principles to the practice of medicine, primarily drug-oriented, for both physical and mental disorders.
A physician, medical practitioner, medical doctor, or simply doctor, is a health professional who practices medicine, which is concerned with promoting, maintaining or restoring health through the study, diagnosis, prognosis and treatment of disease, injury, and other physical and mental impairments. Physicians may focus their practice on certain disease categories, types of patients, and methods of treatment—known as specialities—or they may assume responsibility for the provision of continuing and comprehensive medical care to individuals, families, and communities—known as general practice. Medical practice properly requires both a detailed knowledge of the academic disciplines, such as anatomy and physiology, underlying diseases and their treatment—the science of medicine—and also a decent competence in its applied practice—the art or craft of medicine.
Emergency medicine is the medical speciality concerned with the care of illnesses or injuries requiring immediate medical attention. Emergency physicians specialise in providing care for unscheduled and undifferentiated patients of all ages. As first-line providers, in coordination with emergency medical services, they are primarily responsible for initiating resuscitation and stabilization and performing the initial investigations and interventions necessary to diagnose and treat illnesses or injuries in the acute phase. Emergency physicians generally practise in hospital emergency departments, pre-hospital settings via emergency medical services, and intensive care units. Still, they may also work in primary care settings such as urgent care clinics.
Bioethics is both a field of study and professional practice, interested in ethical issues related to health, including those emerging from advances in biology, medicine, and technologies. It proposes the discussion about moral discernment in society and it is often related to medical policy and practice, but also to broader questions as environment, well-being and public health. Bioethics is concerned with the ethical questions that arise in the relationships among life sciences, biotechnology, medicine, politics, law, theology and philosophy. It includes the study of values relating to primary care, other branches of medicine, ethical education in science, animal, and environmental ethics, and public health.
In the medical profession, a general practitioner (GP) or family physician is a physician who treats acute and chronic illnesses and provides preventive care and health education to patients of all ages. GPs' duties are not confined to specific fields of medicine, and they have particular skills in treating people with multiple health issues. They are trained to treat patients to levels of complexity that vary between countries. The term "primary care physician" is more usually used in the US. In Asian countries like India, this term has been replaced mainly by Medical Officers, Registered Medical Practitioner etc.
Internal medicine, also known as general internal medicine in Commonwealth nations, is a medical specialty for medical doctors focused on the prevention, diagnosis, and treatment of internal diseases. Medical practitioners of internal medicine are referred to as internists, or physicians in Commonwealth nations. Internists possess specialized skills in managing patients with undifferentiated or multi-system disease processes. They provide care to both hospitalized (inpatient) and ambulatory (outpatient) patients and often contribute significantly to teaching and research. Internists are qualified physicians who have undergone postgraduate training in internal medicine, and should not be confused with "interns”, a term commonly used for a medical doctor who has obtained a medical degree but does not yet have a license to practice medicine unsupervised.
Medical ethics is an applied branch of ethics which analyzes the practice of clinical medicine and related scientific research. Medical ethics is based on a set of values that professionals can refer to in the case of any confusion or conflict. These values include the respect for autonomy, non-maleficence, beneficence, and justice. Such tenets may allow doctors, care providers, and families to create a treatment plan and work towards the same common goal. It is important to note that these four values are not ranked in order of importance or relevance and that they all encompass values pertaining to medical ethics. However, a conflict may arise leading to the need for hierarchy in an ethical system, such that some moral elements overrule others with the purpose of applying the best moral judgement to a difficult medical situation. Medical ethics is particularly relevant in decisions regarding involuntary treatment and involuntary commitment.
Primary care is the day-to-day healthcare given by a health care provider. Typically this provider acts as the first contact and principal point of continuing care for patients within a healthcare system, and coordinates other specialist care that the patient may need. Patients commonly receive primary care from professionals such as a primary care physician, a physician assistant, a physical therapist, or a nurse practitioner. In some localities, such a professional may be a registered nurse, a pharmacist, a clinical officer, or an Ayurvedic or other traditional medicine professional. Depending on the nature of the health condition, patients may then be referred for secondary or tertiary care.
A clinic is a health facility that is primarily focused on the care of outpatients. Clinics can be privately operated or publicly managed and funded. They typically cover the primary care needs of populations in local communities, in contrast to larger hospitals which offer more specialized treatments and admit inpatients for overnight stays.
Hospital medicine is a medical specialty that exists in some countries as a branch of family medicine or internal medicine, dealing with the care of acutely ill hospitalized patients. Physicians whose primary professional focus is caring for hospitalized patients only while they are in the hospital are called hospitalists. Originating in the United States, this type of medical practice has extended into Australia and Canada. The vast majority of physicians who refer to themselves as hospitalists focus their practice upon hospitalized patients. Hospitalists are not necessarily required to have separate board certification in hospital medicine.
Family medicine is a medical specialty within primary care that provides continuing and comprehensive health care for the individual and family across all ages, genders, diseases, and parts of the body. The specialist, who is usually a primary care physician, is named a family physician. It is often referred to as general practice and a practitioner as a general practitioner. Historically, their role was once performed by any doctor with qualifications from a medical school and who works in the community. However, since the 1950s, family medicine / general practice has become a specialty in its own right, with specific training requirements tailored to each country. The names of the specialty emphasize its holistic nature and/or its roots in the family. It is based on knowledge of the patient in the context of the family and the community, focusing on disease prevention and health promotion. According to the World Organization of Family Doctors (WONCA), the aim of family medicine is "promoting personal, comprehensive and continuing care for the individual in the context of the family and the community". The issues of values underlying this practice are usually known as primary care ethics.
A primary care physician (PCP) is a physician who provides both the first contact for a person with an undiagnosed health concern as well as continuing care of varied medical conditions, not limited by cause, organ system, or diagnosis. The term is primarily used in the United States. In the past, the equivalent term was 'general practitioner' in the US; however in the United Kingdom and other countries the term general practitioner is still used. With the advent of nurses as PCPs, the term PCP has also been expanded to denote primary care providers.
Behavioral medicine is concerned with the integration of knowledge in the biological, behavioral, psychological, and social sciences relevant to health and illness. These sciences include epidemiology, anthropology, sociology, psychology, physiology, pharmacology, nutrition, neuroanatomy, endocrinology, and immunology. The term is often used interchangeably, but incorrectly, with health psychology. The practice of behavioral medicine encompasses health psychology, but also includes applied psychophysiological therapies such as biofeedback, hypnosis, and bio-behavioral therapy of physical disorders, aspects of occupational therapy, rehabilitation medicine, and physiatry, as well as preventive medicine. In contrast, health psychology represents a stronger emphasis specifically on psychology's role in both behavioral medicine and behavioral health.
Medical education in Australia includes the educational activities involved in the initial and ongoing training of Medical Practitioners. In Australia, medical education begins in Medical School; upon graduation it is followed by a period of pre-vocational training including Internship and Residency; thereafter, enrolment into a specialist-vocational training program as a Registrar eventually leads to fellowship qualification and recognition as a fully qualified Specialist Medical Practitioner. Medical education in Australia is facilitated by Medical Schools and the Medical Specialty Colleges, and is regulated by the Australian Medical Council (AMC) and Australian Health Practitioner Regulation Agency (AHPRA) of which includes the Medical Board of Australia where medical practitioners are registered nationally.
Fee-for-service (FFS) is a payment model where services are unbundled and paid for separately.
Clinical pharmacy is the branch of pharmacy in which clinical pharmacists provide direct patient care that optimizes the use of medication and promotes health, wellness, and disease prevention. Clinical pharmacists care for patients in all health care settings but the clinical pharmacy movement initially began inside hospitals and clinics. Clinical pharmacists often work in collaboration with physicians, physician assistants, nurse practitioners, and other healthcare professionals. Clinical pharmacists can enter into a formal collaborative practice agreement with another healthcare provider, generally one or more physicians, that allows pharmacists to prescribe medications and order laboratory tests.
The philosophy of healthcare is the study of the ethics, processes, and people which constitute the maintenance of health for human beings. For the most part, however, the philosophy of healthcare is best approached as an indelible component of human social structures. That is, the societal institution of healthcare can be seen as a necessary phenomenon of human civilization whereby an individual continually seeks to improve, mend, and alter the overall nature and quality of their life. This perennial concern is especially prominent in modern political liberalism, wherein health has been understood as the foundational good necessary for public life.
Medical diagnosis is the process of determining which disease or condition explains a person's symptoms and signs. It is most often referred to as diagnosis with the medical context being implicit. The information required for diagnosis is typically collected from a history and physical examination of the person seeking medical care. Often, one or more diagnostic procedures, such as medical tests, are also done during the process. Sometimes the posthumous diagnosis is considered a kind of medical diagnosis.
Post-Hospitalist Medicine is the discipline concerned with the medical care of patients residing in Post-Acute, Long-Term Care, Rehabilitation and Assisted Living Facilities. The Physicians whose primary professional focus is the post-hospital medical care of these patients are called Post-Hospitalists.
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