Quality of life (beneficence, nonmaleficence, autonomy) The patient's function had clearly declined in the past week, noted by increased pain and other symptoms. The inability to control this pain with her current regimen has had a significant negative impact on Ms. M. and her family's quality of life.
Contextual features (justice) This case raises several issues related to contextual features and the bioethical principle of justice.
Does the rubber meet the road in or out of the examination room? Pincus has noted that the most effective tools for rapidly decreasing racially influenced disparities may in fact take place outside the examination room.4
Physician assistants and other medical practitioners may get lost in the myriad of evidence and guidelines presented to them on an almost daily basis. PAs may have a tendency to see the specific treatment guidelines as "real" evidence, possibly setting aside related social determinants of health. Battling for control of methodology that defines "reliable" also confounds the approach to evidence.
Ethical principles suggest that PAs engage patients beyond the walls of the examination room. Choosing to set aside evidence from factors on the societal scale may place providers at clear odds with professional and ethical principles of justice, beneficence, and nonmaleficence.
Integrating evidence about unconscious bias Data continue to mount showing that the impact of provider unconscious bias and stereotyping of patients negatively impacts patient care. Nonwhite patients consistently receive unequal levels of care compared with white counterparts, even when issues to which health disparities are commonly attributed (access, comorbidities, insurance status, patient preferences) are accounted for.2
In this case, the patient's pain went untreated because of clinician assumptions about the validity of her pain complaints. Todd's studies on the pain medication provided to patients in ED settings show that nonwhite patients are given less pain medication at discharge.5
The Healthy People 2010 companion document for lesbian, gay, bisexual, and transgender (LGBT) health cites a broad array of bias toward LGBT patients by providers, consistent with a lack of appropriate training on caring for these populations.6 These known barriers complicate the care of LGBT patients.
The ethical conundrum presented by this case relates to improving case-based care for patients using awareness of clinician bias and stereotyping. Much of the research informing PA understanding of unconscious clinician bias comes from investigating the mechanics of human cognition, or how we think. These efforts consistently point to one startling conclusion: increasing provider awareness of clinician bias has the potential to decrease its frequency and impact.7-9 One awareness tool, called perspective taking, promotes provider empathy and has been shown to decrease the impact of bias.9
Are you sure about that? Burgess has found that lack of certainty increases dependence on cognitive shortcuts in the form of unconscious biases and stereotypes.10 The complexity of this case increases the need for the provider to fill in the gaps with information generated from the implicit bias and unconscious stereotyping, a tendency found to occur more frequently in complex cases.11
This case highlights two salient complexities related to the role of evidence in PA practice. What obligation do PAs have to integrate evidence related to social determinants of ill health into their practice? Is it ethical for PAs to focus on treatment guidelines and set aside evidence pointing to structural causes of poor health? Furthermore, how does the PA determine if evidence offered to guide PA practice is accurate and applicable to increasingly diverse populations?
We have previously described the concept of the PA's responsibility to participate in the shaping of the societal context in which patients receive health care. The concept of "Citizen PA" explores PA activism, whereby participation in shaping societal forces may have more impact on patient health than diagnostic and procedural acumen.12,13
An additional area for consideration is how accuracy of evidence can be brought into question when guidelines are created by those in a position to profit from guideline adherence. For example, what is the proper diagnostic interpretation of the patients' BP reading of 136/95 mm Hg? Using the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines, any systolic reading above 120 mm Hg is considered prehypertensive. This new category came with the JNC 7 guidelines of 2003. Nine of the 11 members of the JNC 7 panel had direct financial ties to pharmaceutical companies that could potentially profit from the prescribing driven by the new guidelines.14 This connection between research and profit potentially impacts the integrity of evidence and warrants further exploration. JAAPA
Jim Anderson practices in the Department of Neurological Surgery, Harborview Medical Center, Seattle, Washington, and is a member of the JAAPA editorial board.
Diane Bruessow is in private practice in Middle Village, New York; on the staff of The New York Times; and is a member of the JAAPA editorial board.
F.J. Gianola is a faculty member in the Division of Physician Assistant Studies, MEDEX Northwest, and in the Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle. The authors have indicated no relationships to disclose relating to the content of this article.
F.J. Gianola, PA, DFAAPA; Jim Anderson, PA-C, ATC, department editors
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