This case is one in a series of case studies with commentaries by ACP's Ethics, Professionalism and Human Rights Committee and the Center for Ethics and Professionalism. The series uses hypothetical examples to elaborate on controversial or subtle aspects of issues not addressed in detail in the College's Ethics Manual, the Physician Charter on Professionalism, or other College position statements. The fifth edition of the ACP Ethics Manual, the Professionalism Charter, and additional College policy on ethics, professionalism, and human rights issues are available at http://www.acponline.org/ethics/ethics_man.htm or by contacting the Center for Ethics and Professionalism at 215/351-2839.

Case History

John Ferguson, MD, a well respected internist with specialty training in cardiology, has for years been the person to call for treating high-risk OB patients with cardiac complications. Late one evening, he receives a call from his old friend Marjorie Gavin, an OB with whom he has consulted many times.

Dr. Gavin says, "I've got a 32-year-old patient who, after 2 miscarriages, is just entering her second trimester. It's just like that aortic insufficiency case we worked on together in '96. I am anxious to have her cardiac condition carefully managed right from the start. Can you take her on?"

With obvious regret, Dr. Ferguson explains, "My new group practice can't support my continued work with high-risk patients. Their existing insurance won't cover it, and the additional premium for adequate coverage is prohibitive. They allowed me to finish up with the patients I brought, but I can't take on cardiac care for new OB patients. Now neither General nor Sacred Heart has regular cardiac coverage for these patients. No other cardiologist would take it on, and my cross-cover won't allow it. Both hospitals have been trying for months to recruit, so far without success. Last month I would have sent you to Samuels, but he closed his practice to follow his neurosurgeon wife to California. I'd call Dick Brown at Cambridge Memorial. He's a terrific cardiologist and works extensively with high-risk OB patients. Unfortunately, he's 90 minutes south of here -- quite a trek for your patient."

Dr. Gavin sighs. "This situation is totally out of hand. One of my partners is retiring, and we've been trying to recruit her replacement for over a year. We haven't had a single experienced candidate, and those fresh from training have no interest in practicing in this state. They can't afford the premiums on top of their student loans. With the number of insurers dropping out, it's questionable whether they could get coverage even if they could afford it. My partner's agreed to stay 3 more months, but when she goes, we'll have to start turning patients away."

Dr. Ferguson asks, "Are you going to the demonstration at the State House next month to support the tort reform bill? I've always been against physician strikes to resolve economic issues. It seems unethical to limit patient care for matters of self-interest."

Dr. Gavin affirms her plans to attend. "This isn't just about economic self-interest anymore. It's about the obligation to advocate for long-term patient access to quality care."

Events are scheduled for a Friday and Saturday. Dr. Ferguson's practice is meeting later this week to vote on whether to close down on Friday so the entire group can participate both days, and he's struggling with what to do. He appreciates the access and quality-of-care implications of the malpractice situation and is comfortable that the rally is not a strike, but advocacy in support of a specific bill. The fact that the bill also provides some funding for a patient safety pilot program adds to its appeal. However, he has major concerns about closing the practice on Friday so that he and his colleagues can participate. Most importantly, he is worried that closing the office will damage patient trust by limiting care and inconveniencing patients to focus attention on an issue they may view as economically self-serving. In contrast, at least one of his colleagues views the closing and group attendance at the 2-day event as a crucial public demonstration of the seriousness of the issue to the practice as a whole and feels that, as long as each physician is available by phone and the local emergency rooms are available as a safety net, patients will have adequate access to care. Dr. Ferguson also feels strongly that the decision to publicly advocate for anything should be a free and individual choice, and he is concerned that closing the office will make some in the practice who are uncomfortable about participating in the rally feel coerced.