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• W2893148986 abstract "On the way into each patient’s room in my clinic, I generally glance at the electronic medical record (EMR). At the top of the screen, the patient’s BMI is listed; those with obesity are highlighted in yellow. The only other highlighted text is patient allergies. Does BMI really deserve such recognition? In September 2016, the New York Times examined how obese patients interact with the healthcare system and suggested that EMRs should do away with the extra attention given to BMI scores [7] since physicians already are acutely aware of a patient’s obesity, and because of it, may not fully consider other causes for the patient’s presenting complaints. The author of the piece argued that while obesity sometimes is relevant, an inordinate focus on it—and the resulting exclusion of other considerations—is bad medicine. The author interviewed Dr. Adolph J. Yates Jr., an orthopaedics professor at the University of Pittsburgh School of Medicine. Dr. Yates described the care of patients with obesity and hip or knee arthritis and suggested that these patients are the victims of discrimination. “Patients who may be at a marginally higher risk [for obesity] may be treated as a class instead of individuals. That is the definition of discrimination,” Dr. Yates said [7]. Discrimination is generally the result of bias, and while obesity may be relevant to a patient’s care [4-6, 8-12], it is also a diagnosis that carries stigma and bias. Evidence suggests that obese patients receive lower quality care [13], and physicians may treat obesity differently than other medical conditions, perceiving it as lack of willpower or a patient’s fault [14]. Patients with a number of other conditions are susceptible to similar physician biases that can influence treatment decisions, including smoking, opioid use, depression, and workers compensation status. How do orthopaedic surgeons thread the needle, that is, consider medically relevant information without sliding into biased thinking and, even worse, discriminatory behavior? Avoiding bias is a small component of virtue ethics, a branch of normative ethics that focuses on the moral character of a person carrying out an action [3]. But before considering how to avoid bias, it is useful to consider why we, as human beings, resort to biases as the foundation for decisions in the first place. Social science experiments have demonstrated the speed with which people will rapidly begin to discriminate against those outside their group [15], even when such groups have been formed completely arbitrarily. Evolutionarily, these types of behaviors likely arose from self-preservation, and biases are intrinsic to human nature. In the clinical setting, I believe that this evolutionary tendency is further accentuated by the limited time available for interacting with patients. When we are time limited, we generally resort to heuristics. A heuristic is a mental shortcut, allowing us to make rapid decisions without going through an extended thought process. For example, when a patient has tenderness to the fibula after a twisting injury, I order a radiograph automatically, without going through a thought process considering the Ottawa ankle rules [16]. While heuristics can create time-saving shortcuts, they can also lead to cognitive biases and stereotypes, resulting in errors in care and practice not matching the reality. For example, obese individuals have a higher risk of superficial wound infection after total joint arthroplasty. Yet, the risk remains relatively low, with a 1.46% superficial infection rate in patients with a BMI of 40 to 45 compared to a 0.77% superficial infection rate in patients with normal BMI [17]. Still, I have heard surgeons say that patients with obesity “all get infections.” This stereotyping is likely due to a creation of a heuristic, whereby complex research on infection rates in obesity has been reduced down to “obesity equates infections.” This heuristic is clearly incorrect, and the behavior that results is not ethically defensible, as the reasoning that led to the denial of surgery is unsound. The impulse to treat patients as a class rather than an individual is further complicated when payment models and quality markers create financial incentives to avoid complicated patients like those with obesity. While patient welfare may be the stated reason for refusal of care, there are clearly mixed motivations—caring for medically complex patients is more likely to result in lost revenue and worse quality scores for both physicians and hospital systems. Avoidance of high-cost patients may make sense from a business perspective, but it is not defensible from a medical ethics viewpoint. Physicians have a fiduciary responsibility to “maintain the patient’s best interests as paramount” [1]. This responsibility does not mean that each patient should receive identical treatment, in fact, it requires the opposite: That each patient be considered as an individual, promoting his or her particular best interests. Any diagnoses that are medically relevant must be considered, even if there is associated stigma. Importantly, the physician (fiduciary) and patient (beneficiary) relationship mandates that only the patient’s benefit is under consideration; financial benefits to the physician are immaterial. To uphold this duty, surgeons must work to practice nonjudgmental regard, a principle of medical ethics and a virtue to be cultivated. Just as we learn through training to resist our impulses to visibly cringe at an open fracture or display disgust at a malodorous wound, we must constantly practice avoiding judgement that may devalue or dehumanize a patient, as well as always treating patients as individuals rather than as members of a class (such as “the obese”). The practice of nonjudgmental regard is an aspirational virtue, and the force of bias may be greater than we appreciate. Considering how the ideal, moral physician would act in this situation is the essence of virtue ethics. To ensure one is acting virtuously, I suggest a simple mechanism to help us thread the needle between medical relevance and bias. The American Joint Replacement Registry has created a risk calculator for patients undergoing hip and knee replacement [2]. Though it doesn’t include all potential stigmatized diagnoses, it can be useful for surgeons trying to decide whether a patient’s risk factors—perhaps including obesity—should preclude surgery. For example, if a surgeon were to deny surgery to a patient with obesity based on his or her elevated risk but pursue surgery on a patient with end-stage renal disease in spite of the elevated risk, that surgeon ought to consider whether obesity stigma might be a factor in the decision-making process. Orthopaedic surgery is unique, in that many of the procedures we perform are elective, and while they often deliver great value to our patients, the surgery we do also carries very-real risk. As surgeons choose their patients, it is possible that patients with higher risk profiles—such as patients with obesity—might not be treated as individuals, but instead be treated as a member of a class. There is a moral hazard here: If we approach patients with biases—conscious or unconscious—we may miss diagnoses, contribute to healthcare disparities, and fail to fulfill our obligations to our patients." @default.
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• W2893148986 date "2018-09-22" @default.
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• W2893148986 title "Virtue Ethics in a Value-driven World: Bias in Orthopaedics" @default.
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