Position Statement

Shared Physician-Patient Responsibilities

This Position Statement was developed as an educational tool based on the consensus opinion of the authors. It is not a product of a systematic review process. Readers are encouraged to consider the information presented and reach their own conclusions.

In furtherance of its mission to champion the interests of all patients and advance the highest quality musculoskeletal health, the AAOS believes that appropriately shared physician-patient responsibility in medical care is an essential ingredient for a successful outcome and patient satisfaction.

Introduction

Successful medical care requires active collaboration between the patient (and family as appropriate) and the physician.¹ An informed and engaged patient is key to a successful outcome and patient satisfaction. The patient physician partnership is central to this and is based upon mutual respect, honesty and trust.² It “does not imply that both partners have identical responsibilities or equal power. While physicians have the responsibility to provide health care services to patients to the best of their ability, patients have the responsibility to communicate openly, to participate in decisions about the diagnostic and treatment recommendations, and to comply with the agreed-upon treatment program.”^1,3

The Benefits, Patient Autonomy and Safeguards

1. A physician places the patient’s safety and wellbeing above all other considerations, keeps the patient informed about her/his condition and treatment, and advocates for the patient’s best interests resolving any conflicts of interest in favor of the patient.^4,5,6
2. Through years of education and training, the orthopaedic surgeon acquires extensive knowledge and demanding technical and professional skills, and then maintains competency through lifelong learning in the field that is constantly being advanced, all in order to most effectively serve the patients.^7,8,9
3. “Like patients’ rights, patients’ responsibilities are derived from the principle of autonomy” which “holds that an individual’s physical, emotional and psychological integrity should be respected and upheld.”¹
4. Each party is mutually dependent on the other for the effective discharge of its responsibility in order for the patient to realize the above benefits and safeguards (1 and 2 above).

Informed, Shared Decision Making

1. “When obtaining informed consent for treatment, the orthopaedic surgeon is obligated to present to the patient or to the person responsible for the patient, in understandable terms, pertinent medical facts and recommendations consistent with good medical practice. Such information should include alternative modes of treatment, the objectives, risks and possible complications of such treatment, and the complications and consequences of no treatment.”^10,11 Discussion should include what the patient may expect in the course of treatment and in the outcome. A similar approach should be followed in planning tests, consultation or referrals.
2. Each patient is unique in culture, value system, decision making and response to treatment. Alternatives and choices are available for many orthopaedic conditions. The patient autonomy “principle also recognizes the human capacity to self-govern and choose a course of action from among different alternative options. Autonomous, competent patients assert some control over the decisions which direct their health care.” The orthopaedic surgeon should engage in informed shared decision making with the patient using the patient’s values and respect the patient’s decision even if it is in disagreement with the physician’s recommendation.^12,13
3. “The goal of shared decision making is a well-informed patient acting on well-considered preferences.”¹³

Decision making: Patient’s Rights and Responsibilities

1. For the patient, with the “exercise of self-governance and free choice comes a number of responsibilities.”¹
2. The patient should provide complete and truthful information, express any concerns, request information or clarification in the discussion, and engage actively in understanding and decision making.^1,14
3. The patient should ask the necessary questions to be well informed in the details and choices and what to expect in the course of treatment and outcome as well as what is expected of her/him in the treatment plan. Patients who actively participate in medical interviews influence physicians to adopt a more patient-centered style of communication.¹⁵
4. After reaching a mutually agreed evaluation or treatment plan the patient should cooperate and carry out her/his role in faithful and timely fashion.^1,16,17 The patient must communicate regarding completion of tests/consultations etc., difficulties encountered, if any, and any desire to reconsider the agreed upon plan.¹⁴
5. The patient has an inherent right to not follow the recommended test, consultation or treatment.¹⁸ The patient should communicate this decision to the physician for a mutually productive relationship.¹

Patient Compliance: Physician Role and Patient Autonomy

1. In recommending tests, consultations and treatments etc., the physician should engage in informed, shared decision making.
2. The physician should arrange for or instruct the patient on how to arrange for the test/consultation and for any return visit to see the physician and regarding timelines and any urgency.
3. The physician should interpret the test/consultation results and, as appropriate, engage the patient in informed, shared decision making for further evaluation/treatment.
4. The physician should have a system to act on the results of tests and consultations. However, it is not the duty of the physician to remind patients of or ensure patient compliance with recommended return visits, tests, consultations or treatments.¹⁶ Physician attempts to ensure compliance would create undue pressure on the patient beyond informed, shared decision making and may thus compromise patient autonomy by involuntarily substituting the physician’s values for the patient’s.¹⁴
5. In a case where the physician determines that patient non-compliance materially interferes with the physician’s ability to provide appropriate care, the physician would have the option of terminating the patient-physician relationship following appropriate legal and ethical standards and procedures that facilitate future continued care of the patient by another physician.^19,20,21

The AAOS believes that the orthopaedic surgeon should inform the patient of the medical condition and treatment, respect the patient’s autonomy and values, and encourage the patient to actively engage in her/his treatment and in shared decision making. The AAOS also believes that for successful treatment and patient satisfaction the patient must exercise her/his rights of being informed and autonomy to make choices by being engaged, asking the necessary questions and assuming responsibility for carrying out his/her part in following through with agreed upon recommendations.

References:

1. American Medical Association: Policy E-10.01:Patient Responsibilities, updated June 2001. Accessed on July 10, 2011 at https://ssl3.ama-assn.org/apps/ecomm/PolicyFinderForm.pl?site=www.ama-assn.org&uri=%2fresources%2fdoc%2fPolicyFinder%2fpolicyfiles%2fHnE%2fE-10.02.HTM
2. American Academy of Orthopaedic Surgeons: Code of Ethics and Professionalism for Orthopaedic Surgeons, I. B. Revised 2011. Accessed on July 12, 2011 at http://www.aaos.org/about/papers/ethics/code.asp
3. American College of Physicians: Position Paper: Ethics Manual, Fifth Edition. Section on Physician and the Patient (p.561). Ann Intern Med 2005; 142:560-582
4. American Medical Association: Principles of Medical Ethics, E-1.001, revised June 2001 “VIII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount.” Accessed on July 11, 2011 at https://ssl3.ama-assn.org/apps/ecomm/PolicyFinderForm.pl?site=www.ama-assn.org&uri=%2fresources%2fdoc%2fPolicyFinder%2fpolicyfiles%2fHnE%2fE-1.001.HTM
5. American Academy of Orthopaedic Surgeons: Code of Ethics and Professionalism for Orthopaedic Surgeons, III. A. Revised 2009. Accessed on July 12, 2011 at http://www.aaos.org/about/papers/ethics/code.asp
6. American College of Surgeons: Statement of Principles. Principles II, I. Accessed on July 12, 2011 at http://www.facs.org/fellows_info/statements/stonprin.html
7. American Academy of Orthopaedic Surgeons: Code of Ethics and Professionalism for Orthopaedic Surgeons, IV. A. Revised 2009. Accessed on July 12, 2011 at http://www.aaos.org/about/papers/ethics/code.asp
8. Council on Ethical and Judicial Affairs: Principles of Medical Ethics, V. Chicago, IL, American Medical Association, ed. 2010-2011. “A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public….”
9. American College of Surgeons: Statement of Principles. Principles I A, B and E, and IV A. Accessed on July 12, 2011 at http://www.facs.org/fellows_info/statements/stonprin.html
10. American Academy of Orthopaedic Surgeons: Code of Ethics and Professionalism for Orthopaedic Surgeons, I. F. Revised 2009. Accessed on July 12, 2011 at http://www.aaos.org/about/papers/ethics/code.asp
11. American College of Surgeons: Statement of Principles. Principles II A. Accessed on July 12, 2011 at http://www.facs.org/fellows_info/statements/stonprin.html
12. American Medical Association: Policy D-373.999 Informed Patient Choice and Shared Decision Making. Accessed on July 14, 2011 at https://ssl3.ama-assn.org/apps/ecomm/PolicyFinderForm.pl?site=www.ama-assn.org&uri=%2fresources%2fdoc%2fPolicyFinder%2fpolicyfiles%2fDIR%2fD-373.999.HTM
13. Kon A: The shared decision-making continuum. JAMA 2010;304(8):903-904
14. American College of Physicians: Position Paper: Ethics Manual, Fifth Edition. Section on Informed Consent (p.563). Ann Intern Med. 2005; 142:560-582
15. Cegala D, Post D: The impact of patients’ participation on physicians’ patient-centered Communication. Patient Education and Counseling 2009;77:202–208
16. American Academy of Family Physicians: Patient Responsibility for Follow-Up of Diagnosis and Treatment. 2002. Accessed on July 15, 2011 at http://www.aafp.org/online/en/home/policy/policies/p/patientresponsibility.html
17. Evans H: Do patients have duties? J Med Ethics 2007;33:689–694.
18. American College of Surgeons: Statement of Principles. Principles II A. Accessed on July 12, 2011 at http://www.facs.org/fellows_info/statements/stonprin.html
19. American Medical Association: Policy E-8.115 Termination of the Physician-Patient Relationship. Accessed on July 14, 2011 at https://ssl3.ama-assn.org/apps/ecomm/PolicyFinderForm.pl?site=www.ama-assn.org&uri=%2fresources%2fdoc%2fPolicyFinder%2fpolicyfiles%2fHnE%2fE-8.115.HTM
20. American College of Surgeons: Statement of Principles. Principles II G. Accessed on July 12, 2011 at http://www.facs.org/fellows_info/statements/stonprin.html
21. American College of Physicians: Position Paper: Ethics Manual, Fifth Edition. Section on Initiating and Discontinuing the Patient–Physician Relationship (p.562). Ann Intern Med 2005; 142:560-582.

December 2011 American Academy of Orthopaedic Surgeons.

This material may not be modified without the express written permission of the American Academy of Orthopaedic Surgeons.

Position Statement 1182

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