“No man can serve two masters.”

That timeless wisdom comes to mind when one thinks of present day situations in the department’s Medical Division (a supposed adjunct of the Police Pension Fund [PPF], rather than the NYPD) and at the Police Pension System’s Medical Board. In the former, doctors working in the rank of inspector and above are required to discharge their oath to act in the best interests of their patients — New York City police officers — while at the same time discharging their obligations as superior officers in the NYPD. The confluence of the various medical, ethical and departmental rules and obligations that govern the physicians’ behavior in this context raises the very real potential for a conflict of interest:

The bottom line is that doctors employed by third parties — like the NYPD, where they’re employed to examine ill and injured officers — are by no means exempt from the physician’s code of conduct. As with all physicians, they are sworn to the Hippocratic Oath and are bound by other ethical rules, and their primary responsibility is to their patients.

Unfortunately, in the pressure-packed 2006 NYPD, doctors are hard-pressed not to help management achieve certain budgetary and operational objectives. Despite a contract that provides for unlimited sick benefits and despite pension laws that provide for benefits when an officer becomes disabled in the performance of duty, the fact is that some officers being out sick and others getting disability pensions have an impact on the city’s fiscal situation. The bureaucrats at the city’s Office of Management and Budget are keenly aware of this and prepare spending plans that generally require agencies to be more efficient in the management of budgeted resources. Senior NYPD management, looking to squeeze efficiencies out of an already efficient agency, may be unduly tempted to target cost-cutting measures in areas that really need to be treated with care, legally and because of the rules governing the conduct of the licensed professionals in those areas. This collision of interests creates a serious potential for conflict. And it becomes especially problematic when departmental pressure (explicit or implicit) begins to interfere with a physician’s independent professional judgment. Even the most scrupulous physician becomes confronted with an untenable choice — either fulfill one’s professional duty or properly discharge the orders of one’s employer.

Let’s consider some of the authority that governs the conduct of practicing physicians. The American Medical Association's (AMA) Code of Medical Ethics, first developed in 1847 and maintained and updated by the Council on Ethical and Judicial Affairs, outlines the “principles of medical ethics...standards of conduct” that “define the essentials of honorable behavior” for physicians.

“The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient,” the code says. “As a member of this profession, a physician must recognize responsibility to patients first and foremost (our underline), as well as to society, to other health professionals, and to self.”

The code goes on to list AMA-adopted principles — “not laws, but standards of conduct which define the essentials of honorable behavior for the physician.” These principles state that a physician shall:

“be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.

“uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.

“respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.

“respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.

“continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.

“in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.

“while caring for a patient, regard responsibility to the patient as paramount.

“support access to medical care for all people.”

(Adopted by the AMA's House of Delegates, June 17, 2001.)

The code goes on to discuss in separate detailed sections how these principles are interpreted and applied in actual practice. The section of particular interest to this discussion is E-10.03, “Patient-Physician Relationship in the Context of Work-Related and Independent Medical Examinations,” like examinations occurring at the NYPD and PPF. That section says:

“When a physician is responsible for performing an isolated assessment of an individual’s health or disability for an employer, business, or insurer, a limited patient-physician relationship should be considered to exist.

"Both "Industry Employed Physicians" (IEPs), who are employed by businesses or insurance companies for the purpose of conducting medical examinations, and Independent Medical Examiners" (IMEs), who are independent contractors providing medical examinations within the realm of their specialty, may perform such medical examinations.

“Despite their ties to a third party, the responsibilities of IEPs and IMEs are in some basic respects very similar to those of other physicians. IEPs and IMEs have the same obligations as physicians in other contexts to: (1) Evaluate objectively the patient’s health or disability. In order to maintain objectivity, IEPs and IMEs should not be influenced by the preferences of the patient-employee, employer, or insurance company (our underline) when making a diagnosis during a work-related or independent medical examination. (2) Maintain patient confidentiality as outlined by Opinion 5.09, "Industry Employed Physicians and Independent Medical Examiners." (3) Disclose fully potential or perceived conflicts of interest. The physician should inform the patient about the terms of the agreement between himself or herself and the third party as well as the fact that he or she is acting as an agent of that entity. This should be done at the outset of the examination, before health information is gathered from the patient-employee. Before the physician proceeds with the exam, he or she should ensure to the extent possible that the patient understands the physician’s unaltered ethical obligations, as well as the differences that exist between the physician’s role in this context and the physician’s traditional fiduciary role.

“IEPs and IMEs are responsible for administering an objective medical evaluation but not for monitoring patients’ health over time, treating patients, or fulfilling many other duties traditionally held by physicians. Consequently, a limited patient-physician relationship should be considered to exist during isolated assessments of an individual’s health or disability for an employer, business, or insurer.

“The physician has a responsibility to inform the patient about important health information or abnormalities that he or she discovers during the course of the examination. In addition, the physician should ensure to the extent possible that the patient understands the problem or diagnosis. Furthermore, when appropriate, the physician should suggest that the patient seek care from a qualified physician and, if requested, provide reasonable assistance in securing follow-up care.” — Issued December 1999, based on the report, “Patient-Physician Relationship in the Context of Work-Related and Independent Medical Examinations,” adopted June 1999.

Section E-10.03 indicates that decisions and actions by certain doctors at the Pension System and the department’s Medical Division may violate the AMA’s Code of Medical Ethics.

We will look at those decisions and actions in the next issue.

(First of two parts)