When addressing uncertainty about clinicians’ roles, the physician should consider consultation with peers or even with their own ethics committee. Another resource could be an institutional review board (IRB). Traditionally IRBs address issues directly related to human-subject research. However, some boards are willing to weigh in if all other resources have been exhausted and a thorny issue remains unresolved.
For a primary ophthalmologic disease, the principal physician should probably be the ophthalmologist. However, this should be agreed upon early. Even when the rheumatologist is not the principal physician, he or she plays an important role. The patient’s needs should be paramount. These needs are not served well when the rheumatologist refuses to get involved. This is especially true when the referring clinician and patient need help and there is no obvious better alternative.
For the patient described, the best approach is a coordinated effort between the rheumatologist, ophthalmologist and patient. Continued open communication with coordinated treatment and close follow-up has the potential to produce the best outcome.
Back to the Patient
In the case above, the patient’s ophthalmologist initiated corticosteroid monotherapy. After evaluation by the rheumatologist, a collective decision was made to add mycophenolate mofetil and conservatively reduce the steroid dose. The ophthalmologist monitored the patient’s vision regularly during the slow steroid taper. The patient’s rheumatologist contributed by recommending therapies to help reduce bone loss, scheduling regular laboratory tests and monitoring for both prednisone and mycophenolate mofetil toxicity. The patient’s vision has remained stable over several months.
Questions for the Reader
How have you resolved cases in which clinicians’ roles were unclear? How would you have handled the case described above?
If you have comments or questions about this case, or if you have a case that you’d like to see in Ethics Forum, e-mail us at [email protected].
Kirk D. Jenkins, MD, is a first-year rheumatology fellow at the University of Kentucky in Lexington, Ky., and a member of the ACR’s Committee on Ethics and Conflict of Interest.
Robert H. Shmerling, MD, is the clinical chief of rheumatology at Beth Israel Deaconess Medical Center in Boston and the chair of the ACR’s Committee on Ethics and Conflict of Interest.
Rebecca B. Yarrison, PhD, is an assistant professor with the Program for Bioethics and a clinical ethicist at the University of Kentucky.
Kristine M. Lohr, MD, MS, is the rheumatology training program director, interim chief of the Division of Rheumatology and professor of medicine at the University of Kentucky.
References
- Monson DM, Smith JR. Acute zonal occult outer retinopathy. Surv Ophthalmol. 2011 Jan-Feb;56(1):23–35.
- Dresser R, Frader J. Off-label prescribing: A call for heightened professional and government oversight. J Law Med Ethics. 2009 Fall;37(3):476–486, 396.
- Snyder L, American College of Physicians Ethics, Professionalism, and Human Rights Committee. American College of Physicians Ethics Manual, 6th ed. Ann Intern Med. 2012 Jan 3;156(1 Pt 2):73–104.
- American College of Rheumatology. Code of Ethics of the American College of Rheumatology Inc. http://www.rheumatology.org/about/governance/code_ethics.asp. Published August 2011. Accessed March 10, 2014.
