Society News

Talking to your patients about PPIs

AGA has developed talking points about research released associating PPIs with dementia, chronic kidney disease, and the latest research associating PPI use with all-cause mortality. These resources can help you educate your patients on the data and on the risks and benefits of using PPIs in their care.

• • PPIs and dementia: http://www.gastro.org/news_items/2017/07/20/how-to-talk-with-your-patients-about-ppis-and-dementia.
• • PPIs and chronic kidney disease: http://www.gastro.org/news_items/how-to-talk-with-patients-about-ppis-and-chronic-kidney-disease.
• • PPIs and all-cause mortality: http://www.gastro.org/news_items/a-guide-to-conversations-about-the-latest-ppi-research-results.

Talking to your colleagues about PPIs

AGA members have been discussing this new data linking PPIs to death. Weigh in by visiting the AGA Community, www.community.gastro.org.

Talking to your patients about PPIs

AGA has developed talking points about research released associating PPIs with dementia, chronic kidney disease, and the latest research associating PPI use with all-cause mortality. These resources can help you educate your patients on the data and on the risks and benefits of using PPIs in their care.

• • PPIs and dementia: http://www.gastro.org/news_items/2017/07/20/how-to-talk-with-your-patients-about-ppis-and-dementia.
• • PPIs and chronic kidney disease: http://www.gastro.org/news_items/how-to-talk-with-patients-about-ppis-and-chronic-kidney-disease.
• • PPIs and all-cause mortality: http://www.gastro.org/news_items/a-guide-to-conversations-about-the-latest-ppi-research-results.

Talking to your colleagues about PPIs

AGA members have been discussing this new data linking PPIs to death. Weigh in by visiting the AGA Community, www.community.gastro.org.

Talking to your patients about PPIs

AGA has developed talking points about research released associating PPIs with dementia, chronic kidney disease, and the latest research associating PPI use with all-cause mortality. These resources can help you educate your patients on the data and on the risks and benefits of using PPIs in their care.

• • PPIs and dementia: http://www.gastro.org/news_items/2017/07/20/how-to-talk-with-your-patients-about-ppis-and-dementia.
• • PPIs and chronic kidney disease: http://www.gastro.org/news_items/how-to-talk-with-patients-about-ppis-and-chronic-kidney-disease.
• • PPIs and all-cause mortality: http://www.gastro.org/news_items/a-guide-to-conversations-about-the-latest-ppi-research-results.

Talking to your colleagues about PPIs

AGA members have been discussing this new data linking PPIs to death. Weigh in by visiting the AGA Community, www.community.gastro.org.

In 2017, eligible clinicians can use the AGA Clinical Guidelines app — through attestation of its use — to meet your 2017 CMS Merit-based Incentive Payment System (MIPS) pick your pace requirements as one way to try to avoid a payment penalty in 2019. The AGA Clinical Guidelines app has also been proposed by CMS as a 2018 Improvement Activity under MIPS.

How do you attest for 2017?

First, search for and download the AGA Clinical Guidelines app via the Apple App Store or Google Play.

After actively using the AGA Clinical Guidelines app, you will be able, in the near future, to go to the CMS Enterprise Portal to attest that you have met the 2017 MIPS improvement activity participation requirement. AGA will let you know when the portal opens.

CMS lowered the cost performance category to 0% in the 2017 pick your pace year and gave clinicians three reporting options under MIPS.

• Option one: Report to MIPS for a full 90-day period or full year on quality, improvement activities, and advancing care information, and maximize the chance to qualify for positive payment adjustments.
• Option two: Report less than a year, but for the full 90-day period on one quality measure, more than one improvement activity, or more than the required measures in advancing care information to avoid penalties and receive a possible positive update.
• Option three: Report one quality measure, one improvement activity, or report measures of advancing care information to avoid penalty.

Advanced Alternative Payment Models are another way to participate in MACRA in 2017.

What are improvement activities?

The MIPS pathway under the Medicare Access and CHIP Reauthorization Act (MACRA), uses quality and cost data to determine your payment, and replaces the previous framework that included the Medicare EHR Incentive Program, the Physician Quality Reporting System and the Value-Based Payment Modifier program. Physicians participating in MIPS will be scored on four categories:

• Quality.
• Advancing care information.
• Improvement activities.
• Cost.

The AGA Clinical Guidelines app is one way to satisfy participation in the improvement activities category.

[email protected]

In 2017, eligible clinicians can use the AGA Clinical Guidelines app — through attestation of its use — to meet your 2017 CMS Merit-based Incentive Payment System (MIPS) pick your pace requirements as one way to try to avoid a payment penalty in 2019. The AGA Clinical Guidelines app has also been proposed by CMS as a 2018 Improvement Activity under MIPS.

How do you attest for 2017?

First, search for and download the AGA Clinical Guidelines app via the Apple App Store or Google Play.

After actively using the AGA Clinical Guidelines app, you will be able, in the near future, to go to the CMS Enterprise Portal to attest that you have met the 2017 MIPS improvement activity participation requirement. AGA will let you know when the portal opens.

CMS lowered the cost performance category to 0% in the 2017 pick your pace year and gave clinicians three reporting options under MIPS.

• Option one: Report to MIPS for a full 90-day period or full year on quality, improvement activities, and advancing care information, and maximize the chance to qualify for positive payment adjustments.
• Option two: Report less than a year, but for the full 90-day period on one quality measure, more than one improvement activity, or more than the required measures in advancing care information to avoid penalties and receive a possible positive update.
• Option three: Report one quality measure, one improvement activity, or report measures of advancing care information to avoid penalty.

Advanced Alternative Payment Models are another way to participate in MACRA in 2017.

What are improvement activities?

The MIPS pathway under the Medicare Access and CHIP Reauthorization Act (MACRA), uses quality and cost data to determine your payment, and replaces the previous framework that included the Medicare EHR Incentive Program, the Physician Quality Reporting System and the Value-Based Payment Modifier program. Physicians participating in MIPS will be scored on four categories:

• Quality.
• Advancing care information.
• Improvement activities.
• Cost.

The AGA Clinical Guidelines app is one way to satisfy participation in the improvement activities category.

[email protected]

In 2017, eligible clinicians can use the AGA Clinical Guidelines app — through attestation of its use — to meet your 2017 CMS Merit-based Incentive Payment System (MIPS) pick your pace requirements as one way to try to avoid a payment penalty in 2019. The AGA Clinical Guidelines app has also been proposed by CMS as a 2018 Improvement Activity under MIPS.

How do you attest for 2017?

First, search for and download the AGA Clinical Guidelines app via the Apple App Store or Google Play.

After actively using the AGA Clinical Guidelines app, you will be able, in the near future, to go to the CMS Enterprise Portal to attest that you have met the 2017 MIPS improvement activity participation requirement. AGA will let you know when the portal opens.

CMS lowered the cost performance category to 0% in the 2017 pick your pace year and gave clinicians three reporting options under MIPS.

• Option one: Report to MIPS for a full 90-day period or full year on quality, improvement activities, and advancing care information, and maximize the chance to qualify for positive payment adjustments.
• Option two: Report less than a year, but for the full 90-day period on one quality measure, more than one improvement activity, or more than the required measures in advancing care information to avoid penalties and receive a possible positive update.
• Option three: Report one quality measure, one improvement activity, or report measures of advancing care information to avoid penalty.

Advanced Alternative Payment Models are another way to participate in MACRA in 2017.

What are improvement activities?

The MIPS pathway under the Medicare Access and CHIP Reauthorization Act (MACRA), uses quality and cost data to determine your payment, and replaces the previous framework that included the Medicare EHR Incentive Program, the Physician Quality Reporting System and the Value-Based Payment Modifier program. Physicians participating in MIPS will be scored on four categories:

• Quality.
• Advancing care information.
• Improvement activities.
• Cost.

The AGA Clinical Guidelines app is one way to satisfy participation in the improvement activities category.

[email protected]

AGA is proud to share that the AGA Future Leaders Program has been recognized with the 2017 Power of A Silver Award from the American Society of Association Executives. The Power of A Awards recognize a select number of organizations annually for innovative and effective programs that have a positive impact. The Power of A Awards are the association industry’s highest honor.

The AGA Future Leaders Program, which launched in March 2015, provides a pathway for selected participants to develop the leadership skills necessary to serve AGA. The 1.5-year program provides opportunities for participants to network, connect with mentors, develop leadership skills, and learn about AGA’s governance and operations while advancing their careers and supporting the profession. During the program, participants work on creating fresh and innovative projects to support AGA and the field.

The AGA Future Leaders Program’s commitment to encouraging innovation and building the GI workforce are key reasons it was recognized with this prestigious award.

Please join us in congratulating all of the AGA Future Leaders Program participants, mentors, program chairs, and staff for their part in this accomplishment. To learn more about this program, visit the AGA Future Leaders Program web page, http://www.gastro.org/about/initiatives/aga-future-leaders-program.
 

[email protected]

AGA is proud to share that the AGA Future Leaders Program has been recognized with the 2017 Power of A Silver Award from the American Society of Association Executives. The Power of A Awards recognize a select number of organizations annually for innovative and effective programs that have a positive impact. The Power of A Awards are the association industry’s highest honor.

The AGA Future Leaders Program, which launched in March 2015, provides a pathway for selected participants to develop the leadership skills necessary to serve AGA. The 1.5-year program provides opportunities for participants to network, connect with mentors, develop leadership skills, and learn about AGA’s governance and operations while advancing their careers and supporting the profession. During the program, participants work on creating fresh and innovative projects to support AGA and the field.

The AGA Future Leaders Program’s commitment to encouraging innovation and building the GI workforce are key reasons it was recognized with this prestigious award.

Please join us in congratulating all of the AGA Future Leaders Program participants, mentors, program chairs, and staff for their part in this accomplishment. To learn more about this program, visit the AGA Future Leaders Program web page, http://www.gastro.org/about/initiatives/aga-future-leaders-program.
 

[email protected]

AGA is proud to share that the AGA Future Leaders Program has been recognized with the 2017 Power of A Silver Award from the American Society of Association Executives. The Power of A Awards recognize a select number of organizations annually for innovative and effective programs that have a positive impact. The Power of A Awards are the association industry’s highest honor.

The AGA Future Leaders Program, which launched in March 2015, provides a pathway for selected participants to develop the leadership skills necessary to serve AGA. The 1.5-year program provides opportunities for participants to network, connect with mentors, develop leadership skills, and learn about AGA’s governance and operations while advancing their careers and supporting the profession. During the program, participants work on creating fresh and innovative projects to support AGA and the field.

The AGA Future Leaders Program’s commitment to encouraging innovation and building the GI workforce are key reasons it was recognized with this prestigious award.

Please join us in congratulating all of the AGA Future Leaders Program participants, mentors, program chairs, and staff for their part in this accomplishment. To learn more about this program, visit the AGA Future Leaders Program web page, http://www.gastro.org/about/initiatives/aga-future-leaders-program.
 

[email protected]

The SVS Patient Safety Organization and M2S, in conjunction with the SVS, presented a webinar last month on getting started in the Medicare reimbursement program, including the Merit-based Incentive Payment System (MIPS).

For those who couldn't attend, it is posted, along with the presentation slides, on the Vascular Quality Initiative website's home page. View it today to get up to speed on MIPS and MACRA (Medicare Access and CHIP Reauthorization Act of 2015). 

The SVS Patient Safety Organization and M2S, in conjunction with the SVS, presented a webinar last month on getting started in the Medicare reimbursement program, including the Merit-based Incentive Payment System (MIPS).

For those who couldn't attend, it is posted, along with the presentation slides, on the Vascular Quality Initiative website's home page. View it today to get up to speed on MIPS and MACRA (Medicare Access and CHIP Reauthorization Act of 2015). 

The SVS Patient Safety Organization and M2S, in conjunction with the SVS, presented a webinar last month on getting started in the Medicare reimbursement program, including the Merit-based Incentive Payment System (MIPS).

For those who couldn't attend, it is posted, along with the presentation slides, on the Vascular Quality Initiative website's home page. View it today to get up to speed on MIPS and MACRA (Medicare Access and CHIP Reauthorization Act of 2015). 

Where are they now? What have they been up to? CHEST’s Past Presidents each forged the way for the many successes of the American College of Chest Physicians, leading to enhanced patient care around the globe. Their outstanding leadership and vision are evidenced today in many of CHEST’s strategic initiatives. Let’s check in with Dr. Goldberg.

I arrived in Toronto in 1998 to start my term as President of the American College of Chest Physicians. (I had always loved Toronto, where I had spent months training in pediatric critical care at “Sick Kids” [Toronto’s Children’s Hospital] and collaborating with Audrey King on disability issues and public policy in Ontario.) CHEST 1998 in Toronto was equally exciting. What I remember - with humility – was that being CHEST President is not about “you.” It is about “The President,” who is honored and revered by all members for what CHEST truly represents … excellence in health-care education, communication, and information. Everyone came up to me to respect and honor the role … including awesome Past Presidents who lovingly shared their insights and experience and others (including many who became future presidents) to volunteer their assistance. I was in awe of these leaders and how they demonstrated selfless service.

And so I began my year of presidential service leadership. What I remember best is the respect all around the world for CHEST and what it does to unite people into actions that improve health globally. The President serves CHEST members to facilitate working together, which makes a difference. My presidential year culminated in the 65th anniversary conference in Chicago in 1999. All year, I had worked with my mentor (C. Everett Koop, MD, FCCP(Hon), to plan an opening ceremony that would be inspirational and unforgettable. For years, we had shared personal/private conversations. This time, we planned to communicate in public to inspire others and help them understand key issues we considered critical for the future of health care and global health.

Soon after my Presidential term, I took 2 years off for sabbatical to work more closely with Dr. Koop (2000-2002). Then, I retired to continue to focus on our work together and as personal caregiver for my wife, Evi Faure, MD, FCCP. Dr. Koop and I met many times and also held more public presentations, including the 2003 Surgeons’ General National Meeting on Overcoming Health Disparities at Howard University arranged with CHEST Past President Dr. Alvin Thomas.

All our joint efforts focused on the importance of Communication in Health Care. We shared the belief that communication of health information would create the “informed patient and family” who would then work together in partnership with health-care professional team members. We thought that this would be the best way to improve and reform health-care delivery. We sought to provide information (the “what”) in ways that it would be trusted, understandable, and easily usable (the “how) for patients and famili

http://www.chestnet.org/News/Blogs/CHEST-Thought-Leaders/2013/06/Dr-Koops-Legacy-Reflections-on-Mentorship

http://www.chestnet.org/News/Blogs/CHEST-Thought-Leaders/2013/08/The-Legacy-of-Dr-Koop-Reflections-on-Our-Fireside-Chat

Where are they now? What have they been up to? CHEST’s Past Presidents each forged the way for the many successes of the American College of Chest Physicians, leading to enhanced patient care around the globe. Their outstanding leadership and vision are evidenced today in many of CHEST’s strategic initiatives. Let’s check in with Dr. Goldberg.

I arrived in Toronto in 1998 to start my term as President of the American College of Chest Physicians. (I had always loved Toronto, where I had spent months training in pediatric critical care at “Sick Kids” [Toronto’s Children’s Hospital] and collaborating with Audrey King on disability issues and public policy in Ontario.) CHEST 1998 in Toronto was equally exciting. What I remember - with humility – was that being CHEST President is not about “you.” It is about “The President,” who is honored and revered by all members for what CHEST truly represents … excellence in health-care education, communication, and information. Everyone came up to me to respect and honor the role … including awesome Past Presidents who lovingly shared their insights and experience and others (including many who became future presidents) to volunteer their assistance. I was in awe of these leaders and how they demonstrated selfless service.

And so I began my year of presidential service leadership. What I remember best is the respect all around the world for CHEST and what it does to unite people into actions that improve health globally. The President serves CHEST members to facilitate working together, which makes a difference. My presidential year culminated in the 65th anniversary conference in Chicago in 1999. All year, I had worked with my mentor (C. Everett Koop, MD, FCCP(Hon), to plan an opening ceremony that would be inspirational and unforgettable. For years, we had shared personal/private conversations. This time, we planned to communicate in public to inspire others and help them understand key issues we considered critical for the future of health care and global health.

Soon after my Presidential term, I took 2 years off for sabbatical to work more closely with Dr. Koop (2000-2002). Then, I retired to continue to focus on our work together and as personal caregiver for my wife, Evi Faure, MD, FCCP. Dr. Koop and I met many times and also held more public presentations, including the 2003 Surgeons’ General National Meeting on Overcoming Health Disparities at Howard University arranged with CHEST Past President Dr. Alvin Thomas.

All our joint efforts focused on the importance of Communication in Health Care. We shared the belief that communication of health information would create the “informed patient and family” who would then work together in partnership with health-care professional team members. We thought that this would be the best way to improve and reform health-care delivery. We sought to provide information (the “what”) in ways that it would be trusted, understandable, and easily usable (the “how) for patients and famili

http://www.chestnet.org/News/Blogs/CHEST-Thought-Leaders/2013/06/Dr-Koops-Legacy-Reflections-on-Mentorship

http://www.chestnet.org/News/Blogs/CHEST-Thought-Leaders/2013/08/The-Legacy-of-Dr-Koop-Reflections-on-Our-Fireside-Chat

Where are they now? What have they been up to? CHEST’s Past Presidents each forged the way for the many successes of the American College of Chest Physicians, leading to enhanced patient care around the globe. Their outstanding leadership and vision are evidenced today in many of CHEST’s strategic initiatives. Let’s check in with Dr. Goldberg.

I arrived in Toronto in 1998 to start my term as President of the American College of Chest Physicians. (I had always loved Toronto, where I had spent months training in pediatric critical care at “Sick Kids” [Toronto’s Children’s Hospital] and collaborating with Audrey King on disability issues and public policy in Ontario.) CHEST 1998 in Toronto was equally exciting. What I remember - with humility – was that being CHEST President is not about “you.” It is about “The President,” who is honored and revered by all members for what CHEST truly represents … excellence in health-care education, communication, and information. Everyone came up to me to respect and honor the role … including awesome Past Presidents who lovingly shared their insights and experience and others (including many who became future presidents) to volunteer their assistance. I was in awe of these leaders and how they demonstrated selfless service.

And so I began my year of presidential service leadership. What I remember best is the respect all around the world for CHEST and what it does to unite people into actions that improve health globally. The President serves CHEST members to facilitate working together, which makes a difference. My presidential year culminated in the 65th anniversary conference in Chicago in 1999. All year, I had worked with my mentor (C. Everett Koop, MD, FCCP(Hon), to plan an opening ceremony that would be inspirational and unforgettable. For years, we had shared personal/private conversations. This time, we planned to communicate in public to inspire others and help them understand key issues we considered critical for the future of health care and global health.

Soon after my Presidential term, I took 2 years off for sabbatical to work more closely with Dr. Koop (2000-2002). Then, I retired to continue to focus on our work together and as personal caregiver for my wife, Evi Faure, MD, FCCP. Dr. Koop and I met many times and also held more public presentations, including the 2003 Surgeons’ General National Meeting on Overcoming Health Disparities at Howard University arranged with CHEST Past President Dr. Alvin Thomas.

All our joint efforts focused on the importance of Communication in Health Care. We shared the belief that communication of health information would create the “informed patient and family” who would then work together in partnership with health-care professional team members. We thought that this would be the best way to improve and reform health-care delivery. We sought to provide information (the “what”) in ways that it would be trusted, understandable, and easily usable (the “how) for patients and famili

http://www.chestnet.org/News/Blogs/CHEST-Thought-Leaders/2013/06/Dr-Koops-Legacy-Reflections-on-Mentorship

http://www.chestnet.org/News/Blogs/CHEST-Thought-Leaders/2013/08/The-Legacy-of-Dr-Koop-Reflections-on-Our-Fireside-Chat

July 4th was bittersweet for me, this year. Independence days of my childhood were spent grilling, sitting by the campfire on the lakes and rivers of Northern Michigan, watching the fireworks turn the night sky red, white, and blue. These fond memories were a painful reminder that others like me may not have the privilege to experience such joy, secondary to their background.

I don’t remember the first time that I heard the tale of my parents coming to America. They were both medical students from India, who received brightly colored brochures from American hospitals inviting them to come further their medical training. Due to the deficit of physicians in the United States, the hospitals even loaned money to medical students, so they would do their residencies in America. My parents took advantage of this opportunity and embarked on a journey that would define their lives. Often, my mother would talk about my father leaving for the hospital on Friday morning only to return to his wife and two toddlers on Monday afternoon. As a child, I remember my uncles taking bottles of milk to the hospital to make chai to fuel through their grueling overnight calls. These immigrant tales were the backdrop of my childhood, the basis of my understanding of America. I was raised in an immigrant community of physicians who were grateful for the opportunities that America offered them. They worked hard, reaped significant rewards, and substantially contributed to their communities. Maybe, I am just nostalgic for my childhood, but this experience, I believe, is still an integral part of the American dream.

The recent choice to restrict immigration from specific nations is disturbing at best and reminiscent of an America that I have never known. More than 7,000 physicians from Libya, Iran, Somalia, Sudan, Syria, and Yemen are currently working in the United States, providing care for more than 14 million people. An estimated 94% of American communities have at least one doctor from one of the targeted countries. These physicians are more likely to work in rural and underserved communities and provide essential services.¹ They are immigrants who have come to America to better their lives and, in turn, have bettered the lives of those around them. They are my parents. Not all physicians are good people or are worthy of the American dream, but America is a better place for welcoming those who are willing to work hard to make a better life for themselves. An important criticism of the effect of migration of medical professionals to the United States has been the loss of human capital to their respective nations, but never the ill-effect they have had on the nations they have emigrated to.

• Reinstate the Visa Interview Waiver Program, as the suspension of this program increases the risk for significant delays in new and renewal visa processing for trainees from any foreign country;

• Remove entry restrictions of physicians and medical students from the seven designated countries that have been approved for J-1, H-1B or F-1 visas;

• Allow affected physicians to obtain travel visas to visit the United States for medical conferences, as well as other medical and research related events; and

• Prioritize the admission of refugees with urgent medical needs who had already been checked and approved for entry prior to the executive order.

These recommendations were good but not broad enough. The decision to bar immigration for any period of time, from any country, is an affront to the American dream with long-lasting consequences, most importantly, the loss of health-care services to the American populace. My Congressman knows how I feel about this, does yours?

1. Fivethirtyeight.com/features/trumps-new-travel-ban-could-affect-doctors-especially-in-the-rust-belt-and-appalachia/.Accessed July 18, 2017.

2. Masri A, Senussi MH. Trump’s executive order on immigration—detrimental effects on medical training and health care. N Engl J Med. 2017; 376(19): e39.

3. http://www.immigrationresearch-info.org/report/immigrant-learning-center-inc/immigrants-health-care-keeping-americans-healthy-through-care-a.Accessed July 27, 2017.

4. http://www.nfap.com/wp-content/uploads/2015/05/International-Educator.May-June-2015.pdf.Accessed July 27, 2017 (not available on Safari).

July 4th was bittersweet for me, this year. Independence days of my childhood were spent grilling, sitting by the campfire on the lakes and rivers of Northern Michigan, watching the fireworks turn the night sky red, white, and blue. These fond memories were a painful reminder that others like me may not have the privilege to experience such joy, secondary to their background.

I don’t remember the first time that I heard the tale of my parents coming to America. They were both medical students from India, who received brightly colored brochures from American hospitals inviting them to come further their medical training. Due to the deficit of physicians in the United States, the hospitals even loaned money to medical students, so they would do their residencies in America. My parents took advantage of this opportunity and embarked on a journey that would define their lives. Often, my mother would talk about my father leaving for the hospital on Friday morning only to return to his wife and two toddlers on Monday afternoon. As a child, I remember my uncles taking bottles of milk to the hospital to make chai to fuel through their grueling overnight calls. These immigrant tales were the backdrop of my childhood, the basis of my understanding of America. I was raised in an immigrant community of physicians who were grateful for the opportunities that America offered them. They worked hard, reaped significant rewards, and substantially contributed to their communities. Maybe, I am just nostalgic for my childhood, but this experience, I believe, is still an integral part of the American dream.

The recent choice to restrict immigration from specific nations is disturbing at best and reminiscent of an America that I have never known. More than 7,000 physicians from Libya, Iran, Somalia, Sudan, Syria, and Yemen are currently working in the United States, providing care for more than 14 million people. An estimated 94% of American communities have at least one doctor from one of the targeted countries. These physicians are more likely to work in rural and underserved communities and provide essential services.¹ They are immigrants who have come to America to better their lives and, in turn, have bettered the lives of those around them. They are my parents. Not all physicians are good people or are worthy of the American dream, but America is a better place for welcoming those who are willing to work hard to make a better life for themselves. An important criticism of the effect of migration of medical professionals to the United States has been the loss of human capital to their respective nations, but never the ill-effect they have had on the nations they have emigrated to.

• Reinstate the Visa Interview Waiver Program, as the suspension of this program increases the risk for significant delays in new and renewal visa processing for trainees from any foreign country;

• Remove entry restrictions of physicians and medical students from the seven designated countries that have been approved for J-1, H-1B or F-1 visas;

• Allow affected physicians to obtain travel visas to visit the United States for medical conferences, as well as other medical and research related events; and

• Prioritize the admission of refugees with urgent medical needs who had already been checked and approved for entry prior to the executive order.

These recommendations were good but not broad enough. The decision to bar immigration for any period of time, from any country, is an affront to the American dream with long-lasting consequences, most importantly, the loss of health-care services to the American populace. My Congressman knows how I feel about this, does yours?

1. Fivethirtyeight.com/features/trumps-new-travel-ban-could-affect-doctors-especially-in-the-rust-belt-and-appalachia/.Accessed July 18, 2017.

2. Masri A, Senussi MH. Trump’s executive order on immigration—detrimental effects on medical training and health care. N Engl J Med. 2017; 376(19): e39.

3. http://www.immigrationresearch-info.org/report/immigrant-learning-center-inc/immigrants-health-care-keeping-americans-healthy-through-care-a.Accessed July 27, 2017.

4. http://www.nfap.com/wp-content/uploads/2015/05/International-Educator.May-June-2015.pdf.Accessed July 27, 2017 (not available on Safari).

July 4th was bittersweet for me, this year. Independence days of my childhood were spent grilling, sitting by the campfire on the lakes and rivers of Northern Michigan, watching the fireworks turn the night sky red, white, and blue. These fond memories were a painful reminder that others like me may not have the privilege to experience such joy, secondary to their background.

I don’t remember the first time that I heard the tale of my parents coming to America. They were both medical students from India, who received brightly colored brochures from American hospitals inviting them to come further their medical training. Due to the deficit of physicians in the United States, the hospitals even loaned money to medical students, so they would do their residencies in America. My parents took advantage of this opportunity and embarked on a journey that would define their lives. Often, my mother would talk about my father leaving for the hospital on Friday morning only to return to his wife and two toddlers on Monday afternoon. As a child, I remember my uncles taking bottles of milk to the hospital to make chai to fuel through their grueling overnight calls. These immigrant tales were the backdrop of my childhood, the basis of my understanding of America. I was raised in an immigrant community of physicians who were grateful for the opportunities that America offered them. They worked hard, reaped significant rewards, and substantially contributed to their communities. Maybe, I am just nostalgic for my childhood, but this experience, I believe, is still an integral part of the American dream.

The recent choice to restrict immigration from specific nations is disturbing at best and reminiscent of an America that I have never known. More than 7,000 physicians from Libya, Iran, Somalia, Sudan, Syria, and Yemen are currently working in the United States, providing care for more than 14 million people. An estimated 94% of American communities have at least one doctor from one of the targeted countries. These physicians are more likely to work in rural and underserved communities and provide essential services.¹ They are immigrants who have come to America to better their lives and, in turn, have bettered the lives of those around them. They are my parents. Not all physicians are good people or are worthy of the American dream, but America is a better place for welcoming those who are willing to work hard to make a better life for themselves. An important criticism of the effect of migration of medical professionals to the United States has been the loss of human capital to their respective nations, but never the ill-effect they have had on the nations they have emigrated to.

• Reinstate the Visa Interview Waiver Program, as the suspension of this program increases the risk for significant delays in new and renewal visa processing for trainees from any foreign country;

• Remove entry restrictions of physicians and medical students from the seven designated countries that have been approved for J-1, H-1B or F-1 visas;

• Allow affected physicians to obtain travel visas to visit the United States for medical conferences, as well as other medical and research related events; and

• Prioritize the admission of refugees with urgent medical needs who had already been checked and approved for entry prior to the executive order.

These recommendations were good but not broad enough. The decision to bar immigration for any period of time, from any country, is an affront to the American dream with long-lasting consequences, most importantly, the loss of health-care services to the American populace. My Congressman knows how I feel about this, does yours?

1. Fivethirtyeight.com/features/trumps-new-travel-ban-could-affect-doctors-especially-in-the-rust-belt-and-appalachia/.Accessed July 18, 2017.

2. Masri A, Senussi MH. Trump’s executive order on immigration—detrimental effects on medical training and health care. N Engl J Med. 2017; 376(19): e39.

3. http://www.immigrationresearch-info.org/report/immigrant-learning-center-inc/immigrants-health-care-keeping-americans-healthy-through-care-a.Accessed July 27, 2017.

4. http://www.nfap.com/wp-content/uploads/2015/05/International-Educator.May-June-2015.pdf.Accessed July 27, 2017 (not available on Safari).

Dear CHEST Leaders, Members, and Friends:

The Forum of International Respiratory Societies (FIRS) is an organization comprised of the world’s leading international professional respiratory societies presenting a unifying voice to improve lung health globally. Its members are: the American College of Chest Physicians (CHEST), American Thoracic Society (ATS), Asian Pacific Society of Respirology (APSR), Asociación Latino Americana De Tórax (ALAT), European Respiratory Society (ERS), International Union Against Tuberculosis and Lung Diseases (The Union), the Pan African Thoracic Society (PATS), the Global Initiative for Chronic Obstructive Lung Disease (GOLD), and the Global Initiative for Asthma (GINA). FIRS has more than 70,000 professional members; the physicians and patients they serve magnify our efforts, allowing FIRS to speak for lung health on a global scale.

FIRS is working with the World Health Organization and the United Nations to make sure lung health is represented in national health agendas. FIRS’ position paper on electronic nicotine delivery systems was presented at a side-event at the United Nations High-Level Meeting (UNHL) in New York in 2014 and is now a world standard. At the recent World Health Assembly meeting (May 2017) in Geneva, FIRS launched its Global Impact of Lung Disease report that called for a global clean air standard, strong anti-tobacco laws, and better health care for patients with respiratory disease.

FIRS will be reviewing the new WHO Global Air Quality Guidelines and will help promote them globally through advocacy and messaging, as well as by providing air quality expertise. FIRS will be involved at the Coimbra meeting (Sept 26-29) on improving the urban environment, the Montevideo UN High-Level (UNHL) meeting on chronic disease (Oct 18-20), and the UN Ministerial Meeting in Moscow on tuberculosis, and it is preparing for the 2018 UNHL meetings on antibiotic drug resistance, tuberculosis, and chronic diseases.

Gerard Silvestri, MD, MS, FCCP

CHEST President

Darcy Marciniuk, MD, FCCP

CHEST FIRS Liaison

Dear CHEST Leaders, Members, and Friends:

The Forum of International Respiratory Societies (FIRS) is an organization comprised of the world’s leading international professional respiratory societies presenting a unifying voice to improve lung health globally. Its members are: the American College of Chest Physicians (CHEST), American Thoracic Society (ATS), Asian Pacific Society of Respirology (APSR), Asociación Latino Americana De Tórax (ALAT), European Respiratory Society (ERS), International Union Against Tuberculosis and Lung Diseases (The Union), the Pan African Thoracic Society (PATS), the Global Initiative for Chronic Obstructive Lung Disease (GOLD), and the Global Initiative for Asthma (GINA). FIRS has more than 70,000 professional members; the physicians and patients they serve magnify our efforts, allowing FIRS to speak for lung health on a global scale.

FIRS is working with the World Health Organization and the United Nations to make sure lung health is represented in national health agendas. FIRS’ position paper on electronic nicotine delivery systems was presented at a side-event at the United Nations High-Level Meeting (UNHL) in New York in 2014 and is now a world standard. At the recent World Health Assembly meeting (May 2017) in Geneva, FIRS launched its Global Impact of Lung Disease report that called for a global clean air standard, strong anti-tobacco laws, and better health care for patients with respiratory disease.

FIRS will be reviewing the new WHO Global Air Quality Guidelines and will help promote them globally through advocacy and messaging, as well as by providing air quality expertise. FIRS will be involved at the Coimbra meeting (Sept 26-29) on improving the urban environment, the Montevideo UN High-Level (UNHL) meeting on chronic disease (Oct 18-20), and the UN Ministerial Meeting in Moscow on tuberculosis, and it is preparing for the 2018 UNHL meetings on antibiotic drug resistance, tuberculosis, and chronic diseases.

Gerard Silvestri, MD, MS, FCCP

CHEST President

Darcy Marciniuk, MD, FCCP

CHEST FIRS Liaison

Dear CHEST Leaders, Members, and Friends:

The Forum of International Respiratory Societies (FIRS) is an organization comprised of the world’s leading international professional respiratory societies presenting a unifying voice to improve lung health globally. Its members are: the American College of Chest Physicians (CHEST), American Thoracic Society (ATS), Asian Pacific Society of Respirology (APSR), Asociación Latino Americana De Tórax (ALAT), European Respiratory Society (ERS), International Union Against Tuberculosis and Lung Diseases (The Union), the Pan African Thoracic Society (PATS), the Global Initiative for Chronic Obstructive Lung Disease (GOLD), and the Global Initiative for Asthma (GINA). FIRS has more than 70,000 professional members; the physicians and patients they serve magnify our efforts, allowing FIRS to speak for lung health on a global scale.

FIRS is working with the World Health Organization and the United Nations to make sure lung health is represented in national health agendas. FIRS’ position paper on electronic nicotine delivery systems was presented at a side-event at the United Nations High-Level Meeting (UNHL) in New York in 2014 and is now a world standard. At the recent World Health Assembly meeting (May 2017) in Geneva, FIRS launched its Global Impact of Lung Disease report that called for a global clean air standard, strong anti-tobacco laws, and better health care for patients with respiratory disease.

FIRS will be reviewing the new WHO Global Air Quality Guidelines and will help promote them globally through advocacy and messaging, as well as by providing air quality expertise. FIRS will be involved at the Coimbra meeting (Sept 26-29) on improving the urban environment, the Montevideo UN High-Level (UNHL) meeting on chronic disease (Oct 18-20), and the UN Ministerial Meeting in Moscow on tuberculosis, and it is preparing for the 2018 UNHL meetings on antibiotic drug resistance, tuberculosis, and chronic diseases.

Gerard Silvestri, MD, MS, FCCP

CHEST President

Darcy Marciniuk, MD, FCCP

CHEST FIRS Liaison

When I invited Dr. Wes Ely – the coauthor of a recent article regarding physician-assisted suicide – to write a Critical Care Commentary on said topic, an interesting thing happened: he declined and suggested that I invite a group of students from medical schools across the country to write the piece instead. The idea was brilliant, and the resulting piece was so insightful that the CHEST® journal editorial leadership suggested submission to the journal, and the accepted article will appear in the September issue. Out of that effort, the idea for the present piece was born. The result is an opportunity to hear the students’ voices, not only to stimulate discussion on conscientious objection in medicine but also to remind the ICU community that our learners have their own opinions and that through dialogues such as this, we might all learn from one another.

Lee Morrow, MD, FCCP

“No provision in our Constitution ought to be dearer to man than that which protects the rights of conscience against the enterprises of the civil authority.” – Thomas Jefferson

(Washington HA. The Writings of Thomas Jefferson. New York: Biker, Thorne, & Co. 1854,; Vol 3:147.)

What is the proper role of conscience in medicine? A recent article in the New England Journal of Medicine (Stahl & Emmanuel. N Engl J Med. 2017; 376(14):1380) is the latest to address this question. It is often argued that physicians who cite conscience in refusing to perform requested procedures or treatments necessarily infringe upon patients’ rights. However, we feel that these concerns stem from a fundamental misunderstanding of what conscience is, why it ought to be respected as an indispensable part of medical judgment (Genuis & Lipp . Int J Family Med. 2013; Epub 2013 Dec 12), and how conscience is oriented toward the end goal of health, which we pursue in medicine.

By failing to define “conscience,” the crux of the argument against conscience rights is built on the basis of an implied diminution of conscience from an imperative moral judgment down to mere personal preference. If conscience represents only personal preference – if it is limited to a set of choices of the same moral equivalent as the selection of an ice cream flavor, with no need for technical expertise—then it would follow that a physician ought to simply comply with the patient’s decisions in any given medical situation. However, we know intuitively that this line of reasoning cannot hold, if followed to its conclusion. For example, if a patient presenting with symptoms of clear rhinorrhea and dry cough in December asks for an antibiotic, through this patient-sovereignty model, the physician surely ought to provide the prescription to honor the patient’s request. The patient would have every right to insist on the antibiotic, and the physician would be obliged to prescribe accordingly. We, as students, are trained, however, that it would be morally and professionally fitting, even obligatory, for the physician to refuse this request, precisely through exercise of his/her professional conscience.

If conscience, then, is not simply a subject of one’s personal preferences, how are we to properly understand it? Conscience is “a person’s moral sense of right and wrong, viewed as acting as a guide to one’s behavior” (Conscience. Oxford Dictionary. Oxford, Oxford University Press. 2017). It exhibits the commitment to engage in a “self-conscience activity, integrating reason, emotion, and will, in self-committed decisions about right and wrong, good and evil” (Sulmasy. Theor Med Bioeth. 2008; 29(3):135). Whether or not a person intentionally seeks to form his/her conscience, it continues to be molded through the regular actions of daily life. The actions we perform – and those we omit – constantly shape our individual consciences. One’s conscience can indeed err due to emotional imbalance or faulty reasoning, but, even in these instances, it is essential to invest in the proper shaping of conscience in accordance with truth and goodness, rather than to reject the place of conscience altogether.

By attributing appropriate value to an individual’s conscience, we thereby recognize the centrality of conscience to identity and personal integrity. Consequently, we see that forcing an individual to impinge on his/her conscience through coercive means incidentally violates that person’s autonomy and dignity as a human being capable of moral decision-making.

In the practice of medicine, the free exercise of conscience is especially relevant. When patients and physicians meet to act in the pursuit of the patient’s health, they begin the process of conscience-mediated shared decision-making, rife with the potential for disagreement. Throughout this process, a physician should not violate a patient’s conscience rights by forcing medical treatment where it is unwanted, but neither should a patient violate a physician’s conscience rights by demanding a procedure or treatment that the physician cannot perform in good conscience. Moreover, to insert an external arbiter (eg, a professional society) to resolve the situation by means of contradiction of conscience would have the same violating effect on one or both parties.

One common debate as to the application of conscience in the setting of critical care focuses on the issue of physician-assisted suicide and euthanasia (PAS/E) (Rhee J, et al. Chest. 2017;152[3]. Accepted for Sept 2017 publication). Those who would deny physicians the right to conscientiously object to PAS/E depict this as merely an issue of the physician’s personal preference. Given the distinction between preference and conscience, however, we recognize that much more is at play. For students and practitioners who hold that health signifies the “well-working of the organism as a whole,” (Kass L. Public Interest. 1975; 40(summer):11-42) and feel that the killing of a patient is an action that goes directly against the health of the patient, the obligation to participate in PAS/E represents not only a violation of our decision-making dignity, but also subverts the critical component of clinical judgment inherent to our profession. The conscientiously practicing doctor who follows what they believe to be their professional obligations, acting in accordance with the health of the patient, may reasonably conclude that PAS/E directly contradicts their obligations to pursue the best health interests of the patient. As such, their refusal to participate can hardly be deemed a simple personal preference, as the refusal is both reasoned and reasonable. Indeed, experts have concluded that regardless of the legality of PAS/E, physicians must be allowed to conscientiously object to participate (Goligher et al. Crit Care Med. 2017; 45(2):149).

As medical students who have recently gone through the arduous medical school application process, we are particularly concerned with the claim that if one sees fit to exercise conscientious objection as a practitioner, they should leave medicine, or choose a field in medicine with few ethical dilemmas. To crassly exclude students from the pursuit of medicine on the basis of the shape of their conscience would be to unjustly discriminate by assigning different values to genuinely held beliefs. A direct consequence of this exclusion would be to decrease the diversity of thought, which is central to medical innovation and medical progress. History has taught us that the frontiers of medical advancement are most ardently pursued by those who think deeply and then dare to act creatively, seeking to bring to fruition what others deemed impossible. Without conscience rights, physicians are not free to think for themselves. We find it hard to believe that many physicians would feel comfortable jettisoning conscience in all instances where it may go against the wishes of their patients or the consensus opinion of the profession.

Furthermore, as medical students, we are acutely aware of the importance of conscientious objection due to the extant hierarchical nature of medical training. Evaluations are often performed by residents and physicians in places of authority, so students will readily subjugate everything from bodily needs to conscience in order to appease their attending physicians. Evidence indicates that medical students will even fail to object when they recognize medical errors performed by their superiors (Madigosky WS, et al. Acad Med. 2006; 81(1):94).

It is, therefore, crucial to the proper formation of medical students that our exercise of conscience be safeguarded during our training. A student who is free to exercise conscience is a student who is learning to think independently, as well as to shoulder the responsibility that comes as a consequence of free choices.

Ultimately, we must ask ourselves: how is the role of the physician altered if we choose to minimize the role of conscience in medicine? And do patients truly want physicians who forfeit their consciences even in matters of life and death? If we take the demands of those who dismiss conscience to their end – that only those willing to put their conscience aside should enter medicine – we would be left with practitioners whose group think training would stifle discussion between physicians and patients, and whose role would be reduced to simply acquiescing to any and all demands of the patient, even to their own detriment. Such a group of people, in our view, would fail to be physicians.

Author Affiliations: Geisel School of Medicine at Dartmouth, Hanover, NH (Dr. Dumitru); University of North Carolina School of Medicine, Chapel Hill, NC (Mr. Frush); Ohio University Heritage College of Osteopathic Medicine, Athens, OH (Mr. Radlicz); Columbia University College of Physicians and Surgeons, New York, NY (Mr. Allen); Thomas Jefferson School of Medicine, Philadelphia, PA (Mr. Brown); Faculty of Medicine & Dentistry, University of Alberta School, Edmonton, AB, Canada (Mr. Bannon); Icahn School of Medicine at Mount Sinai, New York, NY (Mr. Rhee).

When I invited Dr. Wes Ely – the coauthor of a recent article regarding physician-assisted suicide – to write a Critical Care Commentary on said topic, an interesting thing happened: he declined and suggested that I invite a group of students from medical schools across the country to write the piece instead. The idea was brilliant, and the resulting piece was so insightful that the CHEST® journal editorial leadership suggested submission to the journal, and the accepted article will appear in the September issue. Out of that effort, the idea for the present piece was born. The result is an opportunity to hear the students’ voices, not only to stimulate discussion on conscientious objection in medicine but also to remind the ICU community that our learners have their own opinions and that through dialogues such as this, we might all learn from one another.

Lee Morrow, MD, FCCP

“No provision in our Constitution ought to be dearer to man than that which protects the rights of conscience against the enterprises of the civil authority.” – Thomas Jefferson

(Washington HA. The Writings of Thomas Jefferson. New York: Biker, Thorne, & Co. 1854,; Vol 3:147.)

What is the proper role of conscience in medicine? A recent article in the New England Journal of Medicine (Stahl & Emmanuel. N Engl J Med. 2017; 376(14):1380) is the latest to address this question. It is often argued that physicians who cite conscience in refusing to perform requested procedures or treatments necessarily infringe upon patients’ rights. However, we feel that these concerns stem from a fundamental misunderstanding of what conscience is, why it ought to be respected as an indispensable part of medical judgment (Genuis & Lipp . Int J Family Med. 2013; Epub 2013 Dec 12), and how conscience is oriented toward the end goal of health, which we pursue in medicine.

By failing to define “conscience,” the crux of the argument against conscience rights is built on the basis of an implied diminution of conscience from an imperative moral judgment down to mere personal preference. If conscience represents only personal preference – if it is limited to a set of choices of the same moral equivalent as the selection of an ice cream flavor, with no need for technical expertise—then it would follow that a physician ought to simply comply with the patient’s decisions in any given medical situation. However, we know intuitively that this line of reasoning cannot hold, if followed to its conclusion. For example, if a patient presenting with symptoms of clear rhinorrhea and dry cough in December asks for an antibiotic, through this patient-sovereignty model, the physician surely ought to provide the prescription to honor the patient’s request. The patient would have every right to insist on the antibiotic, and the physician would be obliged to prescribe accordingly. We, as students, are trained, however, that it would be morally and professionally fitting, even obligatory, for the physician to refuse this request, precisely through exercise of his/her professional conscience.

If conscience, then, is not simply a subject of one’s personal preferences, how are we to properly understand it? Conscience is “a person’s moral sense of right and wrong, viewed as acting as a guide to one’s behavior” (Conscience. Oxford Dictionary. Oxford, Oxford University Press. 2017). It exhibits the commitment to engage in a “self-conscience activity, integrating reason, emotion, and will, in self-committed decisions about right and wrong, good and evil” (Sulmasy. Theor Med Bioeth. 2008; 29(3):135). Whether or not a person intentionally seeks to form his/her conscience, it continues to be molded through the regular actions of daily life. The actions we perform – and those we omit – constantly shape our individual consciences. One’s conscience can indeed err due to emotional imbalance or faulty reasoning, but, even in these instances, it is essential to invest in the proper shaping of conscience in accordance with truth and goodness, rather than to reject the place of conscience altogether.

By attributing appropriate value to an individual’s conscience, we thereby recognize the centrality of conscience to identity and personal integrity. Consequently, we see that forcing an individual to impinge on his/her conscience through coercive means incidentally violates that person’s autonomy and dignity as a human being capable of moral decision-making.

In the practice of medicine, the free exercise of conscience is especially relevant. When patients and physicians meet to act in the pursuit of the patient’s health, they begin the process of conscience-mediated shared decision-making, rife with the potential for disagreement. Throughout this process, a physician should not violate a patient’s conscience rights by forcing medical treatment where it is unwanted, but neither should a patient violate a physician’s conscience rights by demanding a procedure or treatment that the physician cannot perform in good conscience. Moreover, to insert an external arbiter (eg, a professional society) to resolve the situation by means of contradiction of conscience would have the same violating effect on one or both parties.

One common debate as to the application of conscience in the setting of critical care focuses on the issue of physician-assisted suicide and euthanasia (PAS/E) (Rhee J, et al. Chest. 2017;152[3]. Accepted for Sept 2017 publication). Those who would deny physicians the right to conscientiously object to PAS/E depict this as merely an issue of the physician’s personal preference. Given the distinction between preference and conscience, however, we recognize that much more is at play. For students and practitioners who hold that health signifies the “well-working of the organism as a whole,” (Kass L. Public Interest. 1975; 40(summer):11-42) and feel that the killing of a patient is an action that goes directly against the health of the patient, the obligation to participate in PAS/E represents not only a violation of our decision-making dignity, but also subverts the critical component of clinical judgment inherent to our profession. The conscientiously practicing doctor who follows what they believe to be their professional obligations, acting in accordance with the health of the patient, may reasonably conclude that PAS/E directly contradicts their obligations to pursue the best health interests of the patient. As such, their refusal to participate can hardly be deemed a simple personal preference, as the refusal is both reasoned and reasonable. Indeed, experts have concluded that regardless of the legality of PAS/E, physicians must be allowed to conscientiously object to participate (Goligher et al. Crit Care Med. 2017; 45(2):149).

As medical students who have recently gone through the arduous medical school application process, we are particularly concerned with the claim that if one sees fit to exercise conscientious objection as a practitioner, they should leave medicine, or choose a field in medicine with few ethical dilemmas. To crassly exclude students from the pursuit of medicine on the basis of the shape of their conscience would be to unjustly discriminate by assigning different values to genuinely held beliefs. A direct consequence of this exclusion would be to decrease the diversity of thought, which is central to medical innovation and medical progress. History has taught us that the frontiers of medical advancement are most ardently pursued by those who think deeply and then dare to act creatively, seeking to bring to fruition what others deemed impossible. Without conscience rights, physicians are not free to think for themselves. We find it hard to believe that many physicians would feel comfortable jettisoning conscience in all instances where it may go against the wishes of their patients or the consensus opinion of the profession.

Furthermore, as medical students, we are acutely aware of the importance of conscientious objection due to the extant hierarchical nature of medical training. Evaluations are often performed by residents and physicians in places of authority, so students will readily subjugate everything from bodily needs to conscience in order to appease their attending physicians. Evidence indicates that medical students will even fail to object when they recognize medical errors performed by their superiors (Madigosky WS, et al. Acad Med. 2006; 81(1):94).

It is, therefore, crucial to the proper formation of medical students that our exercise of conscience be safeguarded during our training. A student who is free to exercise conscience is a student who is learning to think independently, as well as to shoulder the responsibility that comes as a consequence of free choices.

Ultimately, we must ask ourselves: how is the role of the physician altered if we choose to minimize the role of conscience in medicine? And do patients truly want physicians who forfeit their consciences even in matters of life and death? If we take the demands of those who dismiss conscience to their end – that only those willing to put their conscience aside should enter medicine – we would be left with practitioners whose group think training would stifle discussion between physicians and patients, and whose role would be reduced to simply acquiescing to any and all demands of the patient, even to their own detriment. Such a group of people, in our view, would fail to be physicians.

Author Affiliations: Geisel School of Medicine at Dartmouth, Hanover, NH (Dr. Dumitru); University of North Carolina School of Medicine, Chapel Hill, NC (Mr. Frush); Ohio University Heritage College of Osteopathic Medicine, Athens, OH (Mr. Radlicz); Columbia University College of Physicians and Surgeons, New York, NY (Mr. Allen); Thomas Jefferson School of Medicine, Philadelphia, PA (Mr. Brown); Faculty of Medicine & Dentistry, University of Alberta School, Edmonton, AB, Canada (Mr. Bannon); Icahn School of Medicine at Mount Sinai, New York, NY (Mr. Rhee).

When I invited Dr. Wes Ely – the coauthor of a recent article regarding physician-assisted suicide – to write a Critical Care Commentary on said topic, an interesting thing happened: he declined and suggested that I invite a group of students from medical schools across the country to write the piece instead. The idea was brilliant, and the resulting piece was so insightful that the CHEST® journal editorial leadership suggested submission to the journal, and the accepted article will appear in the September issue. Out of that effort, the idea for the present piece was born. The result is an opportunity to hear the students’ voices, not only to stimulate discussion on conscientious objection in medicine but also to remind the ICU community that our learners have their own opinions and that through dialogues such as this, we might all learn from one another.

Lee Morrow, MD, FCCP

“No provision in our Constitution ought to be dearer to man than that which protects the rights of conscience against the enterprises of the civil authority.” – Thomas Jefferson

(Washington HA. The Writings of Thomas Jefferson. New York: Biker, Thorne, & Co. 1854,; Vol 3:147.)

What is the proper role of conscience in medicine? A recent article in the New England Journal of Medicine (Stahl & Emmanuel. N Engl J Med. 2017; 376(14):1380) is the latest to address this question. It is often argued that physicians who cite conscience in refusing to perform requested procedures or treatments necessarily infringe upon patients’ rights. However, we feel that these concerns stem from a fundamental misunderstanding of what conscience is, why it ought to be respected as an indispensable part of medical judgment (Genuis & Lipp . Int J Family Med. 2013; Epub 2013 Dec 12), and how conscience is oriented toward the end goal of health, which we pursue in medicine.

By failing to define “conscience,” the crux of the argument against conscience rights is built on the basis of an implied diminution of conscience from an imperative moral judgment down to mere personal preference. If conscience represents only personal preference – if it is limited to a set of choices of the same moral equivalent as the selection of an ice cream flavor, with no need for technical expertise—then it would follow that a physician ought to simply comply with the patient’s decisions in any given medical situation. However, we know intuitively that this line of reasoning cannot hold, if followed to its conclusion. For example, if a patient presenting with symptoms of clear rhinorrhea and dry cough in December asks for an antibiotic, through this patient-sovereignty model, the physician surely ought to provide the prescription to honor the patient’s request. The patient would have every right to insist on the antibiotic, and the physician would be obliged to prescribe accordingly. We, as students, are trained, however, that it would be morally and professionally fitting, even obligatory, for the physician to refuse this request, precisely through exercise of his/her professional conscience.

If conscience, then, is not simply a subject of one’s personal preferences, how are we to properly understand it? Conscience is “a person’s moral sense of right and wrong, viewed as acting as a guide to one’s behavior” (Conscience. Oxford Dictionary. Oxford, Oxford University Press. 2017). It exhibits the commitment to engage in a “self-conscience activity, integrating reason, emotion, and will, in self-committed decisions about right and wrong, good and evil” (Sulmasy. Theor Med Bioeth. 2008; 29(3):135). Whether or not a person intentionally seeks to form his/her conscience, it continues to be molded through the regular actions of daily life. The actions we perform – and those we omit – constantly shape our individual consciences. One’s conscience can indeed err due to emotional imbalance or faulty reasoning, but, even in these instances, it is essential to invest in the proper shaping of conscience in accordance with truth and goodness, rather than to reject the place of conscience altogether.

By attributing appropriate value to an individual’s conscience, we thereby recognize the centrality of conscience to identity and personal integrity. Consequently, we see that forcing an individual to impinge on his/her conscience through coercive means incidentally violates that person’s autonomy and dignity as a human being capable of moral decision-making.

In the practice of medicine, the free exercise of conscience is especially relevant. When patients and physicians meet to act in the pursuit of the patient’s health, they begin the process of conscience-mediated shared decision-making, rife with the potential for disagreement. Throughout this process, a physician should not violate a patient’s conscience rights by forcing medical treatment where it is unwanted, but neither should a patient violate a physician’s conscience rights by demanding a procedure or treatment that the physician cannot perform in good conscience. Moreover, to insert an external arbiter (eg, a professional society) to resolve the situation by means of contradiction of conscience would have the same violating effect on one or both parties.

One common debate as to the application of conscience in the setting of critical care focuses on the issue of physician-assisted suicide and euthanasia (PAS/E) (Rhee J, et al. Chest. 2017;152[3]. Accepted for Sept 2017 publication). Those who would deny physicians the right to conscientiously object to PAS/E depict this as merely an issue of the physician’s personal preference. Given the distinction between preference and conscience, however, we recognize that much more is at play. For students and practitioners who hold that health signifies the “well-working of the organism as a whole,” (Kass L. Public Interest. 1975; 40(summer):11-42) and feel that the killing of a patient is an action that goes directly against the health of the patient, the obligation to participate in PAS/E represents not only a violation of our decision-making dignity, but also subverts the critical component of clinical judgment inherent to our profession. The conscientiously practicing doctor who follows what they believe to be their professional obligations, acting in accordance with the health of the patient, may reasonably conclude that PAS/E directly contradicts their obligations to pursue the best health interests of the patient. As such, their refusal to participate can hardly be deemed a simple personal preference, as the refusal is both reasoned and reasonable. Indeed, experts have concluded that regardless of the legality of PAS/E, physicians must be allowed to conscientiously object to participate (Goligher et al. Crit Care Med. 2017; 45(2):149).

As medical students who have recently gone through the arduous medical school application process, we are particularly concerned with the claim that if one sees fit to exercise conscientious objection as a practitioner, they should leave medicine, or choose a field in medicine with few ethical dilemmas. To crassly exclude students from the pursuit of medicine on the basis of the shape of their conscience would be to unjustly discriminate by assigning different values to genuinely held beliefs. A direct consequence of this exclusion would be to decrease the diversity of thought, which is central to medical innovation and medical progress. History has taught us that the frontiers of medical advancement are most ardently pursued by those who think deeply and then dare to act creatively, seeking to bring to fruition what others deemed impossible. Without conscience rights, physicians are not free to think for themselves. We find it hard to believe that many physicians would feel comfortable jettisoning conscience in all instances where it may go against the wishes of their patients or the consensus opinion of the profession.

Furthermore, as medical students, we are acutely aware of the importance of conscientious objection due to the extant hierarchical nature of medical training. Evaluations are often performed by residents and physicians in places of authority, so students will readily subjugate everything from bodily needs to conscience in order to appease their attending physicians. Evidence indicates that medical students will even fail to object when they recognize medical errors performed by their superiors (Madigosky WS, et al. Acad Med. 2006; 81(1):94).

It is, therefore, crucial to the proper formation of medical students that our exercise of conscience be safeguarded during our training. A student who is free to exercise conscience is a student who is learning to think independently, as well as to shoulder the responsibility that comes as a consequence of free choices.

Ultimately, we must ask ourselves: how is the role of the physician altered if we choose to minimize the role of conscience in medicine? And do patients truly want physicians who forfeit their consciences even in matters of life and death? If we take the demands of those who dismiss conscience to their end – that only those willing to put their conscience aside should enter medicine – we would be left with practitioners whose group think training would stifle discussion between physicians and patients, and whose role would be reduced to simply acquiescing to any and all demands of the patient, even to their own detriment. Such a group of people, in our view, would fail to be physicians.

Author Affiliations: Geisel School of Medicine at Dartmouth, Hanover, NH (Dr. Dumitru); University of North Carolina School of Medicine, Chapel Hill, NC (Mr. Frush); Ohio University Heritage College of Osteopathic Medicine, Athens, OH (Mr. Radlicz); Columbia University College of Physicians and Surgeons, New York, NY (Mr. Allen); Thomas Jefferson School of Medicine, Philadelphia, PA (Mr. Brown); Faculty of Medicine & Dentistry, University of Alberta School, Edmonton, AB, Canada (Mr. Bannon); Icahn School of Medicine at Mount Sinai, New York, NY (Mr. Rhee).