8.4 Physician Relationships Under the PMA Code of Ethics: Patients, Colleagues, Allied Health, Students, Industry, HMOs, Hospitals & PhilHealth

Why this area matters

The TOS asks you to "identify the roles the doctor assumes in the practice of medicine given a scenario", apply the doctor's relationships to identify responsibilities, and decide whether a role was played unethically. Its list of relationships is long: patients, other doctors, allied health professionals, students, the pharmaceutical industry, HMOs, institutions and hospitals, administrators, and PhilHealth. The reference document is the Code of Ethics of the Philippine Medical Association (2008). Violating it is a ground for discipline under Section 24(12) of the Medical Act.

General principles (Article I)

• The primary objective of medicine is service to mankind, irrespective of race, age, disease, disability, gender, sexual orientation, social standing, creed or political affiliation. Financial gain is secondary.
• Physicians must be upright, diligent, sober and modest, work in harmony with colleagues, and protect the interests and dignity of allied health professionals.
• Patient health comes before the interests of the physician and of the health-products industry.

Physician and patient (Article II)

Creating the relationship. A physician is free to choose patients. The relationship begins once the physician undertakes to examine or treat, which can include a telephone consult or an emergency room assessment.

Duties once the relationship exists:

• Competent care according to current standards, with compassion and respect for dignity. Consult a specialist in serious or difficult cases.
• Emergency duty: provided there is no risk to his or her own safety, the physician should give at least first aid, then refer to the primary physician or an appropriate facility.
• Honesty and consent: give opinions in good faith; neither conceal nor exaggerate the condition unless that is in the patient's best interest; give timely notice of worsening; obtain voluntary informed consent; respect the right to refuse treatment.
  • For an unconscious or mentally deficient adult, consent comes from the spouse or immediate relatives, or from the person named in an advance directive.
  • For a minor, consent comes from the parents or guardian, or from members of the immediate family of legal age.
• Confidentiality "even after death", except when needed for justice, safety and public health.
• Fair fees that reflect the service, the patient's means, the nature of the case and the physician's standing.

Ending the relationship. It ends on recovery, when the patient dismisses the physician, or when the physician withdraws with reasonable notice and arrangements for continued care. Leaving a patient who still needs care without this is abandonment, which can give rise to malpractice and disciplinary liability.

Physician and colleagues (Article IV)

• Professional courtesy: a physician waives fees for a colleague and the colleague's spouse, children and financially dependent parents.
• Referral protocol: the referring physician sends a clinical abstract and states the purpose: opinion or evaluation, co-management, or transfer of service. A consultant who wants to refer the patient onward must first get the primary physician's permission.
• Substitutes treat a covered patient with equal care and return the patient promptly.
• Commenting on another physician's case during a social or business visit is unethical, except in an emergency.
• Irreconcilable differences about management go to the PMA or the specialty society.
• No commission may be received for referring a patient to a colleague, a third party or an institution. Fee splitting (dichotomy) is unethical. Only nominal gifts on special occasions are allowed.
• Physicians are encouraged to report corrupt or dishonest conduct of colleagues to the PMA or the Board.

Physician and allied health professionals (Article V)

Physicians must never pay or receive commissions to or from allied health workers (laboratories, pharmacies, therapists) for referrals. They respect the professional roles of nurses, pharmacists, medical technologists and therapists. They delegate only tasks within the other professional's legal scope, and they remain responsible for their own orders.

Physician and students

Medical students and graduates under training may perform clinical acts only under the direct supervision of a registered physician and without fees (Medical Act Sec. 11[a]). Patients should know when students take part in their care, and they may decline. Teachers model ethical behavior and must not exploit trainees.

Physician and the health-products industry (Articles IV and VI)

• Samples: the physician may not derive any material gain from product samples.
• Gifts: only gifts of reasonable value that mainly benefit patient care or relate to the physician's work may be accepted. Donations may be solicited for charity, not personal benefit.
• CME and conferences:
  • Medical societies organize the content.
  • Speakers may accept honoraria and reasonable travel costs.
  • Attendees may accept reasonable subsidies.
  • Generic names are used during lectures.
  • Commercial exhibits must not influence the program.
• Disclosure: articles and scientific talks must disclose pharmaceutical support and stay independent of commercial influence.
• Research and post-marketing studies: patients must be properly informed and consent. Industry trials follow national and institutional guidelines for the protection of human participants.
• Advertising and media (Article III):
  • No agents to solicit patients.
  • Signboards may not exceed 1 x 2 meters and may show only the physician's name, specialty, clinic hours and address.
  • In broadcast media, give only general opinions, not individual diagnoses.
  • No commercial endorsement of medical or health products.

Physician, HMOs and payers

Health maintenance organizations contract physicians to serve their members. Ethically, the patient's welfare comes before contractual cost controls. The physician should:

• explain what the plan covers;
• disclose any arrangement that might bias decisions;
• appeal inappropriate denials;
• never falsify a diagnosis to obtain coverage.

Physician, hospitals and administrators

• Physicians practice in a hospital through clinical privileges granted after credentialing, and must follow its bylaws and policies. Hospitals are licensed by the DOH.
• The Anti-Hospital Deposit Law (RA 8344, as amended by RA 10932, 2017) prohibits hospitals and medical clinics from requiring a deposit or advance payment before treating patients in emergency or serious cases. Basic emergency care must be given, and transfer is allowed only after stabilization. Both officials and the institution face penalties.
• Physician-administrators answer for the quality-assurance and patient-safety systems of the facility. That is the basis of hospital corporate negligence liability.

Physician and PhilHealth

Under the National Health Insurance Act as amended and the Universal Health Care Act (RA 11223):

• Physicians must be PhilHealth-accredited to file claims for professional fees.
• Claims must reflect services actually rendered and diagnoses actually made. Filing false, padded or misrepresented claims is prohibited, and penalties include fines, suspension of accreditation and referral for prosecution.
• Physicians should follow the program's benefit rules, including no balance billing for covered members where it applies, and should explain benefits honestly to patients.