Admitting crisis, leaders stress need for education, action on ethics

By Marshall Allen

Sunday, Sept. 21, 2008 | 2 a.m.

If Nevada’s ailing health care system is to be healed, it must start with a healthy dose of ethics.

That was the basis of a daylong summit that attracted state regulators, educators and professionals who resolved to change an ethically lax culture to restore public trust.

The gathering came in the wake of a year of scandals, including a hepatitis C outbreak that affected as many as 50,000 people and the abuse of a program that brings foreign doctors to medically needy communities.

About 40 people attended the workshop last week at UNLV, including representatives of the state licensing boards for dentists, doctors and nurses; the state health division; physician associations and Nevada medical and nursing schools. The invitation-only event was sponsored by the Nevada State Medical Association and University Nevada, Reno’s, Nevada Center for Ethics & Health Policy.

The Sun also was invited to attend because of the newspaper’s coverage of the various health care crises afflicting Southern Nevada.

The participants — including some of the state’s highest ranking medical professionals — spoke frankly of recent events where unethical action — or lack of action — by a few doctors, nurses and their office staff endangered patients or caused them to lose their faith in health care providers. They stressed that everyone with knowledge of wrongdoing is complicit in it — creating a conspiracy of “normalized deviance” that puts patients in harm’s way.

Two revelations were among the reasons cited for the gathering. A year ago, a Sun investigation named a few Las Vegas physicians who had been breaking federal law and state guidelines by exploiting for personal profit a program intended to bring foreign doctors to Nevada’s most medically needy communities. In those cases, even officials from the Nevada State Health Division who received complaints about the violations did nothing to stop them.

In February, the Southern Nevada Health District announced the hepatitis C outbreak at a Las Vegas endoscopy center run by a former member of the Nevada State Medical Examiners Board. Clinic nurses were reusing syringes and single-use vials of anesthetic medicine, which caused the infection to spread.

“The question is: Why would you trust anyone in health care after hearing all this stuff?” Reno pulmonologist Dr. Michael Jackson said in his address to the group.

The day-long session included small-group discussions and presentations focusing on whistleblowing and the role of ethics in health care.

Much of the day’s conversation centered on the importance of ethics education by schools, licensing boards and professional associations. That prompted state epidemiologist Dr. Ihsan Azzam to point out to the Sun what may have been the elephant in the room: That health care professionals know right from wrong, and some choose to do wrong.

“The issue is practices and attitudes,” Azzam said. “The difference is between what people know and what people do.”

Azzam cited a 1997 survey of Nevada doctors in which a third said they would not screen women at age 40 for breast cancer even though they knew that the nationally accepted age for screening had been lowered to 40 from 50.

That finding illustrated that doctors can remain set in their ways, even when it may be inappropriate, Azzam said. Similarly, nurses know not to reuse single-use medicine vials and syringes — but did, leading to the hepatitis C outbreak, Azzam said.

Azzam said it’s vital that Nevada health care leaders figure out how to get medical providers to do their jobs the way they are supposed to.

The perplexing paradox of blatant bad behavior by health care providers who should know better was posed to a small group of the attendees. Larry Matheis, executive director of the Nevada State Medical Association, said “we can’t give up” just because some doctors or nurses refuse to do what’s right. And the public outrage caused by unethical behavior can become a catalyst, he said.

Attendees agreed the health care community has been primed to address ethical failures because of the negative headlines in the past year.

“You get this critical mass where everybody is saying the same thing. It motivates change,” Matheis said. “What’s frustrating is that it’s crisis driven.”

The issue of bad behavior also brings up the subject of regulators, who are often criticized for failing to police health care violations.

“At some point you need to hold people accountable,” Matheis said during one of the small group sessions.

“People will be held accountable,” interjected Dr. Lawrence Sands, chief health officer of the Southern Nevada Health District, the agency that investigated the hepatitis C outbreak.

“There are consequences to breaking the rules,” agreed Denise Selleck-Davis, executive director of the Nevada Osteopathic Medical Association.

Nevada Attorney General Catherine Cortez Masto urged the participants to avoid the temptation to overregulate when medical providers violate their social contract with patients. Instead, they should work with her office to protect consumers by bringing unethical people to justice, she said.

“If we don’t hold somebody accountable and show that we’re protecting consumers then the trust the public has will go by the wayside,” Masto said.

By day’s end, the group said it would strive to form an ethics consortium that includes members of the professions, licensing authorities and teaching institutions to create ethics education resources. In addition, participants said they would examine building an Internet-based ethics resource so health care providers in rural communities have access to ethics advice.

Matheis, who helped organize the meeting, stressed the significance of the ethics summit. For about a year there has been widespread consensus in the medical community that things are on the wrong track, he said. Thursday’s meeting showed a collective desire to steer things in the right direction, he said.

“I think there is a sense that something has gone askew and we’ve got to get it straight,” Matheis said.