OMB#0925-0528
                                                                                                                   EXP. DATE: 07/31/2007

      Values at the Bedside
Physicians’ Experience of Ethical Dilemmas and Resource Allocation

Thank you for your participation. We value your opinion. Since there are important differences between health care systems in different countries, some questions may seem strange or irrelevant to you but please answer as best you can based upon your situation. 

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First, I would like to know if you have you been practicing medicine for at least 1 year?
  				 Yes			 No

During a typical week, do you spend 20% or more of your time in direct patient care activities? 
   Yes			   No 

If respondent answers “no” to either of these questions:
-I am sorry but you are not eligible for this study. Thank you very much for your time. 

If the respondent answers “yes” to both these questions, proceed to questionnaire.

(Note for the interviewer: terms in bold and labeled * are included in the glossary. If the respondent asks for clarification refer to the end of the questionnaire)

I am going to start with a few questions about situations where medical decision-making can be difficult. Please tell me how often you have faced each kind of situation in your work in the last year. Was it never, rarely, sometimes, or often?
1) So in the last year, how often have you been in the following situations?
	Never	Rarely	Sometimes	Often	
a) You cared for a terminally ill patient and the question of limiting life sustaining treatment or writing a Do Not Resuscitate* order came up.					
b) You cared for adult patients whose capacity for decision-making* with respect to their own health was uncertain or impaired. 					
c) You were uncertain whether to maintain confidentiality of medical information.					
d) There was significant disagreement among family members or caregivers on the proper course of treatment for the patient.					
e) Your preferred course of treatment conflicted with institutional policies, professional codes of ethics or laws.					
f) The preferred course of treatment was not pursued because of a patient's insurance status*.					
g) Rules for payment of services* prevented you from using your preferred course of treatment.					
h) Scarcity of resources* required you to make a difficult choice.					
i) A patient's cultural or religious views conflicted with your proposed course of treatment.					
j) The patient disagreed with your preferred course of treatment for other reasons.					
k) You were uncertain if a diagnosis should be disclosed to the patient.					
l) You were asked for assisted suicide or euthanasia.					

2) Which of these types of ethical dilemmas or problems in your work would you say is the most difficult to resolve? 
   a 	   b 	   c 	   d 	   e 	   f 	   g 	   h 	   i 	   j 	   k 	   l 
Was there perhaps another type of difficulty that you really feel was the most difficult?  
If so, please specify:………………………………………………..

3) Please tell me how often you have asked for an ethics consultation when you had a dilemma related to scarcity of resources*. Was it never, rarely, sometimes, or often?

Never	Rarely	Sometimes	Often	

Now the following questions refer to ethical problems related to scarce resources*:

4) During the last six months, how often were you unable to obtain the following services for your patients when you thought they were necessary? This includes unacceptable waiting times. Was it daily, weekly, monthly, less than once a month, or never? If you feel it does not apply to your practice, please tell me that too. 

So, how often were you unable to obtain…..	Daily 	Weekly	Monthly	Less than once a month	Never	N/A	
a) Surgery							
b) Referral to a specialist							
c) Admission to a hospital							
d) Access to mental health services							
e) Admission to a nursing home							
f) Endoscopy for colon cancer screening							
g) Rehabilitation for stroke							
h) Prescription drugs							
i) Referral to ICU							
j) Referral for dialysis							
k) Services for patients at the end of life							
l) An ethics consultation							
m) Was there anything else you were unable to obtain? What was that?
………………………………..							

5) During the last six months, how often did you personally refrain from talking about disease prevention (e.g. smoking cessation, safe sex, etc…) with your patients because you did not have the time? Was it daily, weekly, monthly, less than once a month, or never? Again, if you feel it does not apply to your practice, please tell me that too. 

   Daily 	   Weekly	   Monthly    	   Less than once a month      Never	 
   N/A

6) Now I am going to read statements to you, and ask you to what extent do you agree or disagree. The options are strongly agree, partly agree, neutral, aprtly disagree, and strongly disagree:
	Strongly
Agree	Partly
Agree	Neutral	Partly Disagree	Strongly Disagree	
a) There is a gap between what is medically possible and what can be economically achieved in my country.						
b) Cost to society is important in my decisions to use or not to use an intervention.						
c) Physicians should adhere to clinical guidelines that discourage the use of interventions that have a small proven advantage over standard interventions but cost much more.						
d) I should sometimes deny beneficial but costly services to certain patients because resources should go to other patients that need them more.						
e) Denying medically beneficial but costly services to some of my patients interferes with the doctor-patient relationship.						
f) Everyone in the US should have equal access to needed medical services.						
g) I should make sure all my patients get the medical services they need						
h) I should help my patients when the health care system is unfair to them.						
i) Health care resources in the US are distributed fairly. 						
j) I am given enough means to treat my patients fairly.						
k) Everyone in the US has equal access to needed medical services						
l) I am given enough freedom to utilize resources in my patients’ best interest.						
m) My job or financial security is threatened by current pressures to contain costs in health care.						

7) During the last six months, how often did you personally refrain, because of cost to the health care system, from using the following interventions when they would have been the best intervention for your patient? Was it daily, weekly, monthly, less than once a month, or never? Again, if you feel it does not apply to your practice, please tell me that too.
So, how often did you personally refrain from using… 	Daily	Weekly	Monthly	Less than once a month	Never	N/A	
a) Lab tests?							
b) Routine X-ray?							
c) MRI?							
d) Screening test?							
e) Referral to a specialist?							
f) Referral to an ICU?							
g) Prescription drugs?							
h) Referral for surgery?							
i) Referral for dialysis?							
j) Hospital admission?							
k) Was there anything else you personally refrained from? What was that?
……………………							

8) Now I would like to ask you about how often you might use different kinds of strategies that could help you avoid using expensive interventions. Again, the options are daily, weekly, monthly, less than once a month, or never. If you feel it does not apply to your practice, please tell me that too.

So, how often do you…	Daily	Weekly	Monthly	Less than once a month	Never	N/A	
a) refuse some expensive requests made by patients							
b) substitute a less expensive intervention							
c) explain your reasoning to the patient							
d) do not let the patient know about the expensive option							
e) delay the intervention to see if you can do without it							
f) Is there anything else you do to avoid using expensive interventions? Please specify:………..
……………………….							

9) Now imagine the following situation. A patient you are treating would benefit from an intervention. This intervention is very expensive. It is paid for by public money, or by a private insurer, or both.
I am going to list possible aspects of this situation, and I would like to know if these factors make you more or less likely to use this intervention. The options are…..
So would you be more or less likely to use this intervention if….	Much less likely	Somewhat less likely	No change	Somewhat more likely	Much more likely	
a) Chances of success for the intervention are low						
b) The intervention is primary prevention						
c) The condition requires chronic care						
d) The patient is poor						
e) The benefit to the patient is small						
f) The patient is >85						
g) The patient is frail						
h) The aim is to improve quality of life in a patient whose life expectancy is short						
i) The aim is to prolong the life of a patient whose quality of life you judge to be  is low						
j) The patient will not work again						
k) The condition is attributable to smoking						
l) The condition is attributable to a dangerous sport						
m) The condition is attributable to pregnancy						
n) The patient holds an important position in society						
o) While you think the patient would benefit, the evidence base for the intervention is lacking						
p) The patient asks for the intervention						
q) The patient is cognitively impaired						
r) Chances of success for the intervention are high						
s) Is there anything else you fell would make you more or less likely to use this intervention? Please specify:
…………………………………						

10) In the last six months, how often have you felt under pressure to deny an expensive intervention that you thought was indicated? Was it daily, weekly, monthly, less than once a month, or never? 
   Daily	  Weekly	  Monthly	   Less than once a month	   Never

11) In the last six months, how often have you found in your work that patients have problems that cannot be treated because they cannot afford their share of the costs? Was it daily, weekly, monthly, less than once a month, or never? 
   Daily	  Weekly	  Monthly	   Less than once a month	   Never

12) In the last six months, how often have you been so troubled by limited resources that you thought of leaving clinical care? Was it daily, weekly, monthly, less than once a month, or never? 
   Daily	  Weekly	  Monthly	   Less than once a month	   Never

13) In the last six months, how often have you seen a situation where a patient suffered adverse consequences as a result of limited resources in the health care system? Was it daily, weekly, monthly, less than once a month, or never? 
   Daily	  Weekly	  Monthly	   Less than once a month	   Never

14) What is the most severe adverse consequence you have seen as a result of limited resources in the health care system? Was it ….
   An inconvenience	   A temporary disability	   A permanent disability	
   An acute life-threatening event	   Death	   No adverse consequences at all?
 
15) Based on your experience, how acceptable do you consider the following methods of resource allocation to be? Please answer on a scale of 1 to 5, where 1 is not at all acceptable, and 5 is very acceptable. If you have no experience with the method described, please let me know.
So, how acceptable do you consider…	Not at all acceptable                          Very acceptable	I have no experience with this	
a) Waiting lists for elective surgical operations	
           1            2            3            4            5
	
               6	
b) Classification of referrals by degree of urgency	
             1            2            3            4            5
	
               6	
c) Using direct treatment fees	
             1            2            3            4            5
	
               6	
d) Administrative decision to prioritize some patient groups	
             1            2            3            4            5
	
               6	
e) Restriction of expensive treatments and examinations	
             1            2            3            4            5
	
               6	
f) Emphasis on Evidence Based Practice	
             1            2            3            4            5
	
               6	
g) Closing some hospital beds	
             1            2            3            4            5
	
               6	

16) Again based on your experience, are patients who belong to any of the following groups more likely than others to be denied beneficial care on the basis of cost in your health care environment? The options are yes, no or I don’t know. 
a) patient who are old					    Yes    No	    I don’t know
b) patients who need expensive treatments		    Yes    No	    I don’t know 
c) patients who cannot afford to pay for treatment   	    Yes    No	    I don’t know 	
d) patients who require chronic care			    Yes    No	    I don’t know 
e) patients who are mentally incapacitated		    Yes    No	    I don’t know	
f) patients who are in an ethnic minority		    Yes    No	    I don’t know
g) foreign patients who are legal immigrants		    Yes    No	    I don’t know	
h) foreign patients who are illegal immigrants	    Yes    No	    I don’t know
i) Are there any other patients that you feel are more likely than others to be denied beneficial care on the basis of cost in your health care environment?  Yes : (please specify):………….. 	
           No	 
           I don’t know	

Now I would like you to answer a few questions about your personal background

17) Are you:        Male   or      Female?		
18) What is your age? _ _

19) How many people live within 20 miles of the site of your main practice? Is it
   Fewer that 50,000?	   50, 000 to 100,000?     100,000 to 250,000?
   250,000 to 500,000?	   More than 500,000 ?

20) Do you have specialty training? 
            Yes                                                                        No	
          If respondent answers “yes”:
What specialty training do you have? You may give several answers. Are you trained in:
   Family Medicine? 	   General Medicine?	
   Internal Medicine?              Geriatrics?	   
   Do you have other specialty training? Please specify):………………………

21) In what country were you born? 	
   The US	   Other 
If respondent was born outside the US, specify country:……………

22) How much of your medical training was spent outside of the US? Was it…
   All of it ?   			   Part of it ?		   None of it?

23) Since graduating from medical school, for how many years have you been practicing medicine? _ _

24) How would you best describe your primary medical practice? Is it….  
   a solo practice?	
   a hospital?	
   a primary care group practice ?
   a single specialty group?	
   a multi-specialty group	?
   Is it something else? Please explain this to me:……………………….

25) In what age ranges are your patients? Are some of the patients in your practice 
   under 10 years old ?	
   11-20 years old	?
   21-40 years old ?
   41-60 years old	?
   61-80 years old	?
   81-90 years old ?
   over 90 years old ?

26a) On average, how many hours a week would you say that do you spend in outpatient care?........................
If respondent answers “none” or equivalent, go to question 27. If respondent gives a number of hours >0:
26b) How many patients do you usually see in a half day in clinic? If this does not apply to you, please let me know.		
   Number of patients:……..	   N/A
26b1) Do you have outpatient appointments?
  Yes                                                                        No	
         		 If respondent answers “yes”:
26b2)How long is the waiting time to get an outpatient appointment with you? Is it usually…
   The same day?	   The next day?	   Within a week?	
   Within two weeks?  Within a month ?	   More than a month ?	

27a) On average, how many hours a week do you spend in inpatient care?........................
If respondent answers “none” or equivalent, go to question 28. If respondent gives a number of hours >0:
27b) How many patients are you usually responsible for at one time? If this does not apply to you, please let me know.		
	   Number of patients:……..	   N/A

28) Do you have an appointment with a University Department?	   Yes		   No

29) On balance do the financial incentives in your main practice:
   Favor reducing services to patients?    Favor expanding services to patients?
   Favor neither?

30)
a) Is your primary admitting hospital:	   Public?	or	   Private?
b) Is your primary admitting hospital is: 	   For-profit?	 or	   Not-for-profit?
c) Is it a teaching center affiliated with a university?	   Yes	   No
d) How many patient beds are there in your primary admitting hospital?………………

31) Do you participate in decisions on where the resources are spent in your health care environment?    		   Yes		   No

If respondent answers “yes”: 
32) Are you a member of an official board or committee on allocation of resources?					   Yes		   No

Thank you very much for your time. 

Glossary (if the respondent asks)

Do Not Resuscitate Order
An order not to attempt cardio-pulmonary resuscitation in case of cardiac arrest.

Impaired decision making capacity
In an adult, the lack of some or all of the abilities necessary to make decisions regarding personal health care.

Patient’s insurance status
What medical services are paid for by the state and/or insurance for this patient 

Rules for payment of services
Rules that must be followed in order for specific services to be covered.

Scarcity of resources
A situation where the available health care resources do not cover all the existing medical needs