2020 American Heart Association and American College of Cardiology Consensus Conference on Professionalism and Ethics: A Consensus Conference Report

Abstract

HomeCirculationVol. 143, No. 252020 American Heart Association and American College of Cardiology Consensus Conference on Professionalism and Ethics: A Consensus Conference Report Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessReview ArticlePDF/EPUB2020 American Heart Association and American College of Cardiology Consensus Conference on Professionalism and Ethics: A Consensus Conference Report Ivor J. Benjamin, MD, FAHA, FACC, Conference Co-Chair, AHA C. Michael Valentine, MD, MACC, FAHA, Conference Co-Chair, ACC William J. Oetgen, MD, MBA, MACC, Executive Committee Author Task Force 2 Author, ACC Katherine A. Sheehan, PhD, Executive Committee Author, AHA Ralph G. Brindis, MD, MPH, MACC, FAHA, Task Force Co-Chair, ACC William H. Roach Jr, MS, JD, Task Force Co-Chair, AHA Robert A. Harrington, MD, FAHA, MACC, Author Glenn N. Levine, MD, FACC, FAHA, Author Rita F. Redberg, MS, MD, FACC, FAHA, Author Bernadette M. Broccolo, JD, Discussant Adrian F. Hernandez, MD, MHS, FAHA, Discussant Pamela S. Douglas, MD, MACC, FAHA, Task Force Co-Chair, ACC Ileana L. Piña, MD, MPH, FAHA, FACC, Task Force Co-Chair, AHA Emelia J. Benjamin, MD, ScM, FAHA, FACC, Author Megan J. Coylewright, MD, MPH, FACC, Author Jorge F. Saucedo, MD, MBA, FACC, FAHA, Author Keith C. Ferdinand, MD, FACC, FAHA, Discussant Sharonne N. Hayes, MD, FACC, FAHA, Discussant Athena Poppas, MD, FACC, FAHA, Discussant Karen L. Furie, MD, MPH, FAHA, Task Force Co-Chair, AHA Laxmi S. Mehta, MD, FACC, FAHA, Task Force Co-Chair, ACC John P. Erwin III, MD, FACC, FAHA, Author Jennifer H. Mieres, MD, FACC, FAHA, Author Daniel J. Murphy Jr, MD, FACC, Author Gaby Weissman, MD, FACC, Author and Discussant Colin P. West, MD, PhD, Author and Discussant Willie E. Lawrence Jr, MD, FACC, FAHA, Task Force Co-Chair, AHA Frederick A. Masoudi, MD, MSPH, FACC, FAHA, Task Force Co-Chair, ACC Camara P. Jones, MD, MPH, PhD, Author Daniel D. Matlock, MD, MPH, Author Jennifer E. Miller, PhD, Author John A. Spertus, MD, MPH, FACC, FAHA, Discussant Lynn Todman, PhD, Discussant Cathleen Biga, MSN, FACC, Task Force Co-Chair, ACC Richard A. Chazal, MD, FAHA, MACC, Task Force Co-Chair, AHA Mark A. Creager, MD, FAHA, FACC, Author Edward T. Fry, MD, FACC, Author Michael J. Mack, MD, MACC, Author Clyde W. Yancy, MD, MSc, MACC, FAHA, Author and Discussant Richard E. AndersonMD, Discussant Ivor J. BenjaminIvor J. Benjamin Search for more papers by this author , C. Michael ValentineC. Michael Valentine Search for more papers by this author , William J. OetgenWilliam J. Oetgen Search for more papers by this author , Katherine A. SheehanKatherine A. Sheehan Search for more papers by this author , Ralph G. BrindisRalph G. Brindis Search for more papers by this author , William H. Roach JrWilliam H. Roach Jr Search for more papers by this author , Robert A. HarringtonRobert A. Harrington Search for more papers by this author , Glenn N. LevineGlenn N. Levine Search for more papers by this author , Rita F. RedbergRita F. Redberg Search for more papers by this author , Bernadette M. BroccoloBernadette M. Broccolo Search for more papers by this author , Adrian F. HernandezAdrian F. Hernandez Search for more papers by this author , Pamela S. DouglasPamela S. Douglas Search for more papers by this author , Ileana L. PiñaIleana L. Piña Search for more papers by this author , Emelia J. BenjaminEmelia J. Benjamin Search for more papers by this author , Megan J. CoylewrightMegan J. Coylewright Search for more papers by this author , Jorge F. SaucedoJorge F. Saucedo Search for more papers by this author , Keith C. FerdinandKeith C. Ferdinand Search for more papers by this author , Sharonne N. HayesSharonne N. Hayes Search for more papers by this author , Athena PoppasAthena Poppas Search for more papers by this author , Karen L. FurieKaren L. Furie Search for more papers by this author , Laxmi S. MehtaLaxmi S. Mehta Search for more papers by this author , John P. Erwin IIIJohn P. Erwin III Search for more papers by this author , Jennifer H. MieresJennifer H. Mieres Search for more papers by this author , Daniel J. Murphy JrDaniel J. Murphy Jr Search for more papers by this author , Gaby WeissmanGaby Weissman Search for more papers by this author , Colin P. WestColin P. West Search for more papers by this author , Willie E. Lawrence JrWillie E. Lawrence Jr Search for more papers by this author , Frederick A. MasoudiFrederick A. Masoudi Search for more papers by this author , Camara P. JonesCamara P. Jones Search for more papers by this author , Daniel D. MatlockDaniel D. Matlock Search for more papers by this author , Jennifer E. MillerJennifer E. Miller Search for more papers by this author , John A. SpertusJohn A. Spertus Search for more papers by this author , Lynn TodmanLynn Todman Search for more papers by this author , Cathleen BigaCathleen Biga Search for more papers by this author , Richard A. ChazalRichard A. Chazal Search for more papers by this author , Mark A. CreagerMark A. Creager Search for more papers by this author , Edward T. FryEdward T. Fry Search for more papers by this author , Michael J. MackMichael J. Mack Search for more papers by this author , Clyde W. YancyClyde W. Yancy Search for more papers by this author , and Richard E. AndersonRichard E. Anderson Search for more papers by this author Originally published11 May 2021https://doi.org/10.1161/CIR.0000000000000963Circulation. 2021;143:e1035–e1087is corrected byCorrection to: 2020 American Heart Association and American College of Cardiology Consensus Conference on Professionalism and Ethics: A Consensus Conference ReportTable of Contents1. Introduction e10361.1. Historical Perspective and Current Plan e10371.2. Context Framing e10381.3. The Tenets of Medical Ethics e10391.4. The Principles and Commitments of Medical Professionalism e10391.4.1. Principles of Professionalism e10391.4.2. Commitments of Professionalism e10391.5. The Obligations of Medicine’s Social Contract e10401.5.1. Medical Practitioners Agree to:e10401.5.2. Society Agrees to:e10411.6. Organization of Writing Committee e10421.7. Document Review and Publication Approval e10421.8. Abbreviations e10422. Task Force Reports e10422.1. Task Force 1: Navigating Conflicts: RWIs and COIs in Teaching and Publications, Peer Review, Research Data, Technology, and Expert Testimony e10422.1.1. Recommendations Related to Disclosure of RWIs in Educational Activities and Scientific Publications e10432.1.2. Recommendations Related to Associational and Intellectual Interests e10442.1.3. Recommendations Related to External Assessments of Interests e10452.1.4. Recommendations Related to Research, Publication, Educational Activities, and Implementation Ethics e10462.1.5. Recommendations Related to Peer Review and Grant Study Sections e10472.1.6. Recommendations Related to Expert Testimony and Opinions e10482.2. Task Force 2: Diversity, Equity, Inclusion, and Belonging: Optimizing Cardiovascular Health Care, Research, and Education Through Equity and Respect and Eliminating Bias, Discrimination, Harassment, and Racism e10492.2.1. DEIB: General Concepts e10512.2.2. Specific Accountabilities and Special Groups e10522.2.3. Eradicating Bias, Harassment, Structural Racism, and Structural Sexism, Including Sexual Harassment e10542.2.4. Achieving Equity, Inclusion, and Belonging: A Road Map e10552.2.5. Coda e10562.3. Task Force 3: Enhancing the Well-Being of Clinicians e10562.3.1. Organizational Strategies to Promote Well-Being e10592.3.2. Addressing Well-Being Among Trainees and Researchers e10602.3.3. Well-Being Strategies Focused on Health Information Technology e10612.3.4. Identifying Symptoms of the Disruptive Physician e10622.3.5. Identifying and Assisting the Impaired Clinician e10632.3.6. Additional Considerations and Caveats e10642.4. Task Force 4: Patient Autonomy, Privacy, and Social Justice in Health Care e10642.4.1. Patient Autonomy e10652.4.2. Data Privacy, Transparency, and Access e10652.4.3. Social Justice e10652.4.4. Recommendations: Patient Autonomy e10662.4.5. Recommendations: Data Privacy, Transparency, and Access e10672.4.6. Recommendations: Social Justice and Racism e10692.4.7. Caveats e10702.5. Task Force 5: Modern Healthcare Delivery: Challenges Related to New Care Delivery Systems e10712.5.1. Addressing Potential COIs When Designing and Engaging in New Models and Venues of Cardiovascular Care Delivery e10722.5.2. Medical Professionalism for the Employed Clinician e10732.5.3. Ethical Challenges and Professionalism Related to Billing, Coding, Documentation, and EHRs e10752.5.4. Quadruple Aim: Does an Ethical and Professional Perspective Enhance or Obstruct Patient Satisfaction, Outcomes and Quality, Cost, and Clinician Satisfaction? e10762.5.5. Conclusions e1076References e1077Appendix 1. Author Relationships With Industry and Other Entities (Comprehensive) e1082Appendix 2. Reviewer Relationships With Industry and Other Entities (Comprehensive) e10871. INTRODUCTIONIvor J. Benjamin, MD, FAHA, FACCWilliam J. Oetgen, MD, MBA, MACCKatherine A. Sheehan, PhDC. Michael Valentine, MD, MACC, FAHAThe 2020 American Heart Association and American College of Cardiology Consensus Conference on Professionalism and Ethics (2020 Consensus Conference) comes at a time even more fraught than the eras of the 3 previous meetings on the same topics. A virulent pathogen has challenged the physical and economic health of the entire country; a series of tragedies have awakened a sense of social justice previously unexpressed nationally; and the political climate rivals the divisiveness seen at the birth of the nation.1 Arguably, there could be no better time to review and take a fresh perspective on medical ethics and professionalism in the light of established norms and current stressors. In addition, the American Heart Association (AHA) and the American College of Cardiology (ACC) recognize that this important assessment should be undertaken on a more regular basis. There should be no more 16-year gaps.Building on a solid understanding of previous similar efforts and with a firm appreciation of the obligations of medicine’s social contract, the tenets of medical ethics, and the principles and commitments of medical professionalism, the ACC and the AHA sponsored a conference on medical professionalism and ethics on October 19 to 20, 2020. Multiple medical professional organizations provided valuable input. The purpose of the present 2020 Consensus Conference is to address the practical management of professional and ethical behavior of cardiovascular clinicians and scientists and to make specific recommendations in light of contemporary issues of professionalism and ethics. The consensus committee reviewed previously published documents and current materials to formulate their recommendations.1.1. Historical Perspective and Current PlanThe AHA and the ACC have long individual and collective histories of formally addressing issues of medical ethics and medical professionalism. The 21st Bethesda Conference (Ethics in Cardiovascular Medicine) was held in October 19892; the 29th Bethesda Conference (Ethics in Cardiovascular Medicine [1997]) was held in October 19973; and the collaborative effort (ACC/AHA Consensus Conference on Professionalism and Ethics) was held in June 2004.4 The specific major topics and subtopics discussed in these conferences reflect the ethical and professional issues extant at the time of the assemblies.The 21st Bethesda Conference2 was devoted to discussions of ethical decision making in medicine; the relation of cardiovascular specialists to patients, other physicians, and physician-owned organizations; the allocation of limited resources in cardiovascular medicine; scientific responsibility and integrity in medical research; and the relation of cardiovascular specialists to industry, institutions, and organizations.Subtopics included in the 21st Bethesda Conference discussion were the following: acting in the patient’s interest; respecting the patient’s preferences; distributive justice; physician responsibilities to society; medical decision making; end-of-life decisions; AIDS and the cardiovascular physician; conflicts of interest (COIs) and ethics in medical education; resource limitations and distribution; end-of-life care; cost and efficacy of medical technology; the welfare of the individual patient and the welfare of society; responsibilities of clinical investigators, research objectivity, credibility, and COIs; specific physician relationships with industry (RWIs); physician ownership of healthcare facilities; and physicians’ relationships to institutions and organizations.The 29th Bethesda Conference3 discussed external influences on the practice of cardiology, application of medical and surgical intervention near the end of life, and clinical research in a molecular era and the need to expand its ethical imperatives.Subtopics discussed in the 29th Bethesda Conference included managed care and the reinterpretations of ethical standards and the concept of professionalism; the relationship of medical ethics and business ethics; the application of medical and surgical interventions in elderly patients; palliative care; futile care; forgoing treatment and advance care planning; physician-assisted suicide; ethical considerations in the conduct of clinical trials; the ethical, legal, and social implications of the Human Genome Project; data confidentiality; and genetic information and its implications for medical insurance.The ACC/AHA Consensus Conference4 dwelt on codes of conduct in human subjects research (HSR); investigator participation in clinical research; disclosure of relationships with commercial interests and policies for educational activities and publications; appropriate clinical care and issues of self-referral; expert testimony and opinions; and a code of conduct for organizational staff and volunteer leadership.Subtopics treated in the ACC/AHA Consensus Conference were COIs and proper disclosure; formal scrutiny of research involving human subjects; confidentiality in research activities; indemnification of research activities; avoidance of bias in clinical trials; physician self-referral; direct-to-consumer advertising; cardiovascular specialty hospitals and physician financial COIs; antikickback statutes; Stark laws; expert testimony in professional liability, class action litigation, and patent issues; and nonprofit organizational governance, management, and potential COIs.For the 3 prior ACC or ACC/AHA ethics and professionalism conferences, there were 164 unique attendees; 11.6% were identified as women, and 2.4% were identified as Black. Twenty of the 164 attendees were present at 2 or 3 of the conferences. Of the 164 attendees, 20 were past, present, or future ACC presidents, and 13 were past, present, or future AHA presidents. No attendees were identified as early career or fellows-in-training.In the 2020 Consensus Conference, of the 61 participating attendees, 41.2% were women, 7.9% were Black, and 4.8% were Hispanic. Three of the 61 were present at the prior conference in 2004; 6 were past, present, or future ACC presidents; and 4 were past, present, or future AHA presidents. Two 2020 Consensus Conference attendees were identified as early career, and 4 were fellows-in-training. Figure 1 shows comparative attendee demographic data for the combined earlier conferences and for the 2020 Consensus Conference.Download figureDownload PowerPointFigure 1. American Heart Association (AHA)/American College of Cardiology (ACC) conferences on professionalism and ethics: attendee demographics.Figure 2 shows the academic degrees and professional representations of the attendees at the current conference and at each of the 3 previous conferences. It is important to note that for the purpose of the current conference, the ascendancy of the team care paradigm in 21st century cardiovascular medicine is recognized, and references to physicians in prior publications, by extension, include all members of the healthcare team. In this document, the terms clinician, practitioner, and medical professional will be used in lieu of the term provider.Download figureDownload PowerPointFigure 2. American Heart Association (AHA)/American College of Cardiology (ACC) Conferences on Professionalism and Ethics: attendee academic and professional representation. Mean conference attendance=63.This document is a comprehensive summary of the deliberations of the 5 task forces that made up the 2020 Consensus Conference. Throughout the preparation of this report, efforts were made to be as concise as reasonably possible; however, because this is envisioned to be a reference document, essential detail was deliberately not euthanized for the sake of brevity.1.2. Context FramingThese conferences have reinforced the notion that the operative underpinning for the practice of medicine in the United States is a set of principles of medical ethics. These principles also form the basis for medical professionalism and what has become known in more recent years as medicine’s social contract. Ethical medical practice is an a priori assumption of medicine’s social contract, and the principles of ethics shape that contract, giving rise to the concept of professionalism and the rules by which that contract is implemented from the perspective of the medical professional.5,6The American College of Physicians7 and the American Medical Association (AMA)8 have codes of ethics for physicians. The American College of Physicians’ Ethics Manual provides context, for example, in reviewing the principles of medical ethics and reminding us thatMedicine is not, as Francis Peabody said, “a trade to be learned, but a profession to be entered.” A profession is characterized by a specialized body of knowledge that its members must teach and expand; by a code of ethics and a duty of service that, in medicine, puts patient care above self-interest; and by the privilege of self-regulation granted by society. Physicians must individually and collectively fulfill the duties of the profession.7The tenets of medical ethics, the principles and commitments of medical professionalism, and the specific obligations of medicine’s social contract form the basis of this joint AHA/ACC study of medical ethics and professionalism in the 21st century. By way of creating a common ground of understanding, in this introduction, each of these 3 sets of elements is reviewed.1.3. The Tenets of Medical EthicsThe classic ethical principles of medical practice are duties based in respect for autonomy, beneficence, nonmaleficence, and justice.7,9Respect for autonomy. The duty to protect and foster a patient’s free, uncoerced choices.Beneficence. The duty to promote good and to act in the best interest of the patient.Nonmaleficence. The duty to do no harm in every interaction with patients.Justice. There should be fairness and equity in health care.1.4. The Principles and Commitments of Medical ProfessionalismThe Physician Charter on Medical Professionalism was published in 2002 as a collaboration between the American Board of Internal Medicine Foundation, the American College of Physicians–American Society of Internal Medicine Foundation, and the European Federation of Internal Medicine.10 Both the ACC and the AHA have officially endorsed the charter, as have >100 other medical professional organizations across the world.11 The charter contains eloquent, succinct, and actionable expressions of the principles and commitments of medical professionalism. Its descriptors are reproduced here with permission.101.4.1. Principles of ProfessionalismPrimacy of patient welfare. This principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician-patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle.Patient autonomy. Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients’ decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.Social justice. The medical profession must promote justice in the healthcare system, including the fair distribution of healthcare resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, sex, socioeconomic status, ethnicity, religion, or any other social category.1.4.2. Commitments of ProfessionalismProfessional competence. Physicians must be committed to lifelong learning and be responsible for maintaining the medical knowledge and clinical and team skills necessary for the provision of quality care. More broadly, the profession as a whole must strive to see that all of its members are competent and must ensure that appropriate mechanisms are available for physicians to accomplish this goal.Honesty with patients. Physicians must ensure that patients are completely and honestly informed before the patient has consented to treatment and after treatment has occurred. This expectation does not mean that patients should be involved in every minute decision about medical care; rather, they must be empowered to decide on the course of therapy. Physicians should also acknowledge that in health care, medical errors that injure patients sometimes do occur. Whenever patients are injured as a consequence of medical care, patients should be informed promptly because failure to do so seriously compromises patient and societal trust. Reporting and analyzing medical mistakes provide the basis for appropriate prevention and improvement strategies and for appropriate compensation to injured parties.Patient confidentiality. Earning the trust and confidence of patients requires that appropriate confidentiality safeguards be applied to disclosure of patient information. This commitment extends to discussions with individuals acting on a patient’s behalf when obtaining the patient’s own consent is not feasible. Fulfilling the commitment to confidentiality is more pressing now than ever before, given the widespread use of electronic information systems for compiling patient data and an increasing availability of genetic information. Physicians recognize, however, that their commitment to patient confidentiality must occasionally yield to overriding considerations in the public interest (for example, when patients endanger others).Maintaining appropriate relations with patients. Given the inherent vulnerability and dependency of patients, certain relationships between physicians and patients must be avoided. In particular, physicians should never exploit patients for any sexual advantage, personal financial gain, or other private purpose.Improving quality of care. Physicians must be dedicated to continuous improvement in the quality of health care. This commitment entails not only maintaining clinical competence but also working collaboratively with other professionals to reduce medical error, to increase patient safety, to minimize overuse of healthcare resources, and to optimize the outcomes of care. Physicians must actively participate in the development of better measures of quality of care and the application of quality measures to routinely assess the performance of all individuals, institutions, and systems responsible for healthcare delivery. Physicians, both individually and through their professional associations, must take responsibility for assisting in the creation and implementation of mechanisms designed to encourage continuous improvement in the quality of care.Improving access to care. Medical professionalism demands that the objective of all healthcare systems be the availability of a uniform and adequate standard of care. Physicians must individually and collectively strive to reduce barriers to equitable health care. Within each system, the physician should work to eliminate barriers to access based on education, laws, finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession.A just distribution of limited finite resources. While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost-effective care.Scientific knowledge. Much of medicine’s contract with society is based on the integrity and appropriate use of scientific knowledge and technology. Physicians have a duty to uphold scientific standards, to promote research, and to create new knowledge and ensure its appropriate use. The profession is responsible for the integrity of this knowledge, which is based on scientific evidence and physician experience.Maintaining trust by managing COIs. Medical professionals and their organizations have many opportunities to compromise their professional responsibilities by pursuing private gain or personal advantage. Such compromises are especially threatening in the pursuit of personal or organizational interactions with for-profit industries, including medical equipment manufacturers, insurance companies, and pharmaceutical firms. Physicians have an obligation to recognize, to disclose to the general public, and to deal with COIs that arise in the course of their professional duties and activities. Relationships between industry and opinion leaders should be disclosed, especially when the latter determine the criteria for conducting and reporting clinical trials, writing editorials or therapeutic guidelines, or serving as editors of scientific journals.Professional responsibilities. As members of a profession, physicians are expected to work collaboratively to maximize patient care, to be respectful of one another, and to participate in the processes of self-regulation, including remediation and discipline of members who have failed to meet professional standards. The profession should also define and organize the educational and standard-setting process for current and future members. Physicians have both individual and collective obligations to participate in these processes. These obligations include engaging in internal assessment and accepting external scrutiny of all aspects of their professional performance.1.5. The Obligations of Medicine’s Social ContractMedicine’s social contract is an agreement between 2 parties: society as a whole and medical practitioners.12,13 Some elements of the contract are tacit, and some are codified in the laws and regulations governing the practice of medicine. Examples of the latter are laws establishing the healthcare system, educational requirements, and licensure. The tacit elements are behaviors and attitudes expressed by practitioners such as honesty, commitment, compassion, and altruism, none of which are concepts suitable for legislative or regulatory actions. Contracts—tacit or written—document the obligations agreed to by the parties involved. The obligations of the healthcare social contract, as delineated by Cruess and Cruess,14 are as follows:1.5.1. Medical Practitioners Agree to:Fulfill the role of the healer. The healer is an elemental and well-defined role in all human societies. Attributes of the healer include caring and compassion; insight and self-awareness; openness; respect for the healing function; respect for patient dignity and autonomy; being fully present and without distraction for the patient; and accompanying the patient through the journey of healing.15Achieve and maintain proficiency in the knowledge of their area of practice. At the basic level for initial licensure, all US states require an allopathic or osteopathic medical degree, successful completion of a licensure examination, and between 1 and 3 years of postgraduate training.16 For license renewal, all US states except Colorado and South Dakota require continuing medical education.17 At the higher clinical functioning level, all boards require postgraduate training in an approved program and successful completion of a comprehensive examination for specialty certification. All specialty boards provide time-limited certification, and all require participation in a maintenance of certification program for recent diplomates.18Achieve and maintain a high level of skill in their area of practice. At the level of the medical student, clinical skills are assessed by Step 2 (Clinical Skills) of the United States Medical Licensing Examination process.19 The Accreditation Council for Graduate Medical Education (ACGME) sets skill standards for residents and fellows-in-training.20 For the practicing physician, fulfillment of this obligation of the social contract is aspirational. There is no formal organization or process for assessing and documenting clinical skills beyond clinical training, although hospital medical staff quality committees have the responsibility of monitoring procedural outcomes across a variety of specialties.Provide for the patient’s needs ahead of their own. This is the fundamental expression of altruism, which is a basic tenet of all descriptions of professionalism. The mode