Silence Over Safety? Muzzling Clinicians a Public Health Issue

Jillian Mock

April 04, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's  Coronavirus Resource Center.

COVID-19 has caused battle lines to be drawn. But they're not just between clinicians and the virus. They're also between the healthcare workers and their employers, causing what the American Medical Association calls a "flashpoint" that could affect public health.

In recent weeks, clinicians across the country have spoken out on social media and in the press about unsafe working conditions and shortages of personal protective equipment (PPE) in the face of the growing COVID-19 pandemic.

Some of those clinicians have been reprimanded or even fired for speaking out. And many other healthcare professionals have said they feel they can't tell their story for fear they too will face disciplinary action from their employer, as reported by Medscape Medical News.

These gag orders are of course restrictive for the physicians, nurses, and other clinicians that fall subject to them. But they also may go against the best interests of other clinicians, patients, and the general public during a health emergency, according to many healthcare advocates.

A culture of honesty and transparency is a crucial part of dealing with, and communicating around, a public health crisis, they claim.

"Physicians have a professional and ethical responsibility and need to be able to speak out on these types of issues," Robert McLean, MD, president of the American College of Physicians, told Medscape Medical News

The ACP is one of several professional organizations that have come out against attempts to silence physicians in recent days. Earlier this week, the ACP released a statement supporting physicians who shared concerns about their workplace conditions and lack of adequate PPE, while also rebuking attempts by hospital systems to silence clinician complaints or activism.

"We as a college felt the need to speak out about that and indicate that this is completely wrong," said McLean. "Physicians who are speaking out to make people aware of issues of public health and of public health concern should not be at risk of having their employment terminated or otherwise disciplined."

According to the ACP's ethics policy, physicians who are able should speak out about public health issues for their safety and the safety of their patients, he said. "The benefit to patients is that problems are identified and not swept under the rug."

On Wednesday, the American Medical Association (AMA) also put out a short statement in support of physicians' right to advocate for their patients in the current climate:

"In recent weeks, as physicians have battled the COVID-19 pandemic, the question of when and how to express concern about conditions and safety has become a flashpoint for physicians and their hospital employers."

When hospital conditions or policies conflict with patients' best interests, the AMA said, some employed physicians have said that their hospitals told them they are not allowed to discuss the risks with the press or on social media.

"In response, the American Medical Association calls for reinforcing the principle that places patients' welfare as the first priority in any situation where the interests of physicians and hospitals are in conflict. No employer should restrict physicians' freedom to advocate for the best interest of their patients."

"Selfish Interests"

It is understandable that hospitals are worried about their public image at a time like this, McLean said. "But we can't have the selfish interests of those entities override the interest of the greater public health and the awareness of where there are problems, what those problems are, and then hopefully help various entities, maybe government agencies, improve things."

When contacted by Medscape Medical News to comment on these reports, the American Hospital Association (AHA) referred to a letter sent by AHA President and CEO Richard Pollack on March 27 to the consumer advocacy group Public Citizen, in response to a complaint filed by the group on behalf of themselves and 54 other organizations.

"Outside of the anecdotal reports you shared, the AHA has not heard any reports of hospitals or health systems restricting the free speech of physicians, nurses, or others regarding the conditions related to COVID-19," the letter reads. 

But during a crisis like this one, transparent, honest, and reliable communication is crucial to keeping people safe and coordinating an effective response to a public health threat, Claire Standley, PhD, MSc, an assistant research professor in the Center for Global Health Science and Security at Georgetown University in Washington, DC, told Medscape Medical News.

"What we've seen throughout this crisis and obviously in previous epidemics as well is that effective risk communication is incredibly important," she said.

Standley, who researches health systems and public health capacity with an emphasis on infectious diseases, emphasized that honesty and clarity are crucial for the kind of communication that builds public trust.

This trust can affect how well people adhere to public health guidelines to keep themselves and others safe. When people hear conflicting accounts from different groups — like healthcare workers, hospital systems, and government officials — it can erode their trust in the information they are receiving about a serious situation, she said.

The easiest way to get everyone on the same page is for all entities to be transparent and tell the truth, Standley added.

But there can be a downside to some healthcare workers sharing their stories online: One person's perception does not necessarily reflect the system as a whole, she said.

In a large, diverse, and heterogeneous country like the United States, the situation on the ground can vary widely from place to place, Standley explained, and there's a balance that can and needs to be struck between responsibility in communication and people's right to share information they feel is important.

Ideally, conversations around safe practices and PPE supplies are already happening within hospital systems between frontline clinicians and administrators, she said. "I would hope hospitals were already having those conversations with those providers in other contexts and don't need the public to be forcing their hand."

Not all hospitals have adopted these restrictive policies. Some, like Mount Sinai in New York City, have actively worked to connect their frontline physicians with members of the press to aid outreach and the sharing of accurate communications, according to a Bloomberg report

During an uncertain and unprecedented moment like this, threatening the livelihood of frontline healthcare workers hardly seems like the best way to boost morale and improve patient outcomes, McLean said.

While very few actions are straightforward and simple right now, McLean said this one is: "Don't do that." 

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