AMA Journal of Ethics^®

“Co-creation” refers to an interactive process in which stakeholders work together toward a mutual end [1]. The health care system in particular is large and complex, however, and this complexity brings with it many stakeholders who might have opposing interests. Because no large-scale health care system, or even clinical institution, can exist without physicians, co-creation of these systems will be discussed in the context of physicians’ roles. The Code of Medical Ethics has several opinions that provide guidance to physicians striving to collaborate with others to create systems that can efficiently serve multiple stakeholders’ interests.

Institutional Settings

Hospital administrators and nonclinical stakeholders may have a different perspective than physicians on what constitutes a “good” or effective institution. They may not have a deep understanding of how logistical issues such as bed allotment can impact care at the bedside. For this reason, physicians who are in leadership positions within their health care institutions should offer their perspectives to other stakeholders on issues that may impact patient care.

Specifically, Opinion 10.8, “Collaborative Care” [2], encourages physicians in leadership roles to advocate on the institutional level “for the resources and support health care teams need to collaborate effectively in providing high-quality care” [2]. Such supports include “education about the principles of effective teamwork” and related skills training [2]. Physicians should also promote “the development and use of institutional policies and procedures … to address constructively conflicts within teams that adversely affect patient care” [2]. In the context of co-creation, the team typically comprises any number of individuals—physicians, nurses, administrators, social workers, and, importantly, patients. In each case, the physician-leader of the co-creative team needs to be the advocate for an environment that promotes strong and effective collaboration between all parties.

Large Health Care Systems

Opinion 11.2.1, “Professionalism in Health Care Systems” [3], speaks to the issues and challenges of co-creation in health care systems on a larger scale. As stated in the opinion,

Models for financing and organizing the delivery of health care services often aim to promote patient safety and to improve quality and efficiency. However, they can also pose ethical challenges for physicians that could undermine the trust essential to patient-physician relationships [3].

Challenges to co-creation might occur “when payment models and financial incentives … create conflicts of interest among patients, health care organizations, and physicians” [3]. Myriad other barriers to co-creation might arise when relationships are affected by “structures that influence where and by whom care is delivered” (such as health maintenance organizations) or by “tools intended to influence decision making” (such as formularies) [3]. Because of the complexity of health care systems, physicians who are in leadership positions during the creation or reorganization of large health care systems need to ensure that “practices for financing and organizing the delivery of care” are transparent and reflect input from physicians and patients as stakeholders and also to recognize practices that could undermine physician professionalism, such as overreliance on financial incentives [3]. Certain incentives are ethically acceptable as long as they are fair, evidence-based, support high-value care, and mitigate conflicts of interest. Practices for financing and organizing the delivery of care “should be routinely monitored to … identify and address adverse consequences” and to “identify and encourage dissemination of positive outcomes” [3].

The Code clearly recognizes the important role that physicians play in the co-creation of various types of health care systems. Physicians have not only a unique understanding of clinical experience at the bedside but also an ethical obligation to treat their patients as of paramount importance. This combination of experience and responsibility allows physicians as co-creators of health care systems to work with other stakeholders to implement systems that promote high-value care.