Jane Kang is a rheumatologist, an Assistant Professor of Medicine at Columbia University Medical Center (CUMC), Director of the Rheumatology Fellowship, and an alumna of the Bioethics graduate program. In her office at CUMC, she tells Columbia SPS, “I started the Bioethics graduate program when I was already in practice as a faculty member at Columbia, which, for me, was especially valuable and rewarding. The Bioethics program helps you organize your thoughts within a bioethical framework, so that you have a systematic, focused, and informed way of approaching ethical issues in clinical care and research.”
We spoke with her about how she uses bioethics principles in her practice, the kinds of ethical issues she faces in the realm of rheumatology, and how she incorporates it into her work as a professor.
What made you interested in medicine?
It’s an incredible privilege and honor to be able to make a difference in people’s lives. That’s part of what’s so special and fulfilling about being in medicine. The lifelong learning and problem-solving in medicine is also gratifying, and feeds my intellectual curiosity.
How did you decide to specialize in rheumatology?
The field of rheumatology is truly about the art of medicine, putting the pieces of the puzzle together, with less reliance on advanced medical testing to obtain a diagnosis. In rheumatology, really listening to the patient and performing a full, detailed physical exam is of the utmost importance. If you do all that, you usually have your diagnosis.
Rheumatologic diseases are not always easily classified into specific diagnoses, but often have overlaps or gray areas. These intricacies in rheumatology push me to think outside of the box, which I find both exciting and rewarding. Many rheumatologic diseases are also more esoteric and not as well-known. For those patients who have been searching for answers, a rheumatologist can help them find those answers and a diagnosis, which allows them to receive appropriate therapy to help treat their condition.
What are the ethical issues in rheumatology?
Ethics is inherent in medicine. First, there are ethical issues that any physician may encounter on a daily basis. This may entail discussing the risks and benefits of a new medication that is being recommended, and in rheumatology, it could be immunosuppressive or immunomodulatory therapy. For example, how much information is enough to be certain that a patient is adequately informed to make a decision about his or her treatment?
In rheumatology, a field that encompasses autoimmune and immunologic diseases, ethical concerns may arise because the diseases and the medications used can be more complex and less familiar to patients. Additionally, if a drug a patient needs is not FDA approved for a particular rheumatologic disease – and that is not uncommon given that some of our diseases are more rare and therefore difficult to study in large clinical trials because of that scarcity – that patient may not be able to receive that medication because it is not be covered by their insurance.
There are ethical issues that can arise in rheumatologic research as well. Rheumatology has benefited from an enormous amount of new therapeutic advancements in immunotherapy. For example, in the not so distant past, we only had a handful of medications for rheumatoid arthritis, but now we have a plethora of treatments available. With the growing interest in immunotherapies for rheumatologic diseases, there has also been a massive growth in clinical research in rheumatology. This brings to light many bioethical concerns in research, such as pharmaceutical industry involvement in clinical trials and the use of precision medicine.
Can you give an example of where your bioethics training has helped you in your clinical practice or your academic career?
If my patients are being approached to participate in a clinical trial, I am very conscious about the therapeutic misconception – which is when individuals do not understand the difference between clinical research and clinical care and assume they will certainly benefit from participating in research. In clinical research, the goal is to obtain generalizable knowledge, whereas in clinical care, the physician does what is in the best interest of that individual patient. The inherent goals in clinical research and clinical care are very different, but patients may not always recognize that.
In 2013, I was elected to serve on the American College of Rheumatology Ethics and Conflict of Interest Committee. I continue to serve as a member of this committee currently. My Masters of Bioethics education has been enormously helpful and informative with regards to the work I am involved in with the American College of Rheumatology.
I also direct the Rheumatology Fellowship program at Columbia University Medical Center, and that gives me the opportunity to teach young physicians major principles of bioethics in clinical care and research. Given my background in Bioethics, I give research ethics lectures for the rheumatology fellows on a yearly basis. I want our young physicians to understand how to use a bioethical framework to carefully consider ethical issues. Medical students receive some formal exposure to bioethics, but the exposure that residents and fellows have is limited, and that should not be the case. It is essential that our young physicians know how to systematically think about bioethical issues, because they are the future of medicine.