Cyberchondria: "Doc, I Know My Diagnosis, Tell Me if I am Right"

With the widespread access to the Internet and all the "medical information" sites throughout, it is not surprising that "cyberchondria" (patient worries about diagnoses that they obtained by researching the Internet) is becoming a common experience for physicians to encounter.  Read the article in Amednews.com (American Medical Association News) about cyberchondria and return and let's talk about it.  What are the "goods" and what are the  "bads" aspects of this Internet educational opportunity?  ..Maurice.

A Doctor's Decision: Whether or Not to "Call the Cops"

A most interesting scenario was posted on Medpedia by Scott M. Dyck which I am, in part, reproducing here but you might want to go there to review the responses there but also feel free to make your comments here. If you were the doctor in this case, what would you do? ..Maurice.

You are a general practitioner and a mother comes into your office with her child who is complaining of flu-like symptoms. Upon entering the room, you ask the boy to remove his shirt and you notice a pattern of very distinct bruises on the boy's torso. You ask the mother where the bruises came from, and she tells you that they are from a procedure she performed on him known as "cao gio," which is also known as "coining." The procedure involves rubbing warm oils or gels on a person's skin with a coin or other flat metal object. The mother explains that cao gio is used to raise out bad blood, and improve circulation and healing. When you touch the boy's back with your stethoscope, he winces in pain from the bruises. You debate whether or not you should call Child Protective Services and report the mother. 

Doctor vs Computer: Can a Computer Make a Better Diagnosis?

I found this visitor question on a discussion forum:" i was debating this with some doctors who say that it would be impossible to program a computer to make diagnoses as well as they can. i find this pretty ridiculous. whatever thought process/string of questions they would use to analyze the situation are the same that the computer would be programmed to use. the compute:r would then analyze all available information, ask questions, analyze the answers and assign probabilities. in fact, it seems like this would be way simpler than some of the things computers have already been programmed for. what do u think?"


So what do I think? 

My opinion, as a doctor, is that  what is input into a computer for calculation is the most important  part of the process of making a diagnosis and deciding on a treatment program to benefit the patient.   No amount of computer power or access to data storage will substitute for the physician's input of the history and the physical findings of the patient.  A computer posing questions to a patient and the patient responding will never substitute for a direct doctor-patient communication.  There are many subtleties, nuances  of a history which can never be accessed by a computer, such as body language and verbal expressions  and there is no way for a computer to perform a complete and worthy physical examination.  A robot used in surgery still requires a doctor behind it and no robot will attain the skills to inspect, auscultate, palpate and percuss and then interpret  the findings.  To me, how complete and understood is the input of data both from a patient telling a history and the doctor performing a physical is the basis for the diagnosis.   Poor input will always lead to poor output.  And, finally, it will always take a doctor to analyze the results of the computer to confirm its diagnosis.  I would agree that the doctor with knowledge and with experience and then working together with the computer can be most productive of  the correct diagnosis.

So.. what do you think?

..Maurice.

Patient Modesty: Volume 47

We continue here the discussion regarding how the concerns about healthcare provider gender selection by patients and ways for the patient to be more comfortable with those who attend them can be brought to the attention of all those who provide service and maintain the status quo in the healthcare system.  ..Maurice.


ADDENDUM (1-16-2012)  On this date, PT, a long-time writer to this thread on Patient Modesty, wrote the following comment which includes a potentially valuable suggestion for a method for those who want to change the current medical system regarding patient modesty and caregiver gender selection.  This is what he wrote:
Alan said

" Rosa parks was a single woman who started
a movement with a single act of resistance,Malcolm X
took another path and my style is more like Rosa parks
than Malcolm."


My style is more like Genghis Khan until I
realized that the pen is mightier than the sword. My idea
to solve this issue is a 40 step process, meaning I have
put together 40 different avenues of approach over a
period of about 10 months.

Here is the first avenue, visit www.change.org
to start a petition. Now I suggest you start perhaps at a
hospital or clinic that you in the past had concerns with.
Others around the world will join the petition
and to be effective use multiple facilities in each city. Keep
in mind this is a medium to bring our concerns forward. The
first of many mediums we will use as I suggested in volume
46 of Dr. B's blog.


PT 

Graphic: From Google image resource modified by me with Picasa3.

Do Oaths and Rules Make a "Good" Doctor?

Do oaths and rules make an ethical and caring physician?  

In the realistic and present day world of medical practice, the way medicine is practiced both in terms of emphasis or de-emphasis of oaths, medical school teachings and established legal and professional requirements are going to be different between one physician and another. There are going to be shortcuts and at times excesses depending on the situation and even the mood of the physician. Doctors are going to take chances or they will strictly follow what they believe are standard operating procedures ("standards of practice"). Yes, the Oaths are there, the laws and professional requirements and all the tools for professional behavior as provided by the medical schools are there but in the end, each doctor in their own professional environment will obey them as they see fit at the time. And it is up to their patients and their colleagues to finally grade the doctor. 

Do oaths and rules make an ethical and caring physician?  My conclusion is "probably not". I think it takes more than that. And, if you agree, what "more" is necessary? Let's read your thoughts on the subject. .Maurice.

Should Doctors be Allowed to Strike?

Currently, there is a strike by 10,000 physicians at public hospitals in a state of India in an attempt to get better salaries and work opportunities similar to those in other federal hospitals in India. The government has suspended 40 doctors, and 390 others have been arrested for failing to perform their duties.

Over the years there have been physician strikes elsewhere in the world and in the United States for various reasons including the high cost of malpractice insurance.  A 2004 article in the American Journal of Bioethics by Autumn Fiester argues the ethics against walkouts by physicians, in this case the issue has been the increasing malpractice insurance cost rates not keeping pace with physician reimbursements.

   

My question to the visitors to my blog is whether physicians have a right to strike and if so for what reasons and  if they do, is such individual physician termination of services, without any replacement provided ethical? ..Maurice.

Patient Modesty: Volume 46

Continuing on with the discussion regarding issues of physical modesty in the context of medical care, there continues to be debate throughout these Volumes as to who is responsible for the contested inequalities in attention to these issues and what is necessary for the resolution of these issues.  Is there a conflict between the male and female gender, working apart, in attaining their own individual modesty goals or should both genders look to each other's physical modesty needs and desires and stand and work together to change the medical care system to meet all their goals? I suspect the latter is the wisest.  Perhaps the best suggestion for both genders to become active to the same cause and to get together on a website to develop tools for advocacy.  I would suggest checking in at Suzy's site where the goal is to do just that.  Here is her description of the Mission Statement and Goals:

MISSION STATEMENT:
We believe that each patient is an individual and as such has specific preferences and needs including what accommodations they require to maximize comfort when their modesty must be compromised in the medical experience. Our mission it to act as a liaison between patients and providers in establishing, understanding, and executing the policies and procedures essential to that end. When appropriate we will act as advocates for patients to achieve that goal through interaction, education, and referrals to both patients and providers.

GOALS: Our goal is to help patients achieve dignified and respectful healthcare through education and information. Everyone has different needs and expectations of their healthcare providers, and we provide choices and options in obtaining those needs. We understand that modesty, privacy, and respect are primary needs when facing procedures and we promote educating providers in the sensitivity of those needs.

ADDENDUM (12-23-2011)

 On 12-23-2011, Belinda wrote the following comment : Going back the the "Naked" article, it would seem that now is the time to write protocols for exams with dignity at the forefront with equal accessibility as needed for any kind of exam making draping practices uniform. It would give patients and idea of what to expect and do as much to relieve the awkwardness of such an exam. Any thoughts on this?

I responded with the following:

Belinda, an EXCELLENT suggestion! In fact, to make the suggestion even more productive.. how about the visitors here (even you PT) together create a final consensus list, a series of suggested protocols for attending to all the patient modesty issues experienced in medical care. The development of the list can written to this blog or Dr. Sherman/Doug Capra's or on Suzy's blog.

But not just writing this protocol list to our blogs.. the final consensus list should be sent to Dr. Atui Gawande who wrote the article "Naked" in the New England Journal of Medicine and which was the basis for our entire series of Volumes on patient modesty. As some of you may know, Dr.Gawande is now a very well respected individual for his analysis and writings about a host of important medical issues that need fixing or change. By this project on our part, this may be the most direct way, through Dr.Gawande, to get something moving rather than repeated moaning and yearning on our blogs. How is that for an idea? Again, thanks Belinda for a suggestion to get us all "off our butts" (so to speak). 



..Maurice.
Graphic: "Man and Woman Apart and Together"-Classic icons modified by me with ArtRage.

NOTICE: AS OF TODAY JANUARY 11, 2012 "PATIENT MODESTY: VOLUME 46" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 47

Should Patients Have Online Access to Their Medical Records?

Should all patients be given online access to their medical records? The British healthcare system is currently considering such a possibility. With electronic medical records progressively becoming the norm throughout the medical world, this access would be feasible but would it be wise? Certainly, there would be advantages to the patient who would readily see the written result of the office visit and could then, if necessary, confront the physician with corrections, additions and questions and in a timely fashion. But what are the negatives to such an idea beyond potential loss of patient privacy due to inappropriate or illegal computer access? For example, would this mean that the medical record would have to be written in words understandable by any patient rather than in more concise and professionally understandable terminology and thus perhaps degrade professional communication? Would such access more easily give rise to patients starting malpractice actions due to misunderstandings of what was written to the record? Could patient's be pressured by others (insurance companies or employers as examples) into providing access to the electronic records since they would be more readily available? What do you think? ..Maurice.

Do We Own Our Own Germs?: Ethics and Law in Research

From the current New York Times Sunday Review: IMAGINE a scientist gently swabs your left nostril with a Q-tip and finds that your nose contains hundreds of species of bacteria. That in itself is no surprise; each of us is home to some 100 trillion microbes. But then she makes an interesting discovery: in your nose is a previously unknown species that produces a powerful new antibiotic . Her university licenses it to a pharmaceutical company; it hits the market and earns hundreds of millions of dollars. Do you deserve a cut of the profits?
In on ongoing legal challenge to the patent law which allows isolated human genes to be patented and which was previously overturned, the Court of Appeals for the Federal Circuit of the United States returned a ruling earlier this year that these genes were not simply a product of nature, which would not be eligible for a patent, but indeed could be patented. So..who has the legal rights to that rare and valuable germ growing in your nose or that gene which was part of your body but the one that was recovered and used for, as an example, a genetic test for cancer? And beyond the law.. what are the ethics? What is the good vs bad, what is the right vs the wrong?

..Maurice.

When is Privileged Communication Not Privileged? The Law and Ethics.

Privileged communication is "an exchange of information between two individuals in a confidential relationship."

I present now three scenarios and look toward some wise visitors to this blog to provide me with some answers from the legal point of view but also a view of the ethics. ..Maurice.

Suppose a patient admits to his physician that he is emotionally upset and is having gastro-intestinal symptoms because he killed his wife and buried her body in the back yard and told others that she was on a vacation. Suppose a client who is about to be questioned by the police, admits to his lawyer that he killed his wife and buried her body in the back yard. Would the professional standard in each case see the admission as privileged communication and allow the professional to withhold the information to the police or courts that the patient or client admitted? Suppose the patient with symptoms and that same story went to his physician who was both a physician and a lawyer licensed to practice and revealed the killing but desired the professional as a lawyer to provide professional legal advice and, if necessary, defend his case. Could privileged communication still be preserved?

Patient Modesty: Volume 45

Doug Capra, a regular contributor to this thread, wrote a comment on November 1 2011 which I inadvertently didn't publish but which I think is valuable for our consideration of two issues related to the patient modesty discussions here. Read it and then read my analysis below. ..Maurice.

Relative to the current discussions -- In past posts, I've referenced an articled called "Not Just Bodies" which is based upon a study of the strategies and/or defense mechanisms doctors use to deal with body issues == which include not just nakedness and modesty, but also horrible accidents and diseases. The profession knows well about these issues and addresses them. A major problem, as I see it, is this: Some of the strategies they use protect them psychologically but do little for or actually psychologically harm the patient. Some doctors never really "get over" this issue but just put up fences to protect themselves. There are also studies out there using medical students showing how they deal with this issue. There are some related studies about nurses. I think a myth within the profession is that these issues can easily be hidden from the patient by covering up using these strategies. I question that. I think many patients pick up on this and it may affect their healing and/or psychological health. Most of us, medical professional or not, are often unaware of the face we are actually "showing" to others. It takes quite a bit of self-reflection and knowledge to be aware of this. My other concern is what I've started to call the "deprofessionalization" of medical care in this country -- for cost saving reasons. I'm not so concerned with what are called mid-levels (PA's and NP's) But the use of all kinds of various initialed (cna, cma, pt's, ma, etc.) nurse assistants, some with little maturity and/or training, in this country is frightening. Some have no actual scope of practice, work under the doctor's license, and can do whatever the doctor is willing to risk. It's this trend that bothers me most and IF, and I emphasize the IF, there's a tendency for people with sexual perversions (or other psychological defects) to enter the medical field, it would be in this area. And these are the people these days doing most of the bedside care and, more and more, even some invasive procedures.By Doug Capra

First, I agree that physicians, in order to emotionally not react or show to the patient that they are not unprofessionally reacting to the patient's nudity, may take on a bland, emotionally neutral affect which demonstrates to the patient a sexually inert physician. And since the physician is sexually inert, he or she expects the patient to be likewise. And particularly, if the patient doesn't verbally complain, the physician thinks that the current behavior is fully acceptable.

I also agree with Doug regarding a certain degree of inadequate screening of the motivations of those entering the medical field and particularly those whose time and money and life investments are truly minimal and perhaps sexual interest values may play a role beyond the desire to be a care provider for the sick.

So who can be called a "peeping Tom", the title of this Volume's graphic, is a matter open to discussion. Perhaps we all are "peeping Toms" or "Little Bo Peeps" at one time or another, but it never should be at the physical or emotional expense of any patient. And that is why I think that discussion and dissemination of the issues of patient physical modesty is so important in the consideration of the best patient care. ..Maurice.

NOTICE: AS OF TODAY DECEMBER 20, 2011 "PATIENT MODESTY: VOLUME 45" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 46

Does the Fertilized Egg Equals Legal Person?

From today's New York Times:

"A constitutional amendment facing voters in Mississippi on Nov. 8, and similar initiatives brewing in half a dozen other states including Florida and Ohio, would declare a fertilized human egg to be a legal person, effectively branding abortion and some forms of birth control as murder. With this far-reaching anti-abortion strategy, the proponents of what they call personhood amendments hope to reshape the national debate."

By the time most of my visitors will have read this thread, the voters in Mississippi will have voted and the constitutional amendment will have passed with all its potential consequences or simply defeated and with some folks in Mississippi unsatisfied. Read the article describing the significance of this vote and return and discuss here what you think would be the consequences of such an amendment passing in other states or even become part of the United States Constitution. Should a fertilized human egg be a legal person and the intentional destruction of that person be consider a crime such as a homicide (murder)? ..Maurice.

Medical Bloopers 3: A Medical Communications Defect

The following medical charting errors may appear funny to the casual reader but if they or their cousins are written in medical charts, they not only appear ambiguous but may in some cases be harmful for the safe and effective medical management of patients. These "bloopers" are the results of rushed notations with no rereading by the writer of what was actually written.

This is actually the third in a series of such charting errors (the second in this series was an addition of 6 "bloopers" added to the original 19 and may be found at this link). There may be a few repeated from that second listing in this current presentation. Enjoy. ..Maurice.

Note: These "bloopers" come from a variety of sources and I don't know who to acknowledge for them.

By the time he was admitted, his rapid heart had stopped, and he was feeling better.

Patient has chest pain if she lies on her left side for over a year.

On the second day the knee was better and on the third day it had completely disappeared.

She has had no rigors or shaking chills, but her husband said she was very hot in bed last night.

The patient has been depressed ever since she began seeing me in 1986.

Patient was released to outpatient department without dressing.I have suggested that he loosen his pants before standing, and then when he stands with the help of his wife, they should fall to the floor.

The patient is tearful and crying constantly. She also appears to be depressed.

Discharge status: Alive but without permission.

The patient will need disposition, and therefore we will get Dr. Shapiro to dispose of him.

Healthy appearing decrepit 67 year old male, mentally alert, but forgetful.

The patient refused an autopsy.

The patient has no past history of suicides.

The patient expired on the floor uneventfully.

Patient has left his white blood cells at another hospital.

The patient's past medical history has been remarkably insignificant with only a 45 pound weight gain in the past three days.

She slipped on the ice and apparently her legs went in separate directions in early January.

The patient experienced sudden onset of severe shortness of breath with a picture of acute pulmonary edema at home while having sex which gradually deteriorated in the emergency room.

The patient had waffles for breakfast and anorexia for lunch.

Between you and me, we ought to be able to get this lady pregnant.

The patient was in his usual state of good health until his airplane ran out of gas and crashed.

Since she can't get pregnant with her husband, I thought you would like to work her up.

She is numb from her toes down.

While in the ER, she was examined, X-rated and sent home.

The skin was moist and dry.

Occasional, constant, infrequent headaches.

Coming from New York, this man has no children.

Patient was alert and unresponsive.

When she fainted, her eyes rolled around the room.

Malpractice vs Involuntary Manslaughter: What is the Distinction?

The current legal case being tried in court regarding the death of Michael Jackson by the alleged acts of Dr. Conrad Murray as involuntary manslaughter in contrast to the death being an act of malpractice brings up the question: what is the difference in legal terms between medical malpractice and involuntary manslaughter. And, perhaps, what is the difference in ethical terms? If the physician is found guilty, the physician is punished financially in the first case but by prison time in the second. An excellent article written by Eisenberg and Berlin in the American Journal of Radiology in August 2002 gives case examples and may tend to answer to the question posed in the title of my thread. An excerpt from the article follows:

The circumstances under which a physician's error of medical judgment triggers criminal prosecution are not totally clear. An English court of appeals ruled that to justify a criminal conviction, it must be proven that a physician acted with “gross negligence,” which is characterized by any or all of the following elements: indifference to an obvious risk of injury to health; actual foresight of the risk coupled with the determination nevertheless to run it; an appreciation of the risk coupled with a high degree of negligence in the attempt to avoid it; and inattention or failure to avert a serious risk.

A person whose behavior is “grossly negligent” may be liable for involuntary manslaughter if his or her conduct results in the accidental death of another person. Most jurisdictions hold that something more than ordinary negligence must be proven before the defendant can be found guilty of involuntary manslaughter. This usually requires that there be a substantial danger not only of bodily harm, but also of “serious bodily harm or death.” The defendant must have acted “recklessly,” a term defined as a “gross deviation from the standard of conduct that a law-abiding person would observe” in the same situation The court must consider all the circumstances surrounding the incident, including the social utility of any objective the defendant is trying to fulfill.

What, in my opinion, seems to be missing in the accusation of a physician with a crime of involuntary manslaughter rather than a professional error of malpractice is whether the physician's intent in diagnosis and management was to ignore any attempt toward the professional goal of beneficence (doing a "good" ) to his or her patient. If one could prove that such was not the intent and goal, shouldn't that be the overriding criteria to define a death as professional malpractice and not a crime? On the other hand, I look forward toward what how others to my blog thread look at this distinction. ..Maurice.

Another Look at Medical Futility

What is medical futility? What does it mean to stop or not start some procedure or treatment because such action is futile? And what does futile mean in this context? Over the past 7 years on this blog, I have started a few threads which included this issue. Once, I presented the definition of futility as described by physician-ethicst Dr. Steven Miles in his humorous "A Thai Dictionary of Medical Ethics" in which he described an example of the use of the term "futility"as "a siphon for removing puddles of water that form far ahead on highways on hot summer days." Medical futility is a bit more complicated than that. Recently, for me, a concise description of medical futility was made by an ethicist and teacher Laurence B. McCullough, Ph.D. on a bioethics listserv and with his permission, I present his words below. But also what I would like to read from my visitors is how they look at the term "futile" or "futility" in relation to its use by doctors and whether it represents to them as patients or family members of patients a term which has meaning and should be used. ..Maurice.

In its general clinical meaning, 'futile' means that in evidence-based reasoning there is no reasonable expectation that the usually intended outcomes of a clinical intervention will occur. The roots of the concept can be found in the admonition in the Hippocratic text, The Art, against the madness of thinking that clinical intervention has unlimited power to alter the course of disease or injury. (Blackhall in "Must we always use CPR?" suggested 100% failure rate or 97-99% failure rate with high and unacceptable morbidity.)

Providing futile clinical management is not consistent with professional integrity. (See Brett AS, McCullough LB. When patients request specific interventions: defining the limits of the physician's obligation. N Engl J Med 1986; 315: 1347-1351.) Professional integrity has been a consistent, core consideration of common law on end of life care, starting with Quinlan in 1976.

This general meaning of 'futility' must be specified, to be clinically applicable. (See Jones JW, McCullough LB. Postoperative futility: a clinical algorithm for setting limits. Br J Surg 2001; 88: 1153-1154; Rabeneck L, McCullough LB, Wray NP. Ethically justified, clinically comprehensive guidelines for percutaneous endoscopic gastrostomy tube placement. Lancet 1997; 349: 496-498.)

Physiologic futility: no reasonable expectation that physiologic outcome will be achieved (e.g., antibiotics for viral infection, CPR on totally decapitated human being [from international resuscitation guidelines and my favorite], artificial administration of nutrition to a patient with cancer cachexia). Physiologic futility is not discredited by a transient physiologic effect, such an occasional heartbeat during CPR.

Imminent demise futility: clinical management is expected to be physiologically effective but the patient is expected to die during current admission with no expectation of recovery of interactive capacity. (Medicine is not vitalist in any global tradition of medical ethics. See Baker RB, McCullough LB. The Cambridge World History of Medical Ethics 2009, in which'vitalism' does not appear in the index.)

Clinical or overall futility: clinical management is expected to be physiologically effective and prevent imminent death but the patient is not expected to recover interactive capacity, as in permanent vegetative state diagnosed by American Academy of Neurology guidelines. (Again, medicine is not vitalist.)

Quality of life futility: clinical management is expected to be physiologically effective, prevent imminent death, and preserve interactive capacity but the resulting functional status is not acceptable to the patient from the patient's perspective. (Quality of life is engaging in life tasks and deriving satisfaction from doing so. This concept does not apply to infants or to patients about whom too little is known to reliably identify the life tasks in which they engaged and the values by which they would make judgments about whether engaging in those life tasks with projected functional status will result in sufficient satisfaction.)

The first three specifications fall within clinical expertise; the fourth depends on clinical expertise (prognosis of functional status) but is also a function of the patient's values and beliefs.

These specifications often cannot be invoked a priori. Instead, they become the basis for stopping rules for critical care (initiated by CPR, high-risk surgery) as a trial of intervention. Explaining this concept in advance is a powerful preventive ethics response to requests to "do everything," by focusing on everything that is consistent with excellent medical care.

Race, ethnicity, and money (source of payment) are irrelevant to the conceptualization and clinical application of these specifications, which, when explained, can help address the distrust problem. If someone wants to make discussions of futility toxic, just introduce money, especially with folks of modest economic means or people of color. (Against stupidity, though, even the gods themselves rage in vain. See I Asimov, The Gods Themselves 1972.)

Some surrogate decision makers are not willing or are not able to engage in evidence-based, deliberative discourse. This is a rare but real phenomenon. Education and persuasion end in failure. The remedy becomes the exercise of professional and organizational power, which, in Texas, is sanctioned by our advance directives act. Elsewhere, local healthcare organizations need to agree on a futility policy, so that, when it is enforced by one organization, the others will be in support. (See Halevy A, Brody BA. A multi-institution collaborative policy on medical futility. JAMA 1996; 275: 571-574.)

Laurence B. McCullough, Ph.D.

 Dalton Tomlin Chair in Medical Ethics and Health Policy

 Center for Medical Ethics and Health Policy

 Baylor College of Medicine

 Houston, Texas

Contemporary Art and Education of Medical Students: Beauty and Truth

Diagnosing and treating a patient's illness is many times a challenge which is not easily solved with a snap judgment but requires the doctor's attention to a sequence of important considerations and actions. There is importantly the observation followed by the interpretation of what has been collected in terms of the patient's history, the physical examination of the patient and the diagnostic tests performed. Sometimes, this collection of data is complex, intertwined and frankly ambiguous and confusing. But there may appear after further contemplation and perhaps after consulting with other professionals a pattern which will direct the doctor to make the correct diagnosis and follow with the appropriate treatment. But how is the detection of patterns taught to medical students and physicians?

What is going on in a number of medical schools including the school at which I teach is to give the students an opportunity to look at and think about and discuss among themselves and their instructors contemporary art. Yes, like many illnesses themselves, the art work at first glance may appear wildly confusing but with attention to details, contemplation and discussion with others, the meaning of the painting to the student and perhaps also the meaning of the painting which the painter was attempting to express becomes more clear and definitive.

Schaff, Iskin and Tager writing in the October 2011 issue of Academic Medicine describe that teaching technique using contemporary art. The following is an Abstract of that article.

Many medical schools have incorporated experiences with representational or figurative art into the curriculum in an effort to improve learners' powers of observation, visual diagnostic skills, and pattern recognition skills or to enhance communication skills, foster teamwork, and/or improve empathy. The Keck School of Medicine of the University of Southern California has partnered with Los Angeles' Museum of Contemporary Art to design an educational experience with the goal of honing students' abilities to observe, describe, and interpret complex information. The authors discovered that through a constructivist approach to viewing and discussing nonrepresentational, contemporary art, students were able not only to apply their observational and interpretive skills in a safe, nonclinical setting but also to accept the facts that ambiguity is inherent to art, life, and clinical experience and that there can be more than one answer to many questions. This intervention, entailing extensive guided inquiry, collaborative thinking, and process work, has allowed students and faculty to reflect on the parallel processes at work in clinical practice and art interpretation. In patient encounters, physicians (and physicians-in-training) begin with attention and observation, continue with multiple interpretations of that which they observe, move to sorting through often ambiguous evidence, proceed to collaboration within a community of observers, and finally move to consensus and direction for action. In the worlds of both art and medicine, individuals imagine experiences beyond their own and test hypotheses by integrating their own prior knowledge and intuition and by comparing their evidence with that of others

Another way of looking at the value of such teaching is from the philosophical point of view and consider aesthetics, the beauty of a painting as a reflection of some truth. By analyzing the painting and exploring its beauty, the truth will most likely be apparent. When treating a patient, the doctor should always look for the truth. Isn't that a truism? ..Maurice.

Graphic: "Astigmatism" created by me using ArtRage 10-4-2011.

"I am a nurse but I am also a doctor": Conflicting Identities to the Patient?

Should a nurse with a doctorate degree in nursing identify herself as a doctor to a patient? Here are excerpts from the current New York Times article on this question:

"Doctorates are popping up all over the health professions, and the result is a quiet battle over not only the title “doctor,” but also the money, power and prestige that often comes with it. ...

As more nurses, pharmacists and physical therapists claim this honorific, physicians are fighting back. For nurses, getting doctorates can help them land a top administrative job at a hospital, improve their standing at a university and win them more respect from colleagues and patients. ...

So physicians and their allies are pushing legislative efforts to restrict who gets to use the title of doctor. A bill proposed in the New York State Senate would bar nurses from advertising themselves as doctors, no matter their degree. A law proposed in Congress would bar people from misrepresenting their education or license to practice. And laws already in effect in Arizona, Delaware and other states forbid nurses, pharmacists and others to use the title “doctor” unless they immediately identify their profession."

What do you think? Should M.D.s be identified to the patients as "doctors" and nurses with a doctorate degree be indentified as "nurses"? ..Maurice.

What to do about "Mixed Messages" in Medicine

What do you know about the sending of "mixed messages" to the public and patients by the medical profession either from the government, institutions or from individual physicians? I might define a "mixed message" as virtually advice or education based on one view and at the same time presenting advice or demonstrating behavior of an opposing view. Such "mixed messages" can range from issues such as over-weight physicians advising weight control to their patients, medical institutions advising influenza immunizations to patients but a large proportion of the institution's staff rejecting immunization, a governmental medical agency advising against routine mammograms before age 50 and in contrast to other cancer specialty groups advising mammograms at an earlier age. Even in the critical care unit, the attending physician may recommend to family the reduction of energetic supportive treatment in a end-stage ill patient whereas specialists on the case may encourage further supportive treatments.

As patients, families of patients or just plain citizens who want to stay healthy and need to be educated about matters medical, how should we handle the issue of receiving "mixed messages" from those who we look to for clear information to make our decisions? Or should we just resign ourselves that this is only part of the human condition, a fact of life and we should simply live with it. (..or occasionally die with it.) ..Maurice.

Should children be told that they were "donor conceived"? Would it ever be ethical not to tell them?

Should children be told that they were "donor conceived"? Would it ever be ethical not to tell them?


If they are to be told, at what age should that be? Should an attempt be made to identify the donor? Should the donor be allowed or encouraged to visit the children? When?

If the donor is a woman donating eggs and not a man donating sperm would there be a difference in answers to the above questions?

How would the questions be answered if the questions applied to a surrogate "mother" who only carried the pregnancy to delivery resulting from implantation of the fertilized eggs of a husband and wife? ..Maurice.

Note: I also posted these questions on Medpedia. You can read responses there by clicking on this link.

How Would You Like to be Told that You Have Cancer?

I would like to start a followup conversation on a thread that I began September 25, 2005 titled "Telling 'Bad News': But There is More to Tell" The question is how can a doctor tell a patient that he or she has cancer without the patient "freaking out" at that moment and not being able to be educated by the doctor about the nature of the cancer, the various approaches to treatment and the outcomes. What suggestions would you give regarding how the doctor can meet the emotional needs of such a patient as well as to provide necessary education that will be needed for future decision-making? How would you like to be told that you have cancer? If this has happened to you in the past, it would be worthy for me and other physicians to listen to your story about how you were told and how you dealt with the information and education... and, of course, your suggestions. ..Maurice.

Graphic: Painting John the Baptist by Guido Reni (1575-1642)

Patient Modesty: Volume 44

It has become clear from reading all the responses to this thread "Patient Modesty" that the issue of physical modesty in the context of medical care is not gender specific. Patients of both genders need attention by the healthcare providers to their modesty concerns. And yet, it appears in many situations, this attention is not being applied to that patient and because of resource differences, particularly with regard to the male patient. In addition, perhaps unrecognized to many of us, and as brought to our attention by the "stressed student" (SS) in the previous 2 Volumes even medical students may be aware or personally concerned about how and what they are being taught regarding sensitive genital and rectal examinations. Now.. continuing on with the discussion we will begin Volume 44. ..Maurice.

Graphic: Photograph of bronze Auguste Rodin's "Burghers of Calais-Pierre de Wissant" taken by your moderator 8-13-2011 at the Norton Simon Museum, Pasadena, CA

NOTICE: AS OF TODAY NOVEMBER 8, 2011 "PATIENT MODESTY: VOLUME 44" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 45

The Price of Precaution and the Ethics of Risk

I am borrowing the title of a book by Christian Munthe published by Springer for this thread. I will not be using the title, perhaps, in the same general context as Munthe but using the words as I imagine their meaning when applied to medical care.

One will find many examples of precaution and their corresponding examples of risk in how medical care is provided by physicians and accepted by patients. In fact, not only do these two elements correspond but at times the price, itself, of precaution becomes the risk. Risk is everywhere in medical practice. Risk is present when a patient is selecting a physician. The risk is becoming the patient of a doctor whose professional behavior does not meet the goals of a "good doctor" set by the patient. It is often that the patient really has no chance to predict how the doctor-patient relationship will turn out since the patient is often immersed in the relationship already by the time the uncertainty about that doctor begins to develop. Ideally, the patient should be cautious of all physicians from the onset as to how that relationship will turn out unless the patient doesn't care. Recommendations by neighbors, family or even other physicians may be helpful but are only the views of others regarding what is strictly a personal relationship. Precaution in the making of a selection of a physician is not often fully available due to time and medical urgency and inadequate communication between patient and doctor. The price of precaution in this example can be what turns out to be unnecessary and harmful delay in diagnosis and treatment in the attempt to find a satisfactory medical provider. On the other hand, not accepting a physician for personal consultation without an introductory "get to know you" appointment, if accepted by the physician, would be of great benefit for the patient's comfort with subsequent medical consultations.

On another thread on this blog, it appears that patient physical modesty issues become a risk. The visitors write about the emotional risk of examinations and procedures in terms of their emotions associated with that modesty. It is related to the presence of those attending or looking on being of the opposite gender than the patient. The inability to obtain an environment free of those of opposite gender including the physician, nurses and technicians may lead to a decision by the patient to avoid the exams or procedures even if their life was at stake. Such is the price of their caution.

Yet, even absent the context of physical modesty, precaution may be elicited in a patient's decision whether or not to accept a necessary medical or surgical procedure in face of the risks of that procedure. Presumably, that decision is based on information regarding the statistical value of the procedure vs the side-effects and life risks of the procedure. A patient's precaution decision against the procedure may have a price of further sickness or death.

Risk may often be warranted and thus beneficent to the patient. It may turn out, in medical practice that the price of precaution is not worth the benefit permitting a risk. The physician the patient received before searching for others may be the one who could diagnose promptly and correctly and cure the patient. It could be that the risk of emotional upset related to the physical modesty issue, concerning opposite gender presence is not worth the outcome of avoiding the examination or procedure. And finally, the price of precaution leading to the rejection of a procedure based on statistics instead of "taking a chance" on being the statistical outlier who would benefit despite the risk would be to the detriment or even the death of the patient.

What is your philosophy regarding balancing precaution and the apparent risk in medicine? ..Maurice.

Graphic: "Better Safe than Sorry" text image created by your moderator 8-20-2011.