Bioethics Discussion Blog





Tuesday, April 15, 2014

Patient Modesty: Volume 65

And the discussion continues. 
From Paul writing to Volume 64:

I wonder what women in general, as well as female nurses ,female techs, and other female providers would think if the gender numbers were reversed?

Imagine you go in for a routine exam with your female doctor because you don't want a male doctor. A male chaperone or student is brought in to the room to observe.
You either ask for him to leave or because you were blind sided by it you say nothing and go through it. Only to be angry about it later.

During your exam the doctor finds something and recommends a vaginal ultrasound. You ask for a female but there is only male sonographers that work there. You can say no or swallow your pride and do it. Another male will be assisting you find out at the last minute.

Time for a visit now to a gyn/urologist for a more invasive exam and a cytoscopy. Once again you choose a female doctor but when you arrive all the assistants will be male.

You are found to need an operation. When you arrive a male will be prepping you and another male catheterizing you. By this time you hate the medical system for having to go through all these embarrassing procedures with so many males involved. You say nothing because you are told all the men have seen it all before and your body is nothing special. They have seen it all before so it is silly and immature of you to feel this way.

This is what almost every male has to deal with when we go into the health system. They wonder why men do not go in for their exams. I wonder how many women would hesitate to go if this is what it was like for them?
Oh wait. I think there was something called affirmative action. Now they have female choice for doctors and a support staff of 95 percent women.

I sympathize with the issues of women posting to this site but being a male is even worse.

Which hand of a healthcare provider do you want touching you and whose eyes looking at you, male or female? Do you believe that gender is more important than skill or personality. ..Maurice.

Graphics: From Google Images.

Monday, April 14, 2014

A Doctor's First Words to a Patient

“Interesting belt — where did you get that?”

“I see you are from Youngstown. The key question is, are you a Steelers fan or a Browns fan?”

Daniel R. Wolpaw, M.D., and Dan Shapiro, Ph.D. writing a Perspective article titled "The Virtues of Irrelevance" in the April 3 2014 issue of the New England Journal of Medicine present these as examples of possible opening remarks by a physician to a patient who appears with a medical problem.  The authors suggest that remarks such as these serve 4 "key purposes"  from the physician's point of view which, in establishing the doctor-patient relationship provide "ways to establish the connections that allow us to actually care for the person in front of us."  They explain: "First, they convey that we see the patient as a unique individual. Given the speed of medical practice, it is not surprising that patients worry that their individual concerns will not be heard. Second, these questions reveal that we have had shared experiences, that despite our training and attire we are not so different from the patient. Third, they communicate that we are observant and attending to details, which patients find comforting. And finally, they indicate that we are open to a conversation with the patient."

I am not going to start out with a detailed discussion on my part regarding the pros and cons of a physician beginning the doctor-patient relationship with what might seem as irrelevant communication. What I want to read is what my visitors to this thread think should be the opening question by a physician to their patient: "Tell me about your concerns" or something to that effect or instead to begin with "irrelevance" ..Maurice.

Graphic: Via Google Images from Wall Street Journal by Linzie Hunter and modified by me with Picasa 3.

Tuesday, March 18, 2014

Patient Modesty: Volume 64

In this and the following Volumes, there is no need to go into more detail (and I will not allow that to be published here!) about "unprofessional behavior" if it amounts to describing prurient sexual interest and acts or frank sexual crimes by professionals. This behavior is clearly wrong for a physician or nurse behavior and requires notification of state professional boards in the United States and law enforcement as necessary. That is the solution for that behavior. To educate the patient to ask their provider "are you planning to manipulate my breast or genitals for your own pleasure or do you intend to rape me?" are ridiculous questions to ask at each medical exam or procedure. The way to feel confident in the behavior of the doctor you plan to visit is by getting recommendations from friends and neighbors and by visiting the state board website to see if there are any "bad marks" for that doctor. Also, if the patient can have the opportunity and afford (it certainly may be worth the expense) an introductory visit to talk with the doctor about his or her experiences and views (including religious) and at the start tell the doctor how you want to be treated in terms of your modesty issues but also in other regards. I am sure most patients will be able to size up this doctor and the doctor's environment and enter for an examination at another time with more confidence that the doctor has been "made aware".

What I want is this and the next Volumes to be directed to is listing specific issues to educate and attempt to change the behaviors of the medical system to make the system aware of the need to incorporate programs of attention, mitigation or resolution of issues of patient modesty beyond current concerns about medical mistakes, preventable risks, patients' medical record privacy, ways to pay for patients' medical care and so on.

How do we do this beyond the one on one conversation with a doctor, nurse or medical tech? It is all this that we have to discuss. And where do we start? I believe I have previously mentioned for the United States: the Joint Commission that sets standards for patient care in hospitals and a hospital not passing the regular detailed surveys: no governmental Medicare or Medicaid payments.

In the next Volumes, instead of tearing down the medical system with accusations (and many may well be valid), let's go ahead and progress to "doing something" to meet the requirements for meeting the ethical principles of "justice", "beneficence", "autonomy" and finally "non-malificence" for all patients of either gender and their own degrees of physical modesty. ..Maurice.

Graphic: From Google Images and modified by me with ArtRage and Picasa3


Sunday, March 09, 2014

Doctors May Guess Your Diagnosis and Why They May Be Wrong

This thread is all about heuristic clinical reasoning which means a doctor's mental shortcuts to come to a diagnosis. Heuristic is defined in Wikipedia as:

Heuristic (/hˈrɪstɨk/; Greek: "Εὑρίσκω", "find" or "discover") refers to experience-based techniques for problem solving, learning, and discovery that give a solution which is not guaranteed to be optimal. Where the exhaustive search is impractical, heuristic methods are used to speed up the process of finding a satisfactory solution via mental shortcuts to ease the cognitive load of making a decision. Examples of this method include using a rule of thumb, an educated guess, an intuitive judgment, stereotyping, or common sense.

In more precise terms, heuristics are strategies using readily accessible, though loosely applicable, information to control problem solving in human beings and machines.

In medical practice there may be many reasons which encourage heuristic clinical reasoning such as emergent medical situations or general lack of time for detailed history taking and examinations, lack of resources including an important resource would be a patient who was able to give a medical history or a knowledgeable surrogate. Another factor promoting such reasoning is the expense or potential health hazard to the patient from a procedure which would be appropriate for a definite diagnosis. Finally,  physicians who are not fully educated in a particular specialty may be unaware of all the different diagnoses which are available to consider. Unfortunately, for some physicians heuristic reasoning tends to become a relied upon habit. 

There are a number of categories classifying the types of reasoning which can make up heuristic clinical reasoning.  I found an interesting list by the CanadianAssociation of Emergency Physicians (CAEP).

Here is a list of categories and the description of each by the CAEP:

1. ANCHORING-Focusing on vivid, salient features in a clinical presentation early in the diagnostic process and failing to adjust this first impression later as more information becomes available.
2. ASCERNMENT BIAS-When thinking is unduly influenced by prior expectations (e.g. stereotyping or gender-bias).
3. AVAILABILITY-Options appear more likely when they are readily brought to mind (e.g. a subacrachnoid hemorrhage diagnosis is given more consideration on the differential for headache if it was seen in a case a week ago.)
4. COMMISSION BIAS-The idea that something always needs to be done to the patient instead of letting things take their course--more common in confident physicians; things get done that were unnecessary.
5. CONFIRMATION BIAS-Looking for things to support your diagnosis/hypothesis rather than looking for disconfirming evidence (which is usually a more effective strategy).
6. CONTRAST EFFECT-When interpretation of a particular case is influenced by adjacent cases--even though they are independent of each other.)
7. DIAGNOSES MOMENTUM-When diagnoses gather momentum without gathering evidence.
8. FUNDAMENTAL ATTRIBUTION ERROR- Judging and blaming particular patients (e.g. obese, borderline personality disorder, addicted patients) for their illnesses by focusing on their disposition (character, personality, intelligence) rather than considering their situational circumstances (socio-economic, upbringing, history of physical/sexual abuse).
9. HINDSIGHT BIAS- Learning from past experience is hindsight. However hindsight bias occurs when, knowing the outcome, people either make themselves look good or look bad, thereby distorting any chance of realistic learning.
10. OMISSION BIAS- The tendency toward inaction and non-intervention.  Error arises from things not getting done that should have been done.
11. OVERCONFIDENCE-The general belief that we are better than we really are--a misplaced belief that affects one's thoughts and actions.
12. PLAYING THE ODDS also known as FREQUENCY GAMBLING- is the tendency in equivocal or ambiguous situations to opt for a benign diagnosis on the basis that it is significant more likely than a serious one.
13. PREMATURE CLOSURE-Shutting off thinking before there is sufficient evidence to suggest a particular diagnosis--when the diagnosis is made the thinking stops.
14. REPRESENTATIVENESS RESTRAINT- We tend to look for prototypical manifestations of disease--atypical presentations are more likely to get missed.
15. SEARCH SATISFICING- reflects the universal tendency to call off a search once something is found. Co-morbidities, second foreign bodies, other fractures and co-ingestants in poisoning all might be missed.
16. VISCERAL BIAS- when emotions overly intrude into decision-making.  Countertransference may result in feeling unduly negative or positive toward patients leading to suboptimal decisions regarding diagnosis and management.
17. YIN-YANG OUT-The outlook that once patients have been worked up the Yin-Yang  further effort will be futile.
18. ZEBRA RETREAT- Backing away from a rare diagnosis for reasons other than it being rare: thinking that you will attract a reputation of being esoteric, unrealistic  or a wastrel of resources or time.
19. TRIAGE CUEING- deals with Emergency Room triage: the tendency to inherit the abbreviated thinking that occurred at triage (patients  seen in the minor area are considered as only having minor complaints).
and finally
BLIND SPOT BIAS, a general belief that people have that they are less susceptible to bias than others. 

As you see, there can be many ways that heuristic clinical reasoning can go wrong.  And yet, doctors will use this reasoning as part of the beginning to form a diagnosis when rushed or a diagnosis still not firmly established at the time that some prompt treatment for physical support is critical. But the "guess" has the many limitations as noted above.  So what is most important is that all doctors should be aware that they are at the time practicing heuristic reasoning and should know the details of what potential errors of reasoning can occur by such use and thus use with caution.

Have you ever heard your doctor tell you: "I am just guessing that you have..."? And how did or would you respond? ..Maurice. 

Graphic: From Google Images-Alfred Nobel (1833-1896)

Wednesday, March 05, 2014

Patient Informed Consent from Partially Uninformed Physicians

The title of this thread clearly sets the topic to be discussed.  Informed consent by a patient for an examination or medical-surgical procedure is an established ethical and legal act which has been even more focused throughout the medical profession in the recent decades when previous professional paternalism behavior dissolved to patient autonomy.  However established the practice is preached, the act still depends on several factors. With regard to the patient becoming informed about the details of the examination and procedure, it requires the patient or patient's surrogate making a decision to comprehend what is being communicated, understanding the words and implications of what was learned but also feeling free and comfortable to ask the physician questions about details told and about information which had not been presented but which is of concern to the patient.  These details therefore must be presented directly by the healthcare professional who will be responsible for the exam or procedure and not only by text on a sheet of paper to be read and signed.

With regard to the professional who provides the details to the patient, the information presented should be in a form which is the best for patient understanding and decision-making.  The talk should be comprehensible both in terminology and in how it is presented. The detailing should not be "rushed through" but slow enough for the patient to hear clearly what was said  but also slow enough for the professional to stop and monitor by questioning the patient that the words are truly being understood. An important aspect of the presentation of information from doctor to patient is to maintain attention to patient autonomy and avoid paternalistic remarks or possible options which only fit  that physician's own personal interests.  However, even though physicians may have decided upon their own options or professional decisions and it is appropriate for the doctor to tell the patient what the doctor has decided is best for the patient's health and well-being and why, it finally becomes the patients' own decision which is the primary goal of the informed consent exercise.  For the patient to do that, it requires that the patient actually be informed.

But, how can informed consent by the patient work if the patient's doctor is not fully informed?  And perhaps the entire medical profession is not fully informed about the interpretation of an examination nor the outcome of a procedure. "How can that be?" you might ask.  The answer is very simple. The medical and surgical profession just doesn't know about everything it carries out.  The profession knows a lot but it doesn't know everything and that "thing" it doesn't know may be a "critical thing" for the best interest of the patient. 

Although, in the United States, the Food and Drug Administration (FDA) attends to prevent medications which have been developed to be used on patients without careful scientific evaluation of the drug's safety and efficacy for treatment, there still occurs side-effects and serious complications that only appear once the drugs are used throughout the whole patient population and not simply in the preliminary investigative tests of small numbers of patients.  With regard to surgical instruments and procedures, the government has far less direct control over studies to evaluate safety and comparative values.  Some techniques and procedures may be informally described in the literature and carried out by surgeons with varying degrees of experience and unlike the case with the prescription of medications, each use becomes for that surgeon a learning experience. 

An interesting example of a surgical technique and its developing but still incomplete knowledge of its complications and the best way to prevent them is the procedure of electric uterine morcellation as described in a Viewpoint article in the March 5 2014 issue of the Journal of the American Medical Association.  The procedure is a method for slicing a large organ within the body, in this case the uterus, in order to remove the organ piecemeal through the very small incisions which are used to enter the abdomen for a laparoscopic surgical procedure.  The advantages of laparoscopic surgery  to surgically treat a variety of abdominal diseases and disorders with a minimum of surgical trauma and a much more rapid patient recovery period is common knowledge. What isn't common knowledge and is not fully known at this time  by the surgical profession is the full risks and degree of risks of incorporating electric morcellation of organs including the uterus.  For example, shredding a uterus to facilitate its removal may also shred and disseminate throughout the abdomen a previously undetected uterine cancer within the body of the uterus.  There are more unknowns about the procedure including the full risk/benefit ratio as compared with removal of the entire organ through a standard operative incision. 

So how can informed consent be asked from the patient when the doctor him/herself is not fully informed? The article stresses the importance and necessity for full information disclosure to the patient and including detailing the various  issues for which the surgeon is uninformed such as regarding risks which are "vague and unspecified because of limited data".  It is my opinion that such disclosure requires the risk and benefit information to be provided in an unhurried manner and so the patient understands them, to be provided by the surgeon responsible for the surgery and all the alternate options be presented. However, as noted in the article, with respect to disclosure of risks and benefits "this is difficult when the risks are vague or unquantified because of lack of data or rarity of an event. Yet a lack of data or rarity of an event should not preclude discussion of serious potential complications".

How would you, as a patient, want the physician to inform you about the risks and benefits of a procedure to obtain your "informed consent" when the doctor him/herself is not fully informed? ..Maurice.

Addendum 3-5-2014:  The original graphic obtained from Google Images and modified by me with ArtRage and Picasa 3 is from an excellent article about the responsibilities of the doctor toward the autonomy of the patient written by Dr. Faisal Saeed in the Team Talk website of the ADK Hospital of Male' in the Maldives.  I suggest, to supplement what I have written above, you go to the above link and read Dr. Saeed's article.

Tampering with Evolution? "Three Parent Embryos"

The following article I wrote for is reproduced here with permission



by Maurice Bernstein, MD
Babies are born with  a progressive neurometabolic disorder with a general onset in infancy or childhood, often after a viral infection, but can also occur in teens and adults.  The disease is seen on MRI as dead or dying tissue within the brain and though the child appears normal at birth,  in a few months to two years of age, though earlier or later,  there is loss of basic skills and finally the child may have  heart, kidney, vision and breathing complications.  What is this disorder?  It is a congenital disease carried by the mitochondrial DNA genes of the mother and called  Leigh’s Disease.  Another disorder found in mother’s egg (oocyte) mitochondria  are the  Creatine Deficiency Syndromes characterized  in the child by mental retardation, expressive speech and language delay, autistic like behavior, hyperactivity, epilepsy and movement disorders. And there even many more congenital disorders expressed by abnormal mitochondria and some are described at the United Mitochondrial Disease Foundation website.
A problem in anticipating these disorders  is that the women carrying these abnormal mitochondrial diseases may be healthy.  The possibilities of a mitochondrial DNA abnormality may only be suggested by analysis of the woman’s oocyte.  If thought to be present, then what?  Can the woman ever expect to deliver healthy babies?   And this is where a technique of assisted reproduction, developed in the recent years in animals, may yield  an answer to this question but does involve ethical dilemmas if performed in humans.  It is all about creating a healthy child by removing the mother’s healthy  oocyte DNA and placing it within another (donor) woman’s oocyte from which the cellular genetic material has been removed but what remains is that woman’s healthy mitochondrial DNA.  Then in vitro fertilization is performed using the husband’s sperm thus introducing the husband’s DNA and then followed by implantation of the finally fertilized egg cell  into the mother for the hopeful creation of a healthy baby.
In addition to the prevention of a child born with a mitochondrial genetic abnormality, there are suggestions that a reason for women after the age of 30 to be infertile was because of changes in their mitochondrial DNA with time and that perhaps the same technique would allow these women to have their child with the use of the donor’s “fresh” mitochondrial DNA.
It is this creation of a “three parent embryo” that provides a controversy regarding the ethics of performing this procedure for future therapy  or even now to begin research in humans.  The controversy  is discussed in a comprehensive news article in the February 21 2014 issue of “Science”. According to the article, the use of this technique for human research has been cautiously approved within the United Kingdom but is currently still being considered in the United States by the Food and Drug Administration which has safety and effectiveness responsibilities regarding  gene therapy in general.
So , what are the ethics issues involved?  Should it be permitted to use a technique, with the purpose to avoid a serious disease for the future child (and future generations), that will result in a genetic modification that will be inherited? if we are using  nuclearDNA from one woman and the mitochondrial DNA from another woman to be included in an ovum to be fertilized by a male to create a healthy child are we also introducing into the genetic germ line a “new human”  which would never have previously existed  and, when mature, part of that “new human’s” DNA would be carried on through future generations?   And would this be the first step on a slippery slope allowing genetic modification also of nuclear DNA?  If cloning “new humans” from designed nuclear genetic material is already said to be unethical and is not allowed, shouldn’t this nuclear DNA transfer be likewise forbidden?  Finally, from a legal viewpoint, should the resultant child be said to have three parents and would the “third” parent (donor) have to be identifiable and have any further obligations to the “family”?
I don’t have all the answers but think only about the question of humans themselves introducing scientifically created changes in the genetic germ line through DNA transfer or even frank cloning which would not have been created by “Mother Nature” through evolution.   Couldn’t all this messing with evolution be exactly what evolution was intending: developing us humans to a point when, through our intellect and science, we could add our own “two cents” to the process of evolution?  Therefore, to me, no problem.

ADDENDUM 3-5-2014 (Not part of the original article): If you agree or disagree with my final conclusion about "tampering" with evolution, please feel free to comment with your own opinion. ..Maurice.

Tuesday, February 18, 2014

Mother's Request for Posthumous Sperm Retrieval: What Would Be Your Ethical Decision?

The Case Study in the January-February 2014 issue of the ethics journal "The Hastings Center Report" sets an ethics issue which, though not a major issue like assisted suicide for the terminally ill, nevertheless has occurred. The issue is that of sperm retrieval promptly after a patient is pronounced dead for later insemination in an attempt to create a child but without the specific documented request by the patient.  With a prior request made by the patient, certainly outside the various religious views and within the "Western" culture, this act could be ethically  acceptable. But in the case developed by the ethics journal, the mother of her 29 year-old son now virtually dead by neurological criteria ("brain dead") , and the mother as  his legal surrogate, requests the sperm retrieval, for future use, on the basis of, in the past,  her son's telling her that he "wanted to give her grandchildren." Neither the son's girlfriend nor the son's father was not involved in the mother's decision and request and, in fact, no one was specified as the recipient for later fertilization.  There was no written directive by the son requesting sperm retrieval.  My question for my visitors here is, if you called into the clinical situation as an ethicist, would you, with the history provided, tell the physicians faced with this request that it would be ethical to go ahead with the sperm retrieval?  One fact to consider is that organ retrieval such as kidneys for donation and transplant is considered legal and ethical if said by the family to have been requested by the patient. Do you see any difference between sperm retrieval and use and kidney donation and transplant? ..Maurice.

Addendum: For more information about posthumous sperm retrieval  read the Wikipedia articleYou also may want to read the article "IVF AfterDeath" where through Google Images, the Graphic for this thread was obtained. Finally, come to your own ethical decision and post it here but then go ahead and read the free Case Study in The Hastings Center Report with the two commentaries.

Saturday, February 15, 2014

Informed Consent: Does that Include Personal Detailing of Your Doctor?

There is still debate in the medical, ethical and legislative community as to how much information is enough as part of informed consent for the patient or the patient's surrogate to make a decision as to whether to have an operation or other procedure or medical treatment.  And is there such a thing as "too much information" for the patient to be told and expected to understand? That is still debatable. There is no debate as to the legal necessity for a patient's autonomous decision regarding their treatment but the question is "how much?" but also "what kind?"  For this thread I want to focus on a specific category of "what kind?" and that is: should the patient be permitted to ask personal questions about the doctor and followed by detailing by the doctor to the patient regarding the doctor as a person and as a professional. 
Lance K. Stell PhD, teacher-ethicist, has specified my focus with the following:

Traditionally, Informed Consent disclosure duties of the physician were “procedure focused” NOT provider focused.

Some states (e.g. Pennsylvania and North Carolina) have aggressively restricted statutory Informed Consent disclosures to the recommended procedure, and its alternatives, including the option of no procedure, along with a discussion of the risk/benefits of each option.

Other states have expanded the physician’s disclosure duty to
include the extent of his/her training and experience with the particular
operation (and the hospital's) when the outcome disparities between providers
for the proposed treatment were “material"

This development and entry of Big Data bids to expand disclosure duties (and
pressure on physicians to discuss) considerably. For a few examples:

How many of these procedures have you done, doctor? How many recently? What is
your Morbidity and Mortality Rate and your (and your hospital’s) 30-day unplanned readmission rate? Have you ever had a “never event?” You are proposing to do my operation laparoscopically, but suppose you find it necessary to “convert” to an open operation. Do your privileges include doing the procedure open, or must you call in a colleague who has such privileges for back up? What might be his/her responsibility or role in the setting of such “conversions?”

New rules give me a right to tell you my preferred manner of receiving health-related communication. So please, I prefer all information you give me about risk in statistical terms, not qualitative terms.

Tell me about your Conflicts of Interest. “I noticed that you're on the Federal Government’s list for having received payments from the medical products industry. Does that imply that you’re taking kick-backs or are under suspicion or something?”
 Tell me about the instrumentation you propose to use for my surgery. How big a profit does you hospital get on it? I support cost-effective care. Has any of it been implicated
in Device Problem reports to FDA? If so, have you considered using other instrumentation? Why not? And how are you compensated for your work? I strongly disapprove of "fee for service".

And, this is just the tip of…”By the way, when's the last time you got a good
night’s sleep?"

So when you go to the hospital for an appendectomy, about to start chemotherapy for a diagnosed cancer, are suggested "new" medication rather than the established drug for your illness, is there more you need to know beyond the lab tests, your doctors interpretation of your history, physical and labs? Do you also need to know also more about the personal details about your doctor?  And, if so, should you wait until you are immediately challenged to make an informed consent or should all this be part of the first selection of a doctor for your care? ..Maurice.

Graphic: Images from Google Images and modified by me using ArtRage.

Sunday, February 09, 2014

Patient Modesty: Volume 63

As we start our sixty-third Volume, after reading all the descriptions of "criminality" inside the medical profession within the context of "patient modesty",  I just wondered, to start Volume 63 if we should really define what we are specifically referring to when we use the term "patient modesty". The other aspect of the expression which needs clarification is to whom does the term apply?  Does it apply to every human who is a patient,  including infants and children, to the elderly and demented and to those who are unconscious from anesthesia or in a permanent coma (persistent vegetative state) or, in fact, a patient who is dead?  I think we should all set an accepted definition of the term and to whom the term applies before we argue the case to those within the medical system in an effort to change the system to fully attend to the issues of patient modesty.  So let this be the goal of beginning this Volume.   I repeat, what exactly is "patient modesty" and to whom does it apply or, in fact, not apply? ..Maurice.


Graphic: Modesty in the Dictionary: Photograph taken by me 2-9-2014.

Monday, January 13, 2014

Shadowing a Doctor: A Benefit or Harm?

Entering a physician's office for a visit and examination may allow you to be a participant in a medical exercise called "pre-medical shadowing".  This means that, hopefully with your full informed consent,  a college student called a "pre-med student" who has been studying courses to apply to medical school, will be present to learn what the practice of medicine is all about as seen within the office of a doctor in practice. Some medical educators believe that if  these college students "shadow"(watch)  professional physicians at work they will get some insight into the profession before applying to medical school and their education in this regard may be of some value. 

Though, as a medical educator and physician myself, I find some value in this "shadowing" I do have some concerns and I expressed my opinion to a medical education website as follows:

Does anyone think that "clinical shadowing" by pre-med students will, whatever the benefits from the experience, also instill elements of the "hidden curriculum" taught to 3rd and 4th year students and beyond   even before experiencing the more "humanistic" learning provided 1st and 2nd year students? Or am I becoming overly concerned?

The "hidden curriculum" is defined as being the education of these students and residents by experience mature superiors who promote their own view of medical practice in a way different and perhaps more organizational and bureaucratic but perhaps less humanistic from what their subjects learned in the earlier years of medical school.

A medical educator responded to the website with the following comment:

Maurice's question is a good one, and one on which my colleagues and I have been reflecting.  We have seen evidence of the interference of the shadow in the ways M1 and M2 students make patient notes, using abbreviations that are no longer acceptable or are short-hand used by physicians who learned the longer versions first.  We have also seen evidence in the ways in which students talk about patients: non-compliant; drug seekers; physician-centered, disease-first speak rather than patient-centered, people-first speak.  

The phenomenon seems to be a bit akin to rituals of tribal acceptance.  Medical students are in school to become part of a given subculture, the tribe of medicine.  They may have different reasons for doing so, but the end point is the same: join a culture with its own language, behaviors, norms, and so on.  If they shadow members of this culture, tribal elders who were trained to behave in certain ways, then go to an educational institution that attempts to tell them to behave otherwise, it would seem rational for them to comply with the institution externally but with the tribal elder internally.  The elder is practicing in the field and therefore seems to have more social capital than institutional pre-clinical educators.  

This is a particularly interesting phenomenon given that medical schools are working on creating future leaders for a medical culture that is itself in the midst of an intense transformation.  The tension between tribal tradition and transformational innovation is palpable, manifesting in a variety of ways including the necessary use of practicing elders as faculty and mentors for said future leaders.   

Shadowing may help pre-matriculants to get a better grasp on the daily routines of the profession, but it may also be contributing to a prior knowledge base that hinders development of the medical culture. 

What I find of importance in this response is regarding the possible effect of this "shadowing" on inhibiting  the medical profession to advance medical practice from "old tribal tradition" to new ways, in new times, to improve the patient's value from the doctor-patient  relationship.  

There is much more to consider regarding this issue of  "shadowing" by some undergraduate college student including issues of patient privacy with regard to both sensitive history taking, physical examination and the physician's discussion of emotionally sensitive conclusions with the patient with a student in attendance.

I would be most interested to read what my visitors here think about "shadowing" by pre-medical college students.   ..Maurice.

Graphic: From Google Images.

Friday, January 03, 2014

Patient Modesty: Volume 62

The argument of what all healthcare providers are thinking in terms of sexuality, sexual feelings and sexual intent when they are attending to patients of either gender is truly an empty argument since we will never know.  And as Don (writing in Volume 61) pointed out, the providers will be damned by patients both if they admit their thoughts or refused to admit.  So, instead, let's all gather around the tables for discussion of what is most important: how to get the medical system understand that there is to some patients considerable more to patient modesty concerns than what is taught to the doctors and nurses and techs in school.  That is now what this thread is all about.  ..Maurice.


Graphic: "Empty Tables" A photograph taken by me of an eating area at the Getty Museum, Los Angeles 1-2-2014

Wednesday, December 25, 2013

MUNCHAUSEN SYNDROME BY PROXY: The Potential for Medical Profession to be Co-Participants in Child Abuse.

A father brings his young son to the doctor for prescription medications because the father suspects that the son has "classic" attention deficit/hyperactivity disorder.

The  mother relates to the hospital emergency room with  a history of multiple respiratory, gastro-intestinal and musculo-skeletal symptoms from which her child was suffering and insists that  the child be "hospitalized" for a "complete workup".  A basic workup in the emergency room discloses no disease, the child was not admitted but the mother was told to have followup with a pediatrician.  She returns to the emergency room two days later with the child and more symptoms, requesting the child's admission but having not attempted to visit a pediatrician.

A mother brings a child to the pediatrician because the child has been losing weight.  According to the mother,  multiple food allergies was suspected by the family and the child's diet was markedly reduced (starving) in order to prevent symptoms.

The mother brings a child to a pediatrician pointing at the multiple bruising over the child's body  and giving a history that the child was having recent repeated nosebleeds.  The  physician's examination finds the nasal passages to be normal and the bruises have more the appearance that they were due to trauma and not spontaneous.

What you have read are various degrees of clinical appearances of a condition known as "Munchausen Syndrome by Proxy"(MSP).  The definition of the Munchausen Syndrome itself without "proxy" is a patient's specific mental or behavioral disorder in which the individual fakes a medical illness in order to get medical attention.  In "Munchausen Syndrome by Proxy", this behavior represents medical attention directed to another (usually a child)  because of a fictional history or frank physical or mental abuse by another person usually the caregiver or parent.  Other names given to this state include "factitious disorder by proxy" or the current 2013 American Psychiatric Association title  "factitious disorder imposed by another".  Regardless of the title of this state,  it defines the unnecessary introduction of a child by a caregiver into the medical system for diagnosis and for the treating a "made up" disorder. This factitious disorder imposed by the caregiver can be related to simply the caregiver's  medical ignorance and may be to some extent unintentional, however it also can be motivated by some sort of personal gratification and may include  frank intentional physical or mental abuse of the child to create an appearance of the disorder.

 One might conclude that as a result of the inherent risks of unnecessary diagnosis and treatment the medical profession could be said to be "co-participants" in the child abuse if the healthcare providers at the outset fail to attempt to identify the syndrome  as being present.

It therefore become a duty of the initial physician consulted  to always be aware of the possibility that their child patient may be a victim of a factitious disorder imposed by another.  If that possibility is suspected,  an active attempt to confirm is essential before subjecting the child to hazards of unnecessary diagnosis and treatments.  This means taking a detailed patient history from the parent but also including the parent's medical understanding of the symptoms presented, performing a careful physical examination, communicating with the patient's prior physicians and other pertinent resources including pediatricians who specialize in MSP  as needed for assistance in confirmation. And, if Munchhausen Syndrome by Proxy is confirmed, it should be seriously evaluated as child abuse and consideration for appropriate civil/legal action to be taken for the protection of the child.  Missing to consider and investigate this diagnosis,  the physician and the medical system could be looked upon as co-participants in any damage to the child. 

For more on this topic, read the statement about this issue by the American Academy of Pediatrics and the description in Wikipedia.

After reading about this subject, can you defend the accusation that the physicians involved could be considered as co-participants in child abuse?  And another question: as personal matter, if you brought your child to a pediatrician, how would you feel if you knew the doctor was surveying you as a "by proxy" candidate? ..Maurice.

Graphic: Photo Credit: memekode on Flickr

Saturday, December 21, 2013

What to Eat and How to Live: Government as Your Nanny?

It is all about the role of government is setting limits on what you eat and how you live your own life vs government being simply a teacher, an instructor of the facts and allow its public to live their own personal lives as they see fit.  The recent limit-setting regulations of food, drink and other health issues by Michael Bloomberg as the previous mayor of New York city  has provoked controversy both for and against these actions.  A series of articles in Bioethics Forum, website of  The Hastings Center, bioethics "think tank",  presents views regarding this controversy.   Lawrence O. Goslin (University Professor and Founding O’Neill Chair in Global Health Law at Georgetown University Law Center, and a Hastings Center Fellow) writes "Bloomberg's Health Legacy: Urban Innovator or Meddling Nanny", originally published in the Hastings Center Report September-October 2013,  with the following Abstract.

Michael Bloomberg assumed office as the 108th mayor of New York City on January 1, 2002. As he leaves the mayoralty—having won re—election twice-his public health legacy is bitterly contested. The public health community views him as an urban innovator—a rare political and business leader willing to fight for a built environment conducive to healthier, safer lifestyles. To his detractors, Bloomberg epitomizes a meddling nanny—an elitist dictating to largely poor and working—class people about how they ought to lead their lives. His policies have sparked intense public, corporate, and political ire—critical of sweeping mayoral power to socially engineer the city and its inhabitants.

Here, I seek to show how Bloomberg has fundamentally changed public health policy and discourse. He has used the engine of government to make New York City a laboratory for innovation-raising the visibility of public health, testing policy effectiveness, and probing the boundaries of state power. Even though the courts have blocked some of his boldest initiatives, he has offered a paradigm for the “new public health”—reaching beyond infectious diseases to upstream risk factors in everyday life and the human habitat. I also critically probe various arguments designed to derail his policies, along with the overarching charge of unjustified paternalism.

Apparently, after much negative feedback Goslin received about the article supporting Bloomberg, he wrote his response to the Bioethics Forum titled "Bloomberg’s Health Legacy: What Inflames Consumer Passions in the Food Wars? Goslin argues for some governmental control with the following:

Making the healthy choice is exceedingly hard, with so many forces pointing in the direction of cheap, accessible, aggressively marketed food, alcohol, and tobacco. Consumers, far from having unconstrained choices under the status quo, are actually heavily influenced in their purchasing and lifestyle decisions.

In a semi-rebuttal article written to the Bioethics Forum, Ann Barnhill, an assistant professor in the Department of Medical Ethics and Health Policy in the Perelman School of Medicine at the University of Pennsylvania, states:

While I agree with this analysis, I think it is incomplete. The charge that Bloomberg is a meddling nanny reflects not just distrust with government influence on our lives; it also expresses indignation at Bloomberg’s putative attitude towards us: like little children being minded by a nanny, we can’t be trusted to make decisions for ourselves. What troubles some citizens about Bloomberg’s policies is not just the material impact of these policies on their choices and pocketbooks but also the symbolic value of these policies.

Go and read the complete short articles and then return and tell us what you think of government setting regulations regarding what we eat and what we drink and even more personal choices.   ..Maurice.

Graphic: Nanny State. Expression from and graphic created by me using ArtRage and Picasa 3.

Saturday, December 14, 2013

"See one, Do one, Teach one"

 You must read the satire on the "Glorious Tradition" of the description of medical education as "See one, Do one, Teach one" in the October 1 2012 issueof  the "Daily MedicalExaminer" where a doctor K.R. Thuxston. III, MD writes an essay about the topic, presumably "tongue in cheek" but then who knows.   This concept of a medical student or intern learning a procedure  but in reality actually learning it upon a patient and often the patient unaware of the learning going on was a practice considered acceptable back in the old days of medical professional paternalism.  Ah! But then came the last generation of medical practice and education with an ethical switch from medical professional paternalism to patient autonomy.  "See one and Do one" has become a "no-no" ..well, at least not on a living patient or at least not to "do one" with minimal, if any, supervision unless it is only drawing blood from a vein.  Simulators are all the rage now in medical education.  Simulators characterized by "standardized patient" (actors playing patients)  are used for honing up on interview techniques and general physical examination techniques but particularly female breast and genital exam of both genders.  For surgical practice, the simulators can be divided into organic, a very old technique in education in which animals and fresh human cadavers are utilized and inorganic, the current and future educational tools which comprise  virtual reality simulators and synthetic bench models and who knows what other "gadgets" in the future.  These tools bearing major medical educational investment are said to be of significant educational value but there are still studies going on regarding the validity of that conclusion.   For example even the use of standardized patients to instill the skill for students to later convey satisfactory "end-of-life" communication to real patients is still under investigation (JAMA. 2013;310(21):2257-2258}.

On the other hand, what is wrong with "See one, Do one..."?  Shouldn't patients take an altruistic view of donating their living body to medical education?  And as Dr. Thuxston concluded " Post-op, patients should look down at the ragged, poorly sutured scar on their abdomen and forget about the fact that they can’t wear a swimsuit at the beach anymore.  Instead, they should beam with pride, because the misshapen scar will remind them that their body was once used to teach a budding doctor how to operate."  And you, how about you? A bit of altruism? ..Maurice.

Graphic: Ancient Greek Medicine. Wikipedia via Google Images

Friday, December 13, 2013

Patient Modesty: Volume 61

The question becomes: will changing the medical system's  "bedside manner" be what is necessary to make most of the folks who are writing to this thread more comfortable with regard to their patient modesty issues?  In other words, is it a fixable  issue and all that is needed is simply presenting the medical profession with a different communicating "script"?  Or is the patient modesty issues not just a  script but a significant underlying structural issue.  An example would be: there just are not enough male nurses to care for male patients who would desire male nursing.  Another: there is no organizational way to run an operating room effectively with restrictions on the gender of the participants and changes in protocol.  What I am getting at is that solutions to the issues discussed here may be more complex even if highly desirable.  What do you think? ..Maurice.


Graphic: GIF file from Google Images and American Broadcasting Company

Wednesday, November 27, 2013

Patient Modesty: Volume 60

On November 27 2013, Anonymous wrote in part " There is a culture of dismissal, negativity, and a refusal/inability to acknowledge the issue of sexual abuse within the medical community that prevails. It is this type of prevalent attitude of denial and dismissal that is so dangerous because it perpetuates the abuse.

To comment on Bernstein’s blog feels similar to what it might feel like for a Jewish person to enter Auschwitz and expect to be treated as a human being. It just is not going to happen. There is a culture of dismissal, negativity, and a refusal/inability to acknowledge the issue of sexual abuse within the medical community that prevails. It is this type of prevalent attitude of denial and dismissal that is so dangerous because it perpetuates the abuse."

And from Hexanchus  November 27 2013: 

"OK, let's talk statistics.

Referring to the book:
Sex Offenders : Identification, Risk Assessment, Treatment, and Legal Issues ...
edited by Fabian M. Saleh M.D. Assistant Professor of Psychiatry Harvard Medical School, Albert J. Grudzinskas M.D. Assistant Professor of Psychiatry in Law University of Massachusetts Medical School, Division of Forensic Psychiatry University of Ottawa John M. Bradford M.D. Professor and Head, Toronto Daniel J. Brodsky LL.B. Criminal Defense Lawyer, Canada University of Ottawa

"In the 1980's an attempt was made to estimate the lifetime prevalence of misconduct among various professional groups. A questionnaire study of psychiatrists found that 16% of responders acknowledged at least one sexual contact with a patient (Herman, Gartrell, Olarte, Feldstein & Localio - 1987)."

"Similar studies found that the frequency of self report of sexual misconduct ranged between 8% and 16%, a range that has also been found among most physician groups (Gartrell, Millikan, Goodson, Thiemann & LO - 1992)."

"During the early 1990's, physicians in family medicine, OBGYN and psychiatry were the most common brought board attention for sexual misconduct in Oregon (Erbonn & Thomas- 1997)."

"Both forensic and questionnaire data agree that approximately 90% of offending professionals are male."

Now from me 

So it would appear that this thread has changed its direction set by my visitors from discussion about the patient's modesty issues to one of presumably wide spread medical criminality.  But is such criminality so widespread and so frequent and the consequences on patients so profound (including PTSD) that it has become a failure in the medical system and the political system not to explain to the public what is occurring and what changes in the medical system and law enforcement are going to be made to put a stop to this behavior. All we currently hear about  is providing more medical care to more of the population and the costs of medications and medical care but nothing about  the crimes in medicine except very rare news items of specific cases.  So, Hexanchus, what does your research tell you about what should be done to spread the word about medical criminality and to rein it in?  And Anonymous, what would be the solution to prevent the "denial and dismissal" attitude suggested as present in the medical profession?  Is just a general "stepping on" the medical profession with harsh words the proper approach or are there more constructive approaches to preserve a profession and skills which presumably is still needed by everybody? ..Maurice.

Graphic: "Stepping on the Medical Profession"-Created by me using ArtRage and Picasa 3.  The idea was developed from an image in Google Images.


Sunday, October 27, 2013

Patient Modesty: Volume 59

Thread visitor APRC wrote the following "I think it is very hard for people who work in health care to accept when a patient refuses care, no matter what the reason. After all, you have devoted many years of study, hard work and personal sacrifice to this endeavor, only to be met with obstinance and refusal. I am sure it must boggle the mind of every health care worker out there and cast patients as little more than petulant children.
However, it is the duty of the health care worker to try to see things from the patient's perspective, and not the other way around. YOU are the fiduciary and I am the entrustor. As such, you have the duty to act in my best interest and I have the right to expect you to do so. You have chosen the role of provider, but I have not chosen the role of patient. [perhaps aside from a handful of purely elective medical matters]". 

One could argue, however, it is not that simple. Trust is not just a one way street in the function of the doctor-patient relationship despite the fact that the patient is the one who is sick.  The physician is the one given the responsibility to reverse that sickness. Trust in the physician by the patient has to be set by the limitations of trust the physician can have in the patient: presenting a complete history, cooperating in the completion of an appropriate workup, demonstrating compliance with the medical advice and treatment.  And just as the doctor will have issues of time, full attention and requirements and limits set by others and the uncertainties of diseases which may affect the responsibility for trust. So too, the patient may have personal financial, social or emotional reasons which cause the patient to fail to meet the criteria that the physician looks for in trusting the patient.  Both the physician and the patient have their own limitations which can negatively affect full trust in the other.

All of this represents important considerations in how smooth and comfortable the patient-doctor relationship and interaction with the medical profession develop. And the limitations experienced on both sides influence how patient's requests for modesty and gender selection of providers is handled.  ..Maurice.

Graphic: From Google Images and modified by me with Picasa3